The ethical dimension of problems faced in general medicine: relationship with moral sensitivity*

Objective: to identify the main ethical problems and how these relate to the moral sensitivity of nurses working in a general medicine ward. Method: this qualitative, exploratory, and descriptive study was conducted in a university hospital located in the south of Brazil. A total of 18 nurses working in a general medicine ward were interviewed. A semi-structured interview script was used, and data were analyzed using discursive textual analysis. Results: nurses considered the main ethical problems to include conflicts at the institutional level, situations involving conflicts with patients and/or family members, and conflicts within the staff. The perception of nurses and how they deal with these problems relate to moral sensitivity. Two categories emerged: experiencing ethical problems, and relationship with moral sensitivity. Conclusion: because of the multidimensional nature of moral sensitivity, it trains and enables nurses to recognize and deal with ethical problems faced in clinical practice so that nurses become able to make fair and prudent decisions, improving the quality of nursing care.


Introduction
Nursing care, especially clinical practice, is permeated by an interdependent complex work process, which is inherently an ethical practice in which ethical decisions are made when facing tension, problems and conflicts (1) .
Nurses working in a hospital context play an essential role when providing care to clinical patients, especially in terms of decision-making. For this reason, nurses need to be morally sensitive, have knowledge, experience, and dynamism so that conflicts faced in daily practice that are related to a divergence of values, uncertainty regarding decision-making, and struggles in the relationship established with others, do not result in ethical problems (2)(3) .
Moral sensitivity may be considered a moral and intuitive concept that trains and enables workers to identify the moral component of situations of conflict, make decisions, and manage ethical problems, aware of their role and responsibility (4) .
Moral sensitivity in the nursing field may be seen as the ability or capacity of nurses to recognize the ethical and moral dimension of their behavior when making decisions on behalf of patients. Nurses, however, are often unable to identify these dimensions because their knowledge and skills are tested daily in their practice, resulting in ethical problems (5) .
International studies (4,(6)(7) report that ethical problems may accrue from everyday situations that are experienced in daily practice and involve: questionable care and therapeutic practices, not asking patients an informed consent before performing procedures, insufficient human or material resources, and unequal treatments. Thus, nurses need to be prepared and sensitized morally to recognize the situation causing a given problem and face it with prudence, considering consequences that may affect all those involved.
Perceiving ethical problems was one of the factors that influenced nurses' moral sensitivity (8)(9) the most.
For this reason, it is essential to investigate Brazilian general medicine wards, in which studies addressing ethical problems are not related to moral sensitivity.
Thus, this study was intended to fill in this gap, that is, the need to link moral sensitivity to a perception of ethical problems in clinical settings, considering that moral sensitivity enables nurses to identify ethical and moral issues involving nursing care, promoting ethical and fair decision-making to meet the needs of patients as well as favor their rights and interests.
Therefore, this study's objective was twofold: to identify the main ethical problems and how they are related to moral sensitivity among nurses working in a general medicine ward. with moral sensitivity. Figure 1 presents the elements that define this study's categorization process:

Discussion
Content collected during the interviews shows that nurses consider situations that somehow impede nursing care to be efficiently and efficaciously provided to be ethical issues. A Brazilian study addressing how nursing workers identify ethical problems in clinical and surgical clinical hospitalization wards reports similar findings (2) .
Moral sensitivity enables nurses to identify ethical problems and minimize moral conflicts, improving the quality of care delivery (12) .
The first category "experiencing ethical problems" revealed that nurses identify institutional conflicts, situations of conflict with patients and/or family members, and conflicts within the staff. These findings corroborate those of a study addressing primary health care nurses and the identification of ethical issues, reporting problems concerning management, patients, and within the staff (13) . The identification of ethical issues in clinical settings contributes to improving nursing care.
Thus, nurses need to be morally sensitive to recognize the ethical dimension of their actions when making clinical decisions (14) .
Regarding institutional conflicts, the participants report ethical problems to include: lack of institutional support and an insufficient number of workers.
A literature review (6) corroborates these findings concerning ethical dilemmas experienced by nurses during clinical practice. Problems such as lack of organizational support and lack of human and material resources lead nurses to experience ethical issues that require competence in terms of ethics. Hence, when nurses realize they need improved working conditions and do demand such conditions, they are using their moral sensitivity (12) .
In terms of situations of conflict established with patients and/or family members, disrespect toward patients, ineffective communication, and exposure of patients configure ethical issues. These findings corroborate with a literature review (15) addressing ethical dilemmas in the nursing field, which highlighted that the main problems include conflicts arising from such conflicts (3,16) .
Another ethical problem this study's participants listed included conflicts within the staff, mainly characterized by a lack of respect within the nursing team and interpersonal conflicts. One study (12) addressing Iranian nurses reports that ethical problems related to interpersonal relationships both within the staff and within the inter-professional team, hinder the development of moral sensitivity that would enable them to cope with dilemmas. Therefore, workers experience discomfort, distress, difficulty in adapting to clinical settings, and disqualification of nursing care delivery (17)(18) .
The second category "relationship with moral sensitivity" shows that nurses use elements such as empathy, dialogue, and clinical knowledge to deal with and resolve the ethical issues shown by the first category. These findings are in agreement with the results reported by one study (19)