Moral suffering in nurses of inspection departments in Brazil Sofrimento moral em enfermeiros dos departamentos de fiscalização do Brasil

DOI http://dx.doi.org/10.1590/19820194201600062 Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil. Universidade Federal do Rio Grande, Rio Grande, RS, Brazil. Conflicts of interest: there are no conflicts of interest to declare. Abstract Objective: To identify the frequency and intensity of the causes of moral suffering experienced by nurses in inspection departments in Brazil. Methods: Cross-sectional study with 28 professionals of managerial competence and 113 professionals of inspection competence. The sample was intentional and non-probabilistic. Data were collected through a questionnaire and submitted to descriptive and bivariate analysis. Results: Participants revealed the causes of moral suffering in two stages: firstly, associated with the slow inspection process by the inspected institutions and Corens, and insufficient human resources. Secondly, associated with ethical problems; work conditions; and quality of nursing care. Conclusion: To reflect on the causes of moral suffering in this scenario is to recognize the need for changes that should take place on the basis that sustains the profession’s ethical precepts and moral conducts, so as to strengthen the category.


Introduction
Moral suffering (MS) arises from the professional's sensitivity to moral issues because of conflicting situations.It happens when individuals face issues that require positioning contrary to their personal and/or professional values, and the decision does not produce the outcomes expected. (1)he phenomenon started gaining relevance in the nursing scenario as a result of being considered one of the main problems in the profession, as it affects workers in many activities of daily living.MS was associated with psychological responses (fear, anxiety, insecurity, among others); and work environment (specific situations such as ineffective communication, low autonomy, and insufficient human resources). (2)n a study with nursing staff in three hospitals in southern Brazil, it was evident that nurses had the highest perception of MS, followed by nursing aides and technicians.Nurses also had higher MS intensity over the lack of team work competence, disrespect for patient autonomy, and inadequate working conditions, whereas therapeutic obstinacy caused greater MS intensity among nursing aides.Finally, it is recognized that difficulties in organizing the work environment are an important cause of MS. (3) Healthcare literature generally describes this phenomenon in the clinical setting, revealing the experiences of nurses and professionals who provide direct patient care.This limitation, despite the importance of clinical work, points to the need to investigate MS in other contexts. (4)oral suffering is not limited to the nursing context, as it has been highlighted as a problem in the activities of pharmacists, associated with problems involving work organization, inter-professional relationships with patients; of doctors, due to feelings of powerlessness in face of colleagues' attitudes, and issues related to quality of care and bureaucratic obstacles, among others; and of psychologists, due to conflicting professional relationships, inter-institutional demands, and interdisciplinary disputes.7) In this scenario, the relevance of knowing the causes of MS in nurses who work in Brazilian inspection departments is evident, because studies on this subject were not identified in the literature.Regarding these nurses' daily work, the focus has been directed to problems of ethical and legal dimensions, related to interpersonal relationships and the procedures involving their work process. (8)Just as the ethical issues regarding the practice of these professionals should be subject to reflection, their consequences for the employee's experiences, including MS, must be critically addressed.
The challenge ahead is to explore the causes related to MS in the everyday work of these professionals by the conceptual framework of moral distress. (1)The framework is a process updated to the new needs of the nursing knowledge field.It consists in connecting various concepts or moments of moral experience, such as uncertainty, moral sensitivity, moral deliberation, and moral competence.
Therefore, the objective of this study was to identify the frequency and intensity of the causes of MS experienced by nurses of managerial and inspection competence in inspection departments in Brazil.This is one of the objectives of the doctoral thesis entitled "A fiscalização do exercício profissional de enfermagem no Brasil: problemas éticos" ("The inspection of nursing professional exercise in Brazil: ethical problems"), linked to the Comitê de Ética em Pesquisa com Seres Humanos da Universidade Federal de Santa Catarina (UFSC), supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Methods
This cross-sectional study was developed in the Inspection Department of Brazilian Regional Nursing Councils.
All 26 states and the Federal District that make up the Federative Republic of Brazil have a Nursing Council office, totaling 27.Each council has an inspection department that, overall, counts on 52 professionals with managerial competence (nurse who acts in management: managers) and 329 professionals with inspection competence (nurse whose primary activity is inspection: inspectors), who constituted the study population.
An intentional non-probabilistic sample was chosen, seeking to achieve representation of all councils.Given the voluntary nature of participation, it was possible to obtain the cooperation of inspectors from all councils, and managers from 22 councils.
A questionnaire with closed-ended questions and one open-ended question created by the authors was used for data collection.The questions were drawn from a previous study.The instrument was validated by nursing professors and masters, all familiar with the study subject.To ensure applicability and reliability conditions, face validity guarantee was sought in order to verify the adequacy of questions in the data collection instrument, concerning its form and language in relation to the objective.
The closed-ended questions addressed the following variables: failure to act against foul committed by a nursing professional in professional practice; lack of competence or commitment of the inspection team members; need to prioritize the institutions to be inspected due to the shortage of human resources; insecurity and lack of support upon notification; slow inspection process by Coren and inspected institutions; conflictual inspection process in Coren and inspected institutions.The open-ended question allowed participants to freely express themselves on the causes of MS in their daily work.
The questionnaire was the same for both groups (managers and inspectors).Data were collected from November 2013 to November 2014.Data collection took place in three stages.
The first data collection step was face-to-face, and applied during the 6th National Seminar on Inspection of Nursing Professional Exercise, where the research was promoted and the printed instruments distributed, returning to the researcher at the end of the event.The seminar was chosen for having the presence of a large number of managers and inspectors who work in Brazilian councils.The next step consisted in sending the questionnaire through an electronic link (Google ™ Forms).The strategy was intended to capture participants who had not been in the seminar, and mobilize those who had chosen not to respond at that time.In the third step, to achieve representation for the two types of participants in all regions, an additional strategy was used, which consisted of sending questionnaires by mail.
Data were subjected to two different analyses, using the software Statistical Package for the Social Sciences, version 20.0, Chicago: SPSS Inc.; 2011.Descriptive statistics were applied, by using means and frequency distributions to identify the frequency and intensity of MS causes; and bivariate analysis was performed using contingency tables and association chi-square (χ2), or Fisher's Exact Test, which allowed comparing the participants' experiences.Significance level was p<0.05.Normality tests were applied in each simulation.
Regarding the profile, the predominant age group was 31-40 years for both positions (43% and 50% respectively, for managers and inspectors); and they were mostly women (89% and 86%).Length of experience on the board was higher among managers (43% from 6 to 10 years) compared to inspectors (42% from 1 to 5 years).Most participants had a graduate degree (82% and 80% with specialization and 25% and 15% with master's degrees, respectively, for managers and inspectors).

Frequency and intensity of situations causing moral suffering
From the eight situations (variables) presented, the analysis identified the frequency and importance of each MS cause suggested, both for professionals of managerial competence and of inspection competence.In the case of professionals of managerial competence, it was observed that the prevalence of the phenomenon was associated with the slow inspection process by the institutions inspected, which obtained the frequency "often" (66.7% of respondents), more significant than intensities "intense" (22.2%) and "very intense" (33.3%).The need to prioritize the institutions to be inspected by the shortage of human resources was also highlighted, with the frequency "often" (34.6%) and "always" (26.9%), whereas intensity ranged from "intense" (28.0%), "very intense" (20.0%), to "maximum intensity" (32.0%).
By comparing the participants' experience, the result of the Pearson's correlation coefficient analysis showed statistical significance (within the standards established for this study, p<0.05) in the variable low inspection process by the inspected institutions, associated with frequency (p<0.04); and for the variable conflicting inspection process in the institutions inspected associated with frequency (p<0.05) and intensity (p<0.02).

Causes of moral suffering from everyday work
The results of the open-ended question, which asked participant to indicate up to three MS causes, are presented in this category.All responses were considered and grouped into 5 subcategories, observed in figure 1.
Regarding the subcategories related to MS, the following causes were observed in the perception of managers and inspectors, as presented in chart 1.

Discussion
Results showed consistency between the two groups, because they share the causes of their suffering, with only slight differences in frequency and intensity.Although some common MS sources have been identified, not all professionals will experience feelings of distress or suffering when faced with the situations mentioned. (9,10)t should be noted that higher frequencies and intensities are associated with difficulties in the inspection process, and the lack of human resources.These are problematic situations from which conflicts/moral dilemmas and anxiety emerge, preventing professionals from performing safe and skilled labor, which makes them suffer. (11)n this case, detecting the ethical problem is essential and, to that end, it is important to develop an ethical/moral sensitivity, i.e. a differentiated capacity of perception.Identified as practical wisdom, this sensitivity is a critical and reflective analysis of oneself, one's actions, thinking and being. (1,12)ome discrepancies found in the data collected from the two groups are not surprising, as it is a national level study and a diversity of problems and labor situations among the different realities is expected.A regionalized analysis of the data could reveal interesting differences.This behavior was observed in the data analysis of managers, as to the conflicting inspection process in the audited institutions (involving the frequencies "never," "sometimes" and "often"); and the inability to act against foul committed by a nursing professional in professional practice (involving the intensities "no intensity," "intense" and "very intense").In these cases, more localized research could allow revaluations and/or relevant corrections.
By comparing the frequencies and intensities of the eight situations (variables) presented to managers and inspectors, there was an association with statistical significance for the slow and conflictive inspection process by the audited institutions.This perception may be associated with interpersonal relationships, personal and professional values, and organizational events, given the complex health scenario.Conflicts are not always negative, and if properly understood and managed, they can bring positive results, considering the most contemporary management models.In this case, personal skills in the negotiation process and the use of appropriate strategies to solve or reduce conflicts will provide changes in social relationships and work organization.If not managed properly, however, they can translate into impasses in negotiations with negative consequences for the professionals' working practices and health. (13,14)esults on the open-ended question category, which asked the participant to indicate up to three pertinent MS causes, revealed ethical problems as the most important cause for the participating groups.These were characterized by attitudes contrary to ethics or undesirable from an ethical point of view, related to: political clashes, conflicting relationships, and difficulties linked to professional competence.These problems relate not only to isolated events, but reveal wider problems rooted in institutions and even in the health system.Unfortunately, they are still recognized in the national reality, highlighting the precarious conditions of health institutions, the fragile professional autonomy of nurses, outsourcing of nursing care, and inadequacy of training processes. (15,16)egarding the political conflicts that arise for both participant groups, there was political interference and a lack of transparency in Corens.According to the inspectors' point of view, there is a lack of punishment for public and private managers, institutional obstacles of health systems, and resistance to ethical and legal aspects by health institutions and nursing professionals.
Awareness of the importance of ethical values is essential for professional practice, maintains ethical environments, and prevents serious consequences in healthcare professional actions and outcomes. (17)he practice of professional inspection seeks to preserve ethical values and principles, and when even in the relationships within this group of agents misconduct is reported, either for lack of transparency, honesty or recklessness, there is a serious warning to the Cofen/Corens system.There is no way to justify a relaxation of duties, either by institutions, profes-sionals or inspection agents, giving way to the dangerous banalization of unethical practices that are reported throughout the social context.Therefore, the definition of an institutional policy within the system is necessary, one that meets a new posture and image under construction, both in the sense of profession valorization, and in the instruments that boards may develop to address the causes of these problems, starting with the strive for qualification and the working conditions of their own agents.
Another source of MS was identified in conflicting professional relationships of managers, being associated with the councilors' authoritarian attitude, and the conflicting relationship with inspectors and professionals from the legal sector.In the perception of inspectors, they are associated with the authoritarian relationship with managers, and the conflictual relationships with co-workers, nursing professionals and counselors.Studies confirm that work environments permeated by conflicting relationships, abusive conducts, demands, misunderstandings and insensitivities become heavy environments, causing stress, anxiety, distress and suffering, directly affecting professionals' work performance and health. (15,18) sues related to professional competence were directly associated with lack of autonomy for both participant groups.(21) Managers, however, also highlighted lack of technical expertise by co-workers, and the feeling of worthlessness by Cofen.Inspectors emphasized the impotence of the leadership in solving daily labor problems.In general, when these issues are not perceived and nothing is done to understand and solve them, they can lead to MS. Cases in which individuals have clarity of the situation, but have difficulties in expressing their concerns due to lack of organizational environments concerned about their professional experience are also a cause of MS. (22) The subcategory working conditions presents situations that indirectly influence managers and inspectors as sources of MS.Although not di-rectly responsible for the actions that lead to MS, they represent relevant issues in daily labor, such as dissatisfaction with workload, low pay, work overload, inappropriate facilities, and insufficient resources (personnel and equipment).However, MS does not occur only due to institutional obstacles, but it also involves political and economic aspects.MS can cause feelings like stress, exhaustion, emotional exhaustion, and even lead to job dissatisfaction.25) Relying on the fact that MS is an individual experience, rather than a situational one, it was observed that the subcategory of nursing care quality was also statistically significant, however, only to inspectors. (9)Although standing out as a situation that brings about MS, anguish and uncertainty, the result is identified as positive.Inspectors showed an accurate vision of ethical issues, which relates to the immersion experience and direct observation of practices.Moral sensitivity has already been reported in international studies as a positive attribute.Thus, it is deemed important to support and stimulate strategies that enhance this competence to improve professionals' sensitivity to ethical problems of their daily work. (1,26)he study had as limitations low participation, and participants' difficulty to express themselves on such a complex issue, which justifies further studies.It is suggested that this result may be associated with insecurity, institutional political issues, and even the feeling of disbelief in the return that an academic study can bring to professional practice, especially when the reported causes refer to issues affecting nursing activities in various contexts, and not just for the study participants.

Conclusion
This is the first Brazilian study focused directly on the issues that cause MS in nurses with managerial and inspection competence of the inspection departments.The research addressed the context of nurses who play an important social role for society, and also for professionals of the nursing category.
Silveira LR, Ramos FR, Schneider DG, Vargas MA, Barlem EL   The study showed flaws and even ethical problems, not only within the limits imposed by institutions, managers and nursing professionals, but also in the board's practices.This leads to the threat of trivialization of ethical issues that require a strict approach, and reflection on the actual and necessary conditions for the development of inspection activities.The focus of the study was not to explore alternatives and intervention and improvement actions of the inspecting process already underway in some of the councils, which may change some of the findings.Hence, complementary studies are important to monitor future changes.
Therefore, reflecting on the causes of MS in this scenario is recognizing the need for an assessment of professional behaviors and discussion on professional ethics, because changes must take place on the basis that sustains the profession's ethical precepts and moral conduct, thus strengthening the category.

Figure
Figure 1.Subcategories that express moral suffering causes from everyday labor of professionals of managerial and inspection competence 1. Subcategories that express moral suffering causes from everyday labor of professionals of managerial and inspection competence Causes of moral suffering experienced in everyday work of professionals of managerial and inspection competence Silveira LR, Ramos FR, Schneider DG, Vargas MA,Barlem EL