Moral suffering among nurse educators of technical courses in nursing

Objective: to understand situations of moral suffering experienced at work by nurse educators of technical courses in nursing. Method: a qualitative study with discursive textual analysis by means of semi-structured interviews with ten nurse educators at two professional educational institutions in southern Brazil. Results: two categories were established: lack of commitment on the part of students to the future profession, expressed through disrespect and disregard for the work of nurse educators, with inappropriate behaviors and attitudes; and lack of commitment to the learning-teaching process, expressed by indifference to the professional profi le and lack of interest in lessons and care practices associated with learning gaps. Conclusion: these situations have an impact on experiences of moral suffering by nurse educators, and show a need for rethinking their practice, relationships, and educational spaces, and implementing strategies to favor the confrontation of dilemmas and confl icts experienced in educational practice in technical courses in nursing. Descriptors: Nursing; Teaching; Professional Education; Nursing Ethics; Nursing Education. RESUMO Objetivo: conhecer como enfermeiros docentes dos cursos técnicos em enfermagem têm vivenciado situações de sofrimento moral (SM) no trabalho. Método: pesquisa qualitativa, com análise textual discursiva, mediante entrevistas semiestruturadas com dez enfermeiros docentes de duas instituições de ensino profi ssionalizantes do extremo Sul do Brasil. Resultados: foram construídas duas categorias: descompromisso com a futura profi ssão expresso na relação com o enfermeiro docente, por meio de desrespeito e desvalorização do seu fazer, com comportamentos e condutas inadequadas que denotam falta de comprometimento com a profi ssão; descompromisso com o processo ensino-aprendizagem, manifesto por indiferença com o perfi l profi ssional, desinteresse em relação a ensinamentos e práticas de cuidado, associados a lacunas na aprendizagem. Conclusão: tais situações repercutem em vivências de SM ao enfermeiro docente, fazendo-se necessário repensar sua prática, as relações e os espaços de formação, implementando estratégias para favorecer o enfrentamento dos dilemas e confl itos vivenciados na prática educacional em cursos técnicos em enfermagem. Descritores: Enfermagem; Ensino; Educação Profi ssionalizante; Ética em Enfermagem; Educação em Enfermagem. RESUMEN Objetivo: conocer experiencia de situaciones de sufrimiento moral (SM) en enfermeros docentes de cursos técnicos en su trabajo. Método: estudio cualitativo, con análisis textual discursivo, mediante entrevistas semiestructuradas con diez enfermeros docentes de dos instituciones de enseñanza profesional del Sur de Brasil. Resultados: se determinaron dos categorías: falta de compromiso con la futura profesión expresada en la relación con el enfermero docente por inobservancia y desvalorización de su tarea, con comportamientos y conductas inadecuadas determinantes de falta de compromiso con la profesión; falta de compromiso con proceso de enseñanza-aprendizaje, manifestado por indiferencia con el perfi l profesional, desinterés respecto a enseñanzas y prácticas de atención, asociados a carencias del aprendizaje. Conclusión: las situaciones repercuten en experiencias de SM en el enfermero


INTRODUCTION
Nursing is a profession that aims at assistance, provision of care, research, and education.Education is one of the main roles that nurse educators assume in their professional practice, focusing not only on health education, but also on training new professionals, who, in addition to technical and scientific aspects, need to understand the dimensions of their work, commitment, and the responsibility that they assume when providing care to others (1) .
A study conducted by the Brazilian Federal Nursing Council in 2010 identified 1,449,583 nursing professionals in Brazil, with 287,119 nurses, 625,862 nursing technicians, and 533,422 nursing aides.Of these, 79.98% (1,159,284) were professionals at the auxiliary and technical levels, which characterizes this workforce's representativeness in the health area (2) .
These data corroborate those found in another study (3) , which showed a significant increase in the number of technical-level nursing schools, characterized as a relevant practice field in the education area for nurses.However, the education of nurses occurs in the bachelor's degree system, with preparation predominantly for care practice and not for teaching practice (3)(4) .
The lack of preparation for performance in the teaching profession may be characterized as a difficulty, not only in the didactic-pedagogical aspect, but also in the process as a whole (5) .Nurse educators often find themselves immersed in scenarios that do not favor the development of high-quality nursing practice or prioritize the development of students and the quality of care provided.In addition, nurse educators daily encounter disregard for their work and commitment to education of professionals who will provide care to others.
Furthermore, the reality of teachers of technical courses has been permeated by many changes in both the teaching-learning process and the profile of students such as weaknesses in their previous basic education, limited time availability, and manifestations of lack of commitment and lack of interest (5)(6)(7) .
Teaching work might be also influenced by work conditions, such as high workloads, low pay, bureaucracy, submissiveness, competitiveness, outdated libraries, few possibilities for improvement, accumulation of functions by preceptor nurses when supervising traineeships and developing their care and management activities in the respective units, and disregard for teachers' image and their claims (6,(8)(9) .Situations like these have caused suffering in the daily lives of nurse educators, especially because they are engaged in the education of ethical and committed professionals; this involves moral values and problems, and self-questioning about whether they experience moral suffering.
Moral suffering occurs when individuals know the right thing to do, but institutional or other limitations make it almost impossible to perform what they consider to be right (10) .It extends to the mind, body, and relationships, and involves in situations in which there is awareness of moral issues, along with realization of responsibility and moral judgements about what is right (11) .
Experiences of moral distress described by teachers go beyond dissatisfaction and suffering at work, and may evolve into moral suffering (12) .Nurses and nursing students seem to be vulnerable to moral suffering when confronted with moral issues and dilemmas or decision-making in clinical practice, which may lead to professional dissatisfaction and evolve into moral suffering, with manifestations of anger, frustration, and desire to abandon their profession (13) .
From this perspective, moral suffering in nursing does not have limits; it affects everyone involved with the clinical condition of patients.Therefore, students and teachers may be affected by the same moral dilemmas that nurses, doctors, and therapists experience in their practice environments.However, these experiences and confrontations, or lack of confrontations, do not reduce the teaching staff's responsibility for ethical principles in care practice, nor minimize their responsibility regarding their behavior, which must be an example and model for undergraduate students (14) .
From this perspective, nurse educators may face a number of situations that lead to ethical conflicts and moral problems/ dilemmas.Therefore, with the purpose of understanding issues that involve teaching work in technical courses in nursing and moral suffering, the aim of the present study was to understand situations of moral suffering experienced at work by nurse educators of technical courses in nursing.

METHOD Ethical aspects
The study was approved by the research ethics committee of the local health area, in compliance with recommendations of the Resolution no.466/2012.

Theoretical-methodological framework and type of study
This was an exploratory and descriptive study with a qualitative approach.The description of phenomena is full of meanings arising from the environment; the interpretation of the results occurs based on the perception of a phenomenon in its context, and is coherent, logical and consistent (15) .

Study setting
The study was conducted in two professional educational institutions with nursing technician training, located in a city in southern Rio Grande do Sul: one was public (A) and the other private (B).
At institution A, the course runs in graduate and high school systems, with 18 hours of theoretical-practical classes and 6 hours of practical training.A selection process is used to assign

Data sources
The participants were ten nurse educators who had worked in the courses for at least six months and agreed to participate in the study after signing an informed consent form.

Data collection and organization
Semi-structured interviews were carried out by the first author, with a focus on aspects regarding the practice of teachers, such as facilities, difficulties, conflicts, dilemmas, feelings, and strategies experienced in their work.The interviews were carried out and recorded from September to October 2015 at their work institutions.; the average duration was 41 minutes.The participants were identified by the letters ED, followed by the sequential number of the interview.

Data analysis
Discursive textual analysis of the data was carried out with the deconstruction of the transcribed interview texts; data validation was carried out with the six nurse educators who were available; relationships were established; and the new emergent and a self-organized process was captures (16) .

RESULTS
Two categories were established based on data analysis: lack of commitment to the future profession expressed in the relationship between students and nurse educators; and lack of commitment to the teaching-learning process.
Lack of commitment to the future profession expressed in the relationship with nurse educators Manifestations of lack of commitment in the relationship between students and nurse educators seems to be associated with how they establish their relationships in the context of the teaching-learning process.Teachers find themselves to be disrespected and their work is disregarded, especially when students do not adopt the attitudes and behaviors regarded as necessary for their education, which shows that they not to recognize that a professional course with a focus on provision of care requires responsibility and seriousness: Manifestations of lack of commitment to the education and disrespect toward teachers are noticed when students make use of electronic devices such as cell phones and smartphones in the classroom, not focused on the search for information or learning.These behaviors cause suffering to teachers, who find themselves in a dilemma about how to perform in an integrative but not authoritarian way: Lack of commitment to the teaching-learning process Perception of the lack of commitment of students to their professional education is identified by teachers in several aspects, such as lack of responsibility regarding the importance of punctuality and attendance of theoretical classes and practical training activities, which are necessary requirements for the professional profile of workers, not just serving as elements to be evaluated: They say that they are looking forward to the practical training, that practical training is better.When they are in the last module, with only four months to finish the course, they seem to be dragging on; and they start asking; "What time is it going to finish?" (ED8)

Students who have to work and arrive late for personal reasons want to be evaluated regarding attendance and punctuality the same as those who, regardless of their personal reasons, always arrive on time [...]. (ED5)
The lack of interest in acquiring and deepening knowledge regarding nursing practices, which are essential for the development of care, emerges as a second aspect that causes frustration and suffering to nurse educators, who show themselves to be affected by specific behaviors and attitudes of students: There is a lack of interest, they are always expecting you to speak.Maybe this is the difficulty I see in them, the lack of theoretical foundation to undertake procedures.(ED1)

There is enormous difficulty with studying. Among 20 students, only one shows quality of education, because he pays attention, and you can see that he is dedicated […]. They do not accept failure. This is difficult for me, because how can I approve them, if they did not do the work and they do not know? [...] (ED7)
Unfortunately, students graduate as professionals who do not want to think, and this is frustrating.(ED10)

They will probably cheat on a test, and they do. In situations like these, you notice that you expect a lot from them, and realizes that there is no way. (ED8)
Problems associated with the basic education of students are factors that cause difficulties in the teaching-learning process in technical education in nursing, and cause daily wear on teachers, since previous knowledge is necessary for the development of new practices and knowledge: They come far more unprepared, have difficulties with grammar, mathematics, and you can see this in the application of the rule of three and calculations.They do not have a good theoretical foundation and the medium level knowledge required for the course.[...] They probably do not know how to study.They think that studying is making questionnaires and memorizing things, and when you arrive in the practice field, you come across this.(ED1) Some finish the course and are not able to use scientific terms, if you do not use them in the daily routine.We had students who were not completely literate.Then, I realize that is a due to a number of things, and the main change required is in basic education, back to elementary and high school, so that we can teach more qualified students.(ED10)

DISCUSSION
The present study showed that, in their daily work of teaching, nurse educators in technical courses in nursing experience a number of situations that lead to distress and frustration.However, these situations seem to cause, not only dissatisfaction and suffering in teaching work, but also moral suffering.
Situations that show lack of commitment of students to the profession are noticed by teachers, shown by disrespect and disregard for their work, values, and the practices upheld and encouraged so that students can embraced them.These behaviors lead to dissatisfaction and frustration for teachers, when they feel that their role as teachers is rejected by students, transcending educational, pedagogical and moral aspects, confronting their social, ethical, and moral commitment.Conversely, feeling that their work is valued and receiving recognition of their didactic-pedagogical ability, creativity, and involvement with the teaching-learning process, seem to be sources of pleasure and satisfaction at work (6) .
It is worth mentioning the commitment of teachers to their educational practice.This can be seen in the triangle established in this action, made up of teachers, students, and patients, in which their working practice is not only the performance of an act, but also has a care nature with the purpose of encouraging students to be aware of the relevance and repercussions of their actions (17) .
Similar to the findings of the present study, one study found that teachers may experience feelings of distress and insecurity about not being able to meet the demands of their teaching practice, and because of disregard of the implications of their work by students, users of the service, or other health professionals.In this context, there is apparent disregard of the relevance and seriousness of their work (18) .
From this perspective, education represents a changing process that transcends educational and pedagogical aspects, and requires the commitment of educators and students to the awakening of curiosity, criticality, and reflection.Teachers must develop the ability to question reality, pointing out learning alternatives that go beyond instituted knowledge; and students must be influenced by the need to search for information and knowledge, and develop autonomy in this process (7) .
Students of technical courses in nursing must be aware of the profession's requirements, because their performance is tied to the health and illness process of other people.Nursing, in turn, is translated as the profession of care, in which "care reveals its own existence, or the way of being of nursing" (1) .
Teachers also experience moral suffering because of experiences of disrespect toward values recognized as relevant in professional practice, associated with difficulties in facing them.In many circumstances, when moral values are violated, distress about having acted against their principles and perceptions leads to moral suffering, which, if it becomes persistent, characterizes residual moral sensitivity, and it may harm their personal integrity and lead to abandonment of the profession (19) .
Moral suffering and residual moral sensitivity lead to consequences in the behavior of professionals.When they suffer such feelings, many continue to develop their practice; however, they may not recognize or get involved in situations that require them to show moral sensitivity.Dissatisfaction at work may result in abandonment of the profession, since nurses feel frustration and impotence in the context of their work, and in addition, they may develop burnout, with physical and emotional manifestations (20) .
From this perspective, nurses experience exhaustion and dissatisfaction when they do not have the resources to face and resist these realities, which are manifestations that translated to lack of motivation and distance from their practice, leading to moral suffering (21) .
When approaching issues associated with the lack of commitment of students to their teaching-learning process, behaviors emerge that show possible lack of responsibility for their education, such as not understanding that attendance and punctuality are not just assessment criteria.They are characteristics necessary to the profile of professionals committed to their work, work teams, and the services to be provided to those who are under their care.
Indisputably, the lack of interest of students in education, along with the strengthening of the characteristics necessary to work involved and concerned with care, emerge as important factors in teaching work, which might lead to moral suffering.Nurse educators find themselves engaged with and committed to their participation in the training of professionals.However, they realize that many students are not in agreement with the educational practices proposed, possibly not identifying them as relevant to their professional education process (6) or the profession that they intend to assume as nursing technicians.
In addition, regarding the lack of interest of many students in the educational process, stagnation and self-indulgence stand out, translated into passive behavior and little involvement in the teaching-learning process and abstaining from the responsibility that they should assume in a course that aims at training professionals to provide care; these are attitudes that will probably impact their care practice as professionals.Corroborating these findings, a study developed in a nursing course showed that undergraduate students attend compulsory subjects for curricular traineeship without involvement in their purpose, which is expressed as nonchalant behavior, perceived by preceptors as disregard for the moment experienced as a constituent of their educational process, ignoring the importance of this learning for future experience (8) .
In a more integrated and transformative educational context, it is necessary that students not limit themselves to the obligation to attend courses; they must realize the importance of these activities to their education, with a focus on care practices that are truly carried out with the exercise of reflection and care (1,22) .In addition, it can be considered that dishonest behaviors, such as plagiarism in schoolwork and forging of teachers' signatures, have been configured as ethical problems in the relationship between teachers and students, since students are not developing their abilities and knowledge on specific subjects, with possible repercussions in gaps in the basis of practice (23) .Environments where there are dishonest behaviors like cheating and plagiarism, inflation of grades, incivility, and bullying, may lead to moral suffering in nursing education, influencing work satisfaction and student learning (12) .
In addition, regarding the lack of interest of many students, there are references to deficiencies in basic education and contents of theoretical basis, which interferes with the development of other skills necessary to their education; students often advance through courses, although they present important gaps in learning (6)(7) .One study highlighted the complexity of training nursing professionals when many have learning needs still focused on basic education, possibly interfering with the understanding and learning of preliminary and introductory contents, which is an aspect that contributes to difficulties in acquiring specific knowledge, and a succession of factors that may compromise quality of care (5) .
It is possible that these manifestations shown by students result from early admission to educational institutions, when they are still immature and do not have a clear understanding of the commitment they must make when they choose to attend a course whose professional future involves provision of care, directly and indirectly, to others.The immaturity of students negatively affects the teaching-learning process and work of teachers, leading to dissatisfaction (24) and suffering, including moral suffering.

Study limitations
The limitation of this study was lack of adherence of all the nursing educators working in the two institutions; of 14 teachers, only 10 showed interest in participating.This refusal may have originated in fear of possible retaliation from institutions for disclosing problems and difficulties experienced in daily teaching practice.

Contributions to fields of nursing, health, and public policy
The theme is relevant to the possibility of rethinking the education of nursing technicians, so that their professional education does not contribute to weakening of morals.The present study is expected to encourage reflection on an education that contemplates and strengthens moral development.

FINAL CONSIDERATIONS
The results showed that it is possible to determine that situations of lack of commitment to the future profession expressed in the relationship between students and teachers and the teaching-learning process, which leads to experiences of moral suffering, are present in the daily work of the teachers of technical courses in nursing who participated in the present study.
However, these situations do not seem to be seen by these teachers as problems and moral dilemmas associated with moral suffering.Rather, they are perceived as dissatisfaction, frustration, and suffering at work, resulting in disenchantment with the profession and the desire to abandon it.
Manifestations of lack of commitment of students to the teaching-learning process, and lack of interest in lessons and knowledge as guiding axes of care in the profession, aggravated by learning deficiencies in basic education, characterize situations perceived and experienced by nurse educators, which leads to dissatisfaction at work, evolving into the experience of moral suffering.In this context, rethinking teaching practice, relationships, and educational spaces is required, along with the implementation of focused strategies and strengthening of interaction with pairs, in order to favor the confrontation of dilemmas, distress, and conflict experienced in educational practice.It is of utmost importance to identify strategies that encourage the active participation of students in the teaching-learning process, so that they are able to develop skills for the exercise of a care practice based on reflection, criticality, and commitment to provision of care.
It is understood that discussion of this theme is not limited to the present study.Additional studies on moral suffering in the teaching profession are required, especially in the teaching of technical courses in nursing, with the intention of increasing the understanding of this phenomenon.It is also necessary to investigate and question the other issues involved and search for confrontation strategies that contribute to the training of nursing technicians in spaces of mutual respect and appreciation, with the joint development of knowledge.

I
see that many of them are in the classroom using What-sApp and Facebook, because they have individual internet access.This makes it very difficult to make them pay attention […].(ED7) You see that they turn the volume down, but they are sending messages all the time, that's cell phone disease.(ED1) Discontent and disenchantment are observed with the process of development of knowledge and with teaching itself.Thoughts of abandonment of their practice and early retirement become present in their daily work, which may translate to a level of suffering that goes beyond that experienced at work: Because it comes a time when you feel overwhelmed, and you no longer give importance to a problem that you are not able to handle.(ED9) Three years ago, I was not thinking about retirement, but because of the things that I have seen, I need to retire, […] I will not retire because it is time to.I am disappointed with the things I have seen, both as a teacher and as a nurse.(E3) Sometimes, I feel frustrated, […].I have already thought about working at night and stopping teaching.(ED8) Carla Godinho Duarte E-mail: carla.duarte@riogrande.ifrs.edu.brCORRESPONDING AUTHOR docente, necesitándose reconsiderar su práctica, las relaciones y espacios formativos, implementando estrategias favorecedoras del enfrentamiento de dilemas y conflictos experimentados en la práctica educativa en cursos técnicos de enfermería.Descriptores: Enfermería; Enseñanza; Educación Profesional; Ética en Enfermería; Educación en Enfermería.28 vacancies annually.The teaching staff consists of six undergraduate and graduate nurses, four governed by the Brazilian single legal system and two working as substitute professors.At institution "B", the course runs in classroom attendance modality, with biannual admission of classes of at least 25 students.There are 12 hours of theoretical-practical curricular components and 460 practical training hours.Admission is by application and registration.As prerequisites, candidates must be 16 years of age or older and have a minimum of previously competed high school education or be currently enrolled in high school.The teaching staff consists of eight nurses, hired as hourly paid workers under Brazilian work legislation (CLT, as per its acronym in Portuguese), and only two have pedagogical training.
There have been times when we were disrespected both verbally and by signs and gestures; […] in the practical training, when you tell students "do this, do that," and they do it the way they think is right[…].(ED2)WhenI taught them in medical practice, which I really like, I pushed them, and they complained that it was for doctors, that they were not supposed to give diagnoses.Therefore, this is bad.You think that you are doing a good job, and they complain.(ED8) Moral suffering among nurse educators of technical courses in nursing Duarte CG, et al.Now, delays and absences are a problem.Students arrive in the class, and before the beginning of the class, they want to know what time it is going to finish.The class finishes at 6:15 p.m., and at 2:00 p.m., because they have to leave, they ask "What time is it going to finish?"In addition to leaving before the end of the class, they start arriving late.You have to tell them about this, and you work with adults.(ED3)