Sofrimento moral e satisfação profissional : qual a sua relação no trabalho do enfermeiro ? Moral distress and work satisfaction : what is their relation in nursing work ?

1 Faculdade Integrada de Santa Maria. Santa Maria, RS, Brasil. 2 Universidade Federal de Santa Maria, Departamento de Enfermagem, Santa Maria, RS, Brasil. 3 Universidade Federal de Santa Maria, Departamento de Estatística, Santa Maria, RS. Brasil. 4 Universidade Federal do Rio Grande, Escola de Enfermagem, Rio Grande, RS, Brasil. ABSTRACT Objective: To verify relations between moral distress and work satisfaction in nursing work in the hospital context. Method: A cross-sectional study carried out in a university hospital with nurses by applying a sociodemographic questionnaire, the “Index of Work Satisfaction” and the Brazilian Version of the “Moral Distress Scale”. Descriptive statistics and Spearman’s correlation were used for the analysis. Results: 141 nurses participated in the study. “Autonomy” was the component of greater work satisfaction, appearing as fragile in the greater intensity issues of moral distress. Autonomy was followed by “interaction” and “remuneration” as components of satisfaction, and “lack of competence in the team” and “insufficient working conditions” as having greater intensity and frequency of moral distress, respectively. Conclusion: Comparing these two constructs denoted inverse relationships between them, especially while autonomy, a component of greater satisfaction, also appears as a trigger of moral distress when insufficiently exercised. Thus, it is considered necessary to strengthen nursing work environments for ethical and satisfactory performance.


INTRODUCTION
"Changes in the working world have increased the demands on workers who must be more and more skilled, and produce greater results in terms of quality and productivity" (1) . With this, there is greater psychological burden associated with work, as well as the exposure of workers to occupational risk factors which may compromise their physical and mental health (2) .
These characteristics are also present in the context of nursing work, in which the impossibility or inability to provide good care regarding psychological load and exposures at work become distressing for nurses, such as regarding moral problems (3) . Moral problems are situations which provoke moral reflection, which lead professionals to question themselves and their situation; they occur when trust, rules and routines are fragile and insufficient for decision-making, which also involve personal and professional values coming into conflict (4) . In this case, nurses approach the possible conflicts arising from moral decisions present in the daily lives of health services, which involve priorities and deliberations by professionals of the multidisciplinary team, managers of the institutions and public policies, which directly interfere in the lives of people, families and community (3,5) .
Faced with these conflicting situations, nurses can experience moral dilemmas and moral distress in their work environments. Moral dilemmas and moral distress are defined as ethical problems, of which in the first there are two or more options of actions for a given situation, none of which presents a strong enough argument to sustain decision-making; while the latter may derive from moral dilemmas, since in such cases the professional recognizes the ethically appropriate action to be followed, but they are prevented from acting according to their conscience due to institutional constraints, legal and/or political considerations, etc., perceiving their moral participation as inadequate (6) .
The main situations which can cause moral distress to nurses in their work are related to the organizational environment, professional attitudes and psychological characteristics. These include a poor ethical climate in the institution, the lack of collaboration between the multiprofessional team itself and also with managers, work overload due to inadequate staffing, reduced job satisfaction, intention to leave the job, reduced engagement in work activities, burnout and lack of conditions for exercising power and autonomy (7) .
When experiencing moral distress in these situations, nurses also suffer negative consequences on their health and well-being at work, leading to illness and interfering with their subjectivity and satisfaction with work (5) . Among the main emotional manifestations of moral distress in professionals are frustration, feelings of helplessness, anger and guilt (7) .
Also, as a consequence of the constraint arising from moral distress in which there is perceived ineffective moral participation on the part of the professional, along with apparent risks to their motivation and work satisfaction, there can be low productivity and a decrease in the quality of care provided (8) , being fundamental to investigate the relation between these phenomena, i.e. moral distress and work satisfaction.
Work satisfaction is understood as a phenomenon conditioned by the sum of the different work components, which involves both the current work moment and the workers' expectations (8) . Work satisfaction is a complex and subjective phenomenon, characterized by a pleasurable emotional state resulting from multiple aspects of work and is susceptible to being influenced by values, beliefs, world perceptions, aspirations, sorrows and joys of individuals, which may affect their attitudes and decision-making regarding themselves and their work (9) .
Thus, in view of the addressed aspects, the following is presented as a research question: What is the relation of moral distress and work satisfaction in nursing work in the hospital context? The general objective is to verify relationships between moral distress and work satisfaction in nursing work in the hospital context, and specific objectives are to identify the index of work satisfaction of nurses in the hospital context and also the intensity and frequency of moral distress of nurses in the hospital context.

Study deSign
This is a cross-sectional study implementing a quantitative approach.

Scenario
The study was conducted at a university hospital of medium and high complexity in Rio Grande do Sul state, Brazil, with its structure being exclusively allocated to the Unified Health System (SUS -Sistema Único de Saúde), having 403 beds distributed in the clinical, surgical, pediatric, intensive care, emergency, surgical center and obstetrics hospitalization units, among others. The study population during the data collection period was 217 nurses. A non--probabilistic sample by convenience was employed, in which all the nurses working in the institution were invited to participate through presenting the Informed Consent Form (ICF). However, a minimum sample was calculated for statistical purposes using a formula for finite sampling. Thus, a minimum number of 140 subjects was obtained based on the total number of nurses at the surveyed institution in the period, a significance level of 95% and an error of 0.05. The inclusion criteria were only nurses and having worked for a minimum period of 3 months in the institution; exclusion criteria included being on leave (for any reason) during the data collection period.

data collection
The data collection took place in the period from January to March 2015 by collectors who had been previously trained by the lead researcher. The workers were asked to answer the questionnaire during their work shift. The mean completion time was 20 minutes. A timetable for returning the completed instrument together with the signed ICF was scheduled. A maximum of three attempts were made to collect the instruments.
The data collection instrument consisted of a sociodemographic and work questionnaire, the Index of Work Satisfaction (IWS) and the Moral Distress Scale (MDS) -Brazilian Version. The sociodemographic and occupational characterization included variables such as gender, age, education, length of professional training, length of service in the institution, work unit, among others.
The IWS was selected in order to investigate work satisfaction, being elaborated in a North American context (8) , but already used in other studies in the Brazilian context after its cross-cultural adaptation (10) . It is possible to evaluate the importance attributed by nurses in relation to six components of work through this self-applied instrument: Autonomy, Interaction, Professional Status, Work Requirements, Organizational Policies and Remuneration. It is also possible to identify the work satisfaction perceived by nurses and their actual level of work satisfaction in relation to the components. In its original version and Brazilian validation, the instrument presented Cronbach's alpha from 0.82 to 0.91 and from 0.58 to 0.79 in its components, respectively (8) .
The IWS is composed of two parts (Part A and Part B) and uses the method of attitudes measures, which relates the current work situation to expectations of work (8) . In addition to defining the six components and instructions for completing the instrument, Part A also contains a list which combines the six components of work satisfaction with each other, totaling 15 pairs. Thus, the participant should choose the one considered the most important for their work satisfaction from each pair. Part B contains the Attitudes Scale, with 44 affirmations arranged on a seven-point Likert scale, ranging from "fully agree" (score 1) to "fully disagree" (score 7). The Index of Work Satisfaction is measured by weighting both parts of the instrument.
The MDS -Brazilian Version, originally American (11) , was translated, adapted and validated for the Brazilian context in 2013 to evaluate moral distress (12) . The MDS -Brazilian version presents 39 questions on a seven-point Likert scale, ranging from 0 (zero) for "never occurring or no frequency" to 6 for "very intense or very frequent distress". The scale investigates the frequency and intensity of moral distress, and in its validation in Brazil presented Cronbach's alpha of 0.93 (12) .

data analySiS and proceSSing
The Epi-info ® program was used in order to include data in the research analysis process using double independent typing entry, as well as error and inconsistency checking. The PASW Statistic ® (Predictive Analytics Software, SPSS Inc., Chicago, USA) version 18.0 for Windows and R version 3.0.2 (The R Foundation for Statistical Computing, Vienna, Austria) statistical software programs were used in the analysis.
The analysis of sociodemographic and labor variables was described by absolute and relative frequency (qualitative), while mean and standard deviation or median and interquartile range (quantitative), depending on the normality assumption, were verified by the Kolmogorov-Smirnov test.
In order to verify the Index of Work Satisfaction, the analyzes of part A and B of the instrument and their subsequent weighting were carried out. A frequency matrix was created for determining part A, relating how many times each component was chosen in relation to the others. These response frequencies were converted into a proportion matrix, where the absolute values were divided by the total sample size. This was further transformed into a Z-matrix, with the proportions being converted into standard deviations, generating the weighting coefficients of the components. A correction factor of +2.5 was used to eliminate negative Z-scores. This first analysis allowed to identify the importance attributed by nurses to each component (8) .
In the analysis of part B (attitudes scale), the questions were grouped according to the components, and distribution matrices of response frequency were created to observe the patterns of the nurses' responses. Then, questions with positive statements were reversed for determining the total score of the scale. The total score of the components was calculated by summing the numerical values of each response, which was then divided by the research population. This value was divided by the number of questions of each component, resulting in a mean score.
The Index of Work Satisfaction was obtained by multiplying the component weighting coefficients (Part A) by the average scores of each component (Part B). The Index of Work Satisfaction ranges from 0.9 to 37.1 in a positive direction (8) .
For analyzing moral distress, the factorial analysis of the instrument was carried out to verify its applicability in the studied sample. The internal consistency of the scale was analyzed using Cronbach's alpha. Moral distress was determined by the average of the factors found for: "lack of competence in the nursing team", "denial of the nurse's role as advocate for the patient", "therapeutic obstinacy" and "insufficient working conditions".
Finally, to verify the association of moral distress with work satisfaction, a correlation analysis was performed between the factors of each of the scales, as well as the correlation of two general variables; one of work satisfaction and one of moral distress. The Spearman correlation coefficient was used to perform the correlation due to the asymmetric distribution of the data, and significance values of α < 0.05.

RESULTS
A total of 141 nurses participated in the study, with 127 (90.1%) females, 96 (68.1%) were married or with a partner, 78 (55.4%) had one or two children, and a median age of 37 (32.25-47.00). Among the participating nurses, 80 (56.7%) had specializations, 41 (29.1%) worked in a mixed shift rotation, and 126 (89.4%) had no other job. The nurses had a median training time of 12 years (7.00-20.00) and a working time in the institution of 7 years (0.42-12.42), working in the same unit for approximately 2.5 years (0.33-8.00), and in the same shift with a median 1.5 years (0.25-6.00).
In the IWS analysis, an absolute frequency matrix that described how many times each component was chosen in relation to the other components was initially created. Then, the absolute frequency matrix was converted into a proportion matrix, and the proportion matrix was subsequently transformed into a Z-matrix, with the proportions converted into standard deviations, presenting the weighting coefficients according to Table 1. From Table 1, it is possible to observe the order of importance attributed by nurses to the components, and it can be stated that the most important component for their work satisfaction was autonomy, followed by interaction and remuneration.
Regarding the individual analysis of the items that make up the "autonomy" factor, the following question was highlighted: "31 -In my work, I sometimes have to do things that go against my best professional judgment", which obtained agreement from 68 (48.2%) nurses, while 13 (9.2%) were neutral or undecided.
Next, the total score of each component and its average score were calculated with the analysis of part B. The mean score was multiplied by the weighting coefficient (Part A) for the result of the adjusted score of each component. The adjusted scores were then summed and divided by the number of components, thus reaching the Index of Work Satisfaction. Thus, it is observed that the Index of Work Satisfaction of nurses was 10.81, which is understood as low considering the range of the instrument score.
The results of the intensity and frequency of moral distress in nurses are presented in Table 3. Based on the results of Table 3, it is possible to affirm that the factor which generates the greatest intensity of moral distress is "lack of competence in the team", and the one of greater frequency of moral distress is "insufficient working conditions".
Regarding the analysis of the individual items of each factor, in the "lack of competence in the team" factor, the item 26 "Working with medical or nursing students who lack the necessary competence that the patient's condition requires" was highlighted with greater intensity -mean of 3.99 (± 1.94) and median 5.00 (3.00-6.00). In the factor "denial of the nurse's role as an advocate of patients", the following two items stood out: "18 -Assisting a physician who, in my opinion, is acting incompetently with the patient", had an average of 3.51 (±2.46) and median of 5.00 (1.00-6.00); and "34 -Avoid taking action in cases of patient death associated with professional negligence", with an average of 3.50 (±2.46) and median of 5.00 (0-6.00). In the "therapeutic obstinacy" factor, emphasis was placed on item "5 -Starting intensive life-saving procedures, when they believe they will only delay death", with an average of 3.54 (±2.07) and median of 4.00 (2.00-5.00). And lastly in the factor "insufficient working conditions", item "13 -Working with nursing staff with a level which I consider unsafe", was highlighted with an average of 3.80 (±2.20) and median of 5.00 (2.00-6.00).
Finally, the Spearman correlation analysis was performed to verify possible associations between moral distress and work satisfaction, as can be observed in Table 4. Legend: lack of competence in the team (LC); denial of the nurse's role as an advocate of patients (DEN); therapeutic obstinacy (TO); insufficient working conditions (IWC); autonomy (A); organizational policies (OP); work requirements (WR); interaction (I); Professional status (PSt); remuneration (R); moral distress (MS); professional satisfaction (PS). * p < 0.05 ** p < 0.01 Thus, based on Table 4, it was verified that there were no statistically significant associations between the moral distress and work satisfaction scores; however, it is observed that there is a strong correlation between the factors of each instrument, such as "lack of competence in the team" with "denial of the nurse's role as an advocate of patients"; and "autonomy" with "organizational policies". Likewise, although not statistically significant, it is possible to observe that the results in this sample showed a negative correlation between the variables "general moral distress" and "general work satisfaction", indicating that these constructs are inversely proportional.

DISCUSSION
A total of 141 nurses participated in the study, which corresponds to 65% of the institution's nurse population in the period. It should be noted that the institution was in transition to management by the Brazilian Hospital Services Company (EBSERH -Empresa Brasileira de Serviços Hospitalares) and at the time of its first staffing during the data collection period, therefore many nurses were not included in the minimum working time for the inclusion criterion, which was considered necessary inserting the participants into the unit's and institution's routines. Of the participants, 127 (90.1%) were female, as has already been observed in other studies on moral distress and work satisfaction in which the majority of the participants were female, considering that nursing is also historically considered as a predominantly female profession (12)(13) .
Regarding the relation of moral distress and work satisfaction, no statistically significant associations were found; however, it is possible to observe some comparisons between these constructs by the analysis of their individual items and factors.
It was verified that autonomy was the most preferred component of work satisfaction among the nurses in the study, which corroborates the assessments' findings of nurses from public hospitals of medium and high complexity in the southern region of Brazil (14)(15) and differs from other international scenarios such as in private hospital nurses in Malaysia, where the most preferred component was remuneration, and nurses from Australia and New Zealand, who opted for the professional status (16)(17) .
Regarding the present study, it can be said that autonomy is valued and privileged in the action area of these nurses, since they worked in a public and federal teaching hospital in which there are teachers in the administrative area (including nursing) in the management of this setting, in which nurses would have greater possibilities to both exercise their autonomy and to confront problematic situations, which may differ from other national and international locations, as exemplified.
However, from question 31 it was observed that albeit being in a service with these characteristics, most nurses agreed that sometimes they needed to perform actions which did not correspond to their better professional judgment, which may configure as the occurrence of moral distress. Conversely, when the questions which present the greatest intensity of moral distress are analyzedespecially those referring to the "denial of the nurse's role as an advocate of patients", assisting doctors who act incompetently with a patient or avoiding taking action in cases of patient death associated with professional negligence -there seems to be reduced autonomy and resistance, in which nurses cannot act according to their professional values.
In this perspective, in evaluating the association of moral distress with collaboration between nurses and physicians, autonomy and work satisfaction in Italian nurses, it was observed that the severity of moral distress was associated with low collaboration among these professionals, dissatisfaction in the care decision-making for the patient, and an intention to leave the job, as well as the low professional status reported within the multiprofessional team which limited their opportunities to exercise autonomy (18) .
It should be emphasized that the contribution of autonomy to work satisfaction can be associated with the possibility of nurses acting according to their knowledge and values, with opportunities to express their opinions and to participate effectively in decision-making at work, involving the search for technical information, scientific knowledge and creativity in the performance of the work process (15) .
Together with autonomy, the second most satisfying component was interaction. Interaction can be considered an important attribute for professional satisfaction because of the nurses' job of working in a multidisciplinary team, in which interpersonal relationships with other workers, patients and family members are constant. The work organization and in particular some specific sectors prioritize this component due to the requirement of greater ability for relations and communication in the team, which favors accomplishing certain activities and the well-being of these workers (14)(15) , as well as exercising autonomy for the sake of collaboration when faced with decision-making, also favoring patient care and safety (18) .
Thus, a stimulus to the nursing team in the interaction with other professionals is perceived as necessary in order to strengthen exercising autonomy and the interaction itself, so that dialogue with staff and managers is favored and decision-making is shared in order to benefit work satisfaction and thus avoid moral distress.
Thus, from the analysis of the adjusted scores, it was identified that the Index of Work Satisfaction of nurses was 10.81, which refers to a low satisfaction index, but this is similar to other studies in the Brazilian scenario. It was observed that the Index of Work Satisfaction was 13.28 with newly admitted nurses and 10.95 with intensive care nurses, both also in public hospitals (14)(15)19) . These indices may be associated with environments which are not conducive to nursing practice, demonstrated by the fragility in organizational support and control over the environment (19) . This index in other scenarios (such as with www.ee.usp.br/reeusp Rev Esc Enferm USP · 2019;53:e03510 nurses from Australia and New Zealand) was much higher, reaching 31.86 (16) . Thus, the levels of work satisfaction may be associated with organizational aspects, in which low levels may suggest weaknesses in nursing care such as overload and stress, often identified as triggers of dissatisfaction in nursing work (20) ; aspects which also seem to be associated with the occurrence of moral distress among these workers.
In the analysis of moral distress, it was identified that the factor "lack of competence in the team" is what causes greater intensity of distress, while "insufficient working conditions" is the most frequent source of moral distress; on the one hand, this seems to be similar to low work satisfaction, and on the other hand (as observed in the study with intensive care nurses) an environment which is not conducive to practice decreases the level of satisfaction (19) .
The lack of competence observed in the work team refers to the insecurity felt by the professional when acting with other professionals of the nursing or health team or with support services considered unsafe due to the apparent lack of skill or technical competence, while "insufficient working conditions" are related to the precarious organization of work involving lack of material and personnel resources, with consequent work overload (21) . The "denial of the nurse's role as an advocate of the patients" involves situations in which the defense of the patient's rights is no longer performed by nursing; and "therapeutic obstinacy" involves the distress resulting from the performance of futile patient care (19)(20)(21)(22) .
It can be said that in all these factors -"lack of competence in the team", "insufficient working conditions", "denial of the nurse's role as an advocate of patients" and "therapeutic obstinacy" -moral distress occurs through obstruction in the moral deliberation process, from which the worker cannot follow the course of action which they consider most appropriate due to difficulties in exercising their autonomy and ethical-moral competence. This also impairs their moral integrity (4) and can consequently influence their level of work satisfaction.
Accordingly, it is possible to observe that all factors were inversely proportional in associating the factors of the two scales; in addition, other research has already pointed out an association between moral distress and a decrease in work satisfaction, highlighting the dissatisfaction both as a feeling and as a form of illness (4,(16)(17) . Dissatisfaction has been associated with moral distress in situations of organizing the work process (23) , being related to employee turnover, absenteeism, lack of autonomy, and the occurrence of ethical conflicts, which in turn have consequences on the work quality (4,7,16) .
Thus, new studies that search for strategies which can make nursing work environments healthier and that favor work satisfaction are considered important to avoid conflicts and the development of moral distress by workers through elements such as investment in improving knowledge about ethical issues and decision-making, improving understanding of one's beliefs and values and their interactions with diverse cultures, and support among colleagues and staff focused on better patient care (3) .
As a limitation of the study, transversal design is mentioned, which does not allow for inferring causality, but it demonstrates important results for the health of workers in the nursing area, since it contributes to fill gaps in the literature, as well as to demonstrate data from a university hospital at a particular moment in the transition of its management.

CONCLUSION
Similarities were observed between these two constructs in finding a low level of work satisfaction and moderate levels of intensity and frequency of moral distress, mainly because the component to which the nurses attributed greater satisfaction (the autonomy) can constitute an element which triggers moral distress when not exercised in their daily work. The non-possibility of exercising autonomy and resistance regarding conflicting situations, as observed in questions of greater intensity of moral distress, may lead nurses to experience it, since the majority agreed with the need to sometimes perform tasks that go against their best judgment. Faced with this aspect, an inverse relationship between work satisfaction and moral distress in nursing is revealed.
Thus, it is suggested to carry out new studies with different methodological approaches to deepen understanding and identify aspects associated with the intersection between these phenomena, looking for elements which can contribute to constructing environments and labor relations that favor ethical action, the exercise of autonomy and communication, and cooperation in the team.