Association between moral distress and supporting elements of moral deliberation in nurses

Objective: to identify the association between moral distress and the supporting elements of moral deliberation in Brazilian nurses. Method: a cross-sectional study conducted with Brazilian nurses working in health services at different complexity levels. The research protocol consisted of the Brazilian Scale of Moral Distress in Nurses, a sociodemographic and labor questionnaire, and a list of bases and ethical elements used for moral deliberation. For analysis, descriptive statistics, chi-square test, and Poisson regression were used. Results: 1,226 nurses took part in the study. The 12 elements associated with the moral deliberation process were classified as important for nurses’ actions, especially the professional experience acquired, code of ethics/law of professional practice, and ethical and bioethical principles. The relationship of moral distress showed higher prevalence in the Beliefs, culture and values of the patient, Beliefs and personal values, and Intuition and Subjectivity elements. Conclusion: the results showed a balance between the subjective criteria of professional experience and the objective ones of deontology for moral deliberation.


Introduction
Given the complexity of the health care system and care, nursing professionals can often face difficult situations related to structural, organizational and relational aspects among colleagues and in the professional-user relationship, during their work process. These situations involve ethical issues and require positions and deliberation, which evoke in the professionals feelings of uncertainty, discomfort and restlessness in the face of conflicts and divergences of opinions with those involved, including other professionals, patients and family members.
In this perspective, the professionals can experience moral distress, which, classified as a moral problem, occurs when they cannot conduct their action according to their judgments and personal and professional values, perceiving as inadequate their moral participation, that is, they feel powerless to act according to their conscience, either by internal or external constraints (1) .
In this sense, it can be said that moral distress is constituted from an obstruction in the process of moral deliberation, based on the individual experience and awareness about ethically appropriate conduct, that is, by interrupting the process of moral deliberation, it becomes inconclusive and fruitless because it has not reached the desired objective, producing feelings of impotence and inconvenience in the professional (2) .
It is noteworthy, therefore, that the process of moral distress is inversely related to the process of moral deliberation, since the latter refers to the ability to conduct a conflicting situation in a reasonable, prudent and achievable manner, considering the values and duties involved (3) .
The moral deliberation process is a systematic and contextualized itinerary of analysis of ethical problems to find concrete solutions, among prudent alternatives. This analysis is not abstract, but considers the circumstances of the act and the foreseeable consequences. The goal of deliberation is prudent courses of action. In clinical bioethics, prudence is expressed in the ability to value what is involved in the case, with a view to reasonable decisions (4) .
In the meantime, it can be said that the process of moral deliberation can constitute a tool for the ethical positioning of nurses in the face of perceived moral problems and conflicts (5) , as in situations that generate moral distress, since this has serious consequences for nursing workers, both in the personal dimension, with physical and emotional symptoms, and in the professional dimension, such as the development of burnout or even abandoning the profession (6) .
Among the factors that interfere in nurses' moral deliberation, which may also be related to the moral deliberation process, are professional experience and practice, confidence, intuition, use of protocols, collaboration with experienced colleagues, organizational culture, education, awareness of the situation and exercising the autonomy (7) .
When considering that the moral deliberation process can be influenced by several aspects, the present study is justified by the need to identify the supporting elements of this process, that is, what may be the factors and ethical skills that favor the conduct of reflection, dialog and prudent and responsible resolution of moral problems as in the case of moral distress (8) .
Thus, the objective was to identify the association between moral distress and the supporting elements of moral deliberation in Brazilian nurses.
The studies on moral distress in the field of nursing, especially in the last five years and also in Brazilian settings, have pointed out several generating situations or risk factors, strongly associated with the environment, including the structure and organization of the work process, as well as such as interpersonal relationships that are established (9)(10)(11)(12)(13) . After decades of studies, it is confirmed that the necessary and sufficient conditions to define moral suffering refer to the combination of the experience of a moral event and psychological suffering, in a direct causal relationship.
If, on the one hand, research studies emerge that show moral distress, the measurement instruments still require continuous reviews and improvements, just as it is essential to expand the discussions on the following: the impact of moral distress on the health professionals and the organizations (14) ; the "nebulosity", the limits of the concept and the elaboration of strategies to face it and the relationships with other concepts related to moral experience, such as power, moral courage, moral hazard/risk, moral sensitivity and moral deliberation in work and work and training scenarios (15)(16)(17) .
Thus, it is considered that identifying and discussing The data collection instrument comprised the Brazilian Scale of Moral Distress in Nurses (EDME-Br) (18) along with an item of sociodemographic and labor characterization of the participants, and a list of bases and ethical elements used for moral deliberation. For associating moral distress and bases and ethical elements, the chi-square test was used, in which the variables were dichotomized, that is, moral distress categorized as low (0 to 2.00) and moderate/high  Table 1.
It is observed that all the elements listed were  Finally, in Table 3, the multivariate analysis of the association between moral distress and the set of bases and elements for ethical action in the face of conflicts is submitted.
It was observed from Table 3, which in the gross regression all variables remain associated with moral distress, indicating that those who attach high importance to ethical components have higher prevalences of moral distress. To the adjusted regression, where all the elements were tested together, the variables "acquired professional experience" and "defense of the interests and needs of the patients" remained associated with moral distress, with a prevalence of 19% and 11% higher, respectively, compared with those who attach low importance to ethical elements.

Discussion
It was observed that all the supporting elements of moral deliberation were individually associated with moral distress, demonstrating a higher prevalence of moral distress in the groups that also attributed greater importance to the elements, which can be explained positively in the sense that nurses who recognize the importance of the elements, and probably use them, possibly has a moral sensitivity to perceive the moral problems and conflicts present in their daily work, applying them in an attempt to solve them.
Moral sensitivity can be understood as a personal competence that involves a contextual and intuitive aspect, configuring an essential dimension of the interrelational aspect of nursing care in the ethical decisionmaking process because it allows the individual to recognize moral conflicts and people in vulnerable situations, and be aware of its consequences and implications for the others (19) .
In the combined analysis of all the elements, only two variables remained associated, which indicated a 19% and 11% higher prevalence of moral distress, that is, professional experience and the defense of patients' interests and needs, respectively.
Professional experience and greater clinical practice can have an influence on moral deliberation in nursing because nurses with longer practice times have greater self-confidence, also relying on situations already experienced, in identifying patterns, as well as in collaboration with colleagues, to determine their decisions (7) .
It is also pointed out that, in ethical decisions, and judicious manner (20) . Still, when relating to moral distress, it is possible to highlight that nurses who use professional experience in the face of the deliberative processes, perceive conflicts and moral problems more clearly, suffering more.
In the same way as the element defending the interests and needs of patients, in which those who perceive conflicts seek to defend the rights of patients, www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2020;28:e3332.
exercising advocacy in nursing. Nursing advocacy has been described in different ways in the literature, both as a philosophical basis and in terms of conduct and actions to assist the patient in obtaining the necessary health care, and in protecting and defending the patient's rights to quality care (21) .
The moral distress linked to the practice of advocacy by nurses can be due to the established barriers, such as, for example, the organizational structure and culture of health services and the power relationships present in the multi-professional team, which often neglect the knowledge of nurses and discourage them from acting according to their consciences (22) . Differences in values and beliefs between those involved in the same situation can be a source of conflicts for them, which in the specificity of health institutions may be due to differences in perceptions, lack of material resources, lack of personnel, budget cuts, use of technologies, power relations, lack of autonomy, vulnerability of users, among others (23) .
In the case of uncertainty, this can be understood as a moral uncertainty, which is classified as a moral problem, which occurs when the professional does not know how to determine the correct course of action ethically, but is perceived in a discomfort, in a discomfort, presenting a sense that something is not adequate when following the established course of action, choosing not to seek clarification, it may be afraid of appearing inconvenient and unreasonable (1) .
Intuition in the processes of moral deliberation stems from the unconscious perception, often based on experience, but susceptible to bias and errors, as it does not involve conscious rationality and focuses the decision mainly on emotional aspects and feelings about the patient's condition, and not on a specific evidence.
Except when intuition is triggered in the identification of similar patterns or situations, in which this recognition is seen as conscious and favors the perception of important characteristics differences within a situation, better guiding the decision (7) .
Finally, in the descriptive analysis, when punctuating the importance attributed to the use of each of the elements for moral deliberation, professional experience (62.7%), ethical and bioethical principles (58.1%) and code of ethics stood out and professional practice law (58%) with high importance.
The code of ethics and the law of professional practice are the basic legislation for nurses to act, which together with ethical and bioethical principles, provide a rationality that overcomes intuition and uncertainty, helping professionals in the face of difficulties in solving problems and moral dilemmas (24) .