Moral suffering in nurses of inspection departments in Brazil

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.

Health care coordination and monitoring; Ethics, nursing; Ethics; Moral damage

Resumo

Objetivo

Identificar a frequência e a intensidade das causas de sofrimento moral vivenciado por enfermeiros nos departamentos de fiscalização do Brasil.

Métodos

Estudo transversal realizado com 28 profissionais de competência gerencial e 113 profissionais de competência fiscalizatória. A amostra foi intencional e não probabilística. Os dados foram obtidos por meio de questionário e submetidos à análise descritiva e bivariada.

Resultados

Os participantes revelaram causas do sofrimento moral em dois momentos: Primeiro associado ao processo de fiscalização lento por parte das instituições fiscalizadas e Corens; e insuficiência de recursos humanos. Segundo associado aos problemas éticos; condições de trabalho; e qualidade da assistência de enfermagem.

Conclusão

Refletir sobre as causas do sofrimento moral neste cenário é reconhecer a necessidade de algumas mudanças que devem acontecer na base que sustenta os preceitos éticos e condutas morais da profissão, para assim fortalecer a categoria.

Regulação e fiscalização em saúde; Ética em Enfermagem; Ética; Dano moral

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)

The 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)

In 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)

Moral 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. Thus, the healthcare work environment is a source of MS, which shows the seriousness of the situation and reinforces the importance of broadening the discussion of the subject.(⁵-⁷)

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.(8) 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 questions were answered using a five-point Likert scale. For frequency questions, 1 was used for “never”, 2 for “rarely”, 3 for “sometimes”, 4 for “often”, and 5 for “always.” In assessing intensity, the references were as follows: 1 for “no intensity,” 2 for “low intensity”, 3 for “intense”, 4 for “very intense”, and 5 for “maximum intensity”.

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.

The study was registered under the Plataforma Brasil under number Certificado de Apresentação para Apreciação Ética (CAAE): 20169313.1.0000.0121.

Results

Using consecutive collection strategies, the sample of participants included the following distribution of respondents (% of the sample): North region (inspectors 10.6% - 17.9% managers); Northeast region (inspectors 27.4% - 32.1% managers); Center-West region (inspectors 8.8% - 14.3% managers); Southeast region (inspectors 36.3% - 25% managers); and South region (inspector 16.8% - 10.7% managers).

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%).

With lower prevalence, and without posing a major impact on these professionals’ daily lives, insecurity or lack of support to notify was observed, with answers “never” (25.9%), “rarely” (40.7%), and “sometimes” (25.9%), and intensity between “no intensity” (26.9%) and “low intensity” (38.5%). The conflicting inspection process by Coren was expressed with frequencies “never” (23.1%), “rarely” (30.8%) and “sometimes” (34.6%), with intensity ranging from “no intensity” (22.2%), “low intensity” (40.7%), to “intense” (22.2%). Finally, regarding the lack of competence or commitment of the inspection team members, most participants stressed the frequencies “never” (18.5%), “rarely” (40.7%), and “sometimes” (25.9%), to which “low intensity” (34.6%) and “intense” (30.8%) were attributed.

The analysis of situations experienced by professionals of inspection competence showed that the main events in these professionals’ perception were related to the slow inspection process by the audited institutions, where responses are concentrated within “sometimes” (24.3%), “often” (38.7%) and “always” (19.8%), with intensities “intense” (25.9%), “very intense” (25.9%), and “maximum intensity” (23.1%). Other important situations involve the slow inspection process by Coren, in this case the most frequent responses were “sometimes” (33.9%), “often” (24.8%) and “always” (19.3%), and for intensity the responses emphasized were “intense” (23.6%), “very intense” (23.6%), and “maximum intensity” (26.4%), and the need to prioritize the institutions to be inspected by the shortage of human resources, with more frequent responses “sometimes” (24.1%), “often” (28.7%) and “always” (23.1%), and intensities of “intense” (22.9%), “very intense” (23.8%), and “maximum intensity” (21.9%).

There were situations, however, which were not relevant as an MS cause, such as the lack of competence or commitment of inspection team members, with responses “never” (38.4%) and “rarely” (37.5%), and importance ranging from “no intensity” (39.8%) to “low intensity” (24.1%), and the insecurity or lack of support to notify, with the predominance of responses “rarely” (36.6%) and “sometimes” (28.6%), with intensity attribution of “no intensity” (20.2%), “low intensity” (33.9%), and “intense” (19.3%).

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.

Figure 1
Subcategories that express moral suffering causes from everyday labor of professionals of managerial and inspection competence

Regarding the subcategories related to MS, the following causes were observed in the perception of managers and inspectors, as presented in chart 1.

Chart 1
Causes of moral suffering experienced in everyday work of professionals of managerial and inspection competence

Subcategories	Managers’ MS causes	Inspectors’ MS causes
Ethical issues	Inability to act against foul committed by an inspector; Reckless conduct related to the legal sector; Political interference in the activities of Corens; Lack of transparency of some councils; Unawareness of the councils work by some professionals of the institution (inspectors/managers); Lack of work autonomy; Authoritarian attitude of councilors; Conflicting or hostile situation with inspectors; Feeling of professional devaluation by Cofen.	Lack of transparency of some councils; Lack of transparency of some council professionals; Political interference in the activities of Corens; Impotence of leadership in solving internal conflicts; Disputes regarding the conduct of co-workers; the conduct of the nursing staff and the conduct of councilors; Oppressing management; Disrespect by nursing and health institutions’ professionals to fail to comply with what is established; Access denied in health institutions; Lack of autonomy in face of inspection demands; Impunity of public and private managers.
Quality of nursing care	Nurses’ actions not consistent with their role; Lack of commitment/knowledge of health institutions’ managers	Impotence in face of health institutions that do not commit to the safe exercise of nursing practice; Poor working conditions offered to nursing professionals; Ethical violations committed by nursing professionals due to circumstances/ political issues; Absence of 24-hour nurses; Health managers’ lack of commitment and knowledge; Difficulty in producing evidence in face of the harassment experienced by nursing professionals.
Work organization	Lack of referrals and agility of ethical processes by the legal area; Lack of legal support during activities; Lack of inspection activities standardization; Bureaucratic issues involving the inspection process.	Lack of inspection activities standardization; Lack of support/endorsement of the legal area of councils; Insufficient legal support in face of the diversity of situations faced in inspections; Solitary work during inspection activities; Lack of training.
Image of the Coren and Cofen system	Dissatisfaction of nursing professionals with Corens; Unawareness of the roles of Cofen/Corens system by nursing professionals.	Unawareness of the role of Cofen /Corens system by nursing professionals; Distorted and disrespectful attitude towards Cofen/Corens by health institutions and nursing professionals.
Work conditions	Dissatisfaction with workload (claim for 30 hours); Low pay and/or unequal pay among regions; Human and financial resources (mainly transport) insufficient to carry out inspection actions.	Lack of financial resources, materials and insufficient or inadequate human resources; Low pay; Dissatisfaction with workload (claim for maximum workload of 30 hours); Inadequate facilities; Work overload.

• MS - Moral suffering

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)

It 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)

In 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)

Some 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)

Results 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)

Regarding 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) The 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, professionals 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)

Issues related to professional competence were directly associated with lack of autonomy for both participant groups. This intense perception of lack of autonomy for managers and inspectors was tied to the challenges they face in making decisions, and the freedom to act according to their professional principles, as identified in international studies.(¹⁹-²¹) 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 directly 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. Therefore, moral distress takes over professionals, affecting their well-being, and therefore their work.(²³-²⁵)

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)

The 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.

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.

Acknowledgements

The Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq ) the PhD scholarship provided to Luciana RS author and productivity in research grant provided 1A level to Flavia RSR author.

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Publication Dates

• Publication in this collection
  Jul-Aug 2016

History

• Received
  20 May 2016
• Accepted
  29 Aug 2016