CULTURAL ADAPTATION AND VALIDATION OF THE MORAL SENSITIVITY QUESTIONNAIRE AMONG BRAZILIAN NURSES

ADAPTACIÓN CULTURAL Y VALIDACIÓN DEL MORAL SENSITIVITY QUESTIONNAIRE PARA ENFERMEROS BRASILEÑOS

ABSTRACT

Objective:

cultural adaptation and validation of the Moral Sensitivity Questionnaire to assess moral sensitivity among Brazilian nurses.

Method:

methodological study with 106 nurses from two hospitals located in the south of Brazil. The instrument was culturally adapted according to international guidelines, following six steps: translation, reconciliation of translated versions, back translation, expert panel, pretest, and final review. The Brazilian version was validated in the Brazilian context using factor analysis and Cronbach’s alpha.

Results:

after the expert panel’s assessment, pretest, and verification of face and content validity, the instrument was considered satisfactory to be applied among Brazilian nurses. Six constructs were identified: Respect for patients’ autonomy, modified autonomy, experiencing moral conflict, having confidence in medical and nursing knowledge, structuring moral meanings, and teamwork. The instrument presented satisfactory internal consistency, with a Cronbach’s alpha equal to 0.62; the Cronbach’s alpha of the six constructs ranged from 0.60 to 0.67.

Conclusion:

the Brazilian version of the Moral Sensitivity Questionnaire is valid and reliable to be applied among Brazilian nurses and can improve understanding of factors involving decision-making when facing ethical conflicts.

DESCRIPTORS:
Validation study; Ethics; Moral; Nursing care; Nursing; Nursing team

RESUMEN

Objetivo:

adaptar culturalmente y validar el Moral Sensitivity Questionnaire para evaluación de la sensibilidad moral en enfermeros brasileños.

Método:

estudio metodológico, realizado en 106 enfermeros de dos hospitales, en el sur de Brasil. Fue realizada la adaptación cultural del instrumento según recomendaciones internacionales, siguiendo seis etapas: traducción; resumen de las traducciones; back translation; comité de especialistas; pretest; y, revisión final por los investigadores. La validación para utilización en el contexto brasileño se realizó por medio del análisis factorial Alfa de Cronbach.

Resultados:

después de los procedimientos de evaluación por el comité de especialistas, pretest, validez aparente y de contenido, el instrumento fue considerado satisfactorio para aplicación en enfermeros brasileños. Fueron identificados seis constructos: respeto a la autonomía del paciente; autonomía modificada; experimentando conflicto moral; confianza en el conocimiento médico y de enfermería; significado estructural moral; y, trabajo en equipo. El instrumento presentó consistencia interna satisfactoria, con Alfa de Cronbach 0,62; los seis constructos variaron entre 0,60 y 0,67.

Conclusión:

el Moral Sensitivity Questionnaire, en su versión brasileña, es un instrumento válido y confiable para ser aplicado por enfermeros brasileños y podrá contribuir para la comprensión de factores que participan en la toma de decisiones delante de conflictos éticos.

DESCRIPTORES:
Estudio de validación; Ética; Moral; Cuidados de enfermería; Enfermería; Grupo de enfermería

RESUMO

Objetivo:

adaptar culturalmente e validar o Moral Sensitivity Questionnaire para avaliação da sensibilidade moral em enfermeiros brasileiros.

Método:

estudo metodológico, realizado com 106 enfermeiros de dois hospitais do Sul do Brasil. Foi realizada adaptação cultural do instrumento segundo recomendações internacionais, seguindo seis fases: primeira tradução; resumo das traduções; back translation; comitê de especialistas; pré-teste; revisão final pelos pesquisadores; e, por fim, a sua validação para utilização no contexto brasileiro por meio de análise fatorial e alfa de Cronbach.

Resultados:

após procedimentos de avaliação pelo comitê de especialistas, pré-teste, validade de face e conteúdo, o instrumento foi considerado satisfatório para aplicação em enfermeiros brasileiros. Foram identificados seis constructos: respeito à autonomia do paciente; autonomia modificada; experimentando conflito moral; confiança no conhecimento médico e de enfermagem; significado estrutural moral; e trabalho em equipe. O instrumento apresentou consistência interna satisfatória, com alfa de Cronbach 0,62 e os seis constructos variaram entre 0,60 a 0,67.

Conclusão:

o Moral Sensitivity Questionnaire, em sua versão brasileira, é um instrumento válido e confiável para sua aplicação em enfermeiros brasileiros e poderá contribuir para a compreensão de fatores que envolvem a tomada de decisão diante dos conflitos éticos.

DESCRITORES:
Estudos de validação; Ética; Moral; Cuidados de enfermagem; Enfermagem; Equipe de enfermagem

INTRODUCTION

Moral sensitivity includes an individual’s experiences and personal development along with others’ experiences. It is constantly changing and developing throughout one’s professional life.1 Moral sensitivity is considered an ability of nurses to recognize good and evil concepts when providing care to patients. Nurses should be aware of ethical events and situations involving patients, acknowledging their responsibility when dealing with ethical problems.2

Ethical conflicts are frequent in nursing practice and accrue from situations that concern patients, multidisciplinary teams, or the work organization itself. Conflicts may also occur due to miscommunication within the staff, insufficient knowledge of workers, or different aspects that permeate the care delivery routine.3 When experiencing ethical conflicts during daily practice, nurses are required to make decisions, especially when a patient is in a vulnerable situation. Moral sensitivity in this context is a personal attribute that is necessary to deal with conflicts and understand the consequences of decision-making.4

Brazilian studies reveal that a lack of structure, material resources, and insufficient staffing are the primary causes of nursing workers experiencing conflicts within health settings. These are routine situations that hinder the work and prevent the delivery of integral care.5^-6 Workers with a greater sensitivity to perceive moral conflicts, i.e., greater moral sensitivity, experience moral distress when facing ethical problems but are prevented from acting according to what they considered to be ethically sound.7^-8

Therefore, nursing workers need to be prepared to face ethical conflicts, and one of the factors that need to be developed is moral sensitivity. Moral sensitivity supports workers in making ethical decisions to benefit patients, despite barriers imposed to care delivery.9 One Brazilian study addressing nurses from the south reveals that some factors such as taking part in courses addressing ethics, communication, teamwork, professional autonomy, and knowledge, is essential to help workers recognize and deal with ethical situations.10

International studies addressing moral sensitivity within the nursing field are abundant,1^-3 but few studies are found in the Brazilian context.4^,10 Given the relevance of decision-making when nurses face moral conflicts, and a recognition of the role of moral sensitivity in this process, the use of instruments able to measure moral sensitivity among nurses, is essential to improve the quality of care delivery and strengthen the ethical dimension.

The Moral Sensitivity Questionnaire (MSQ) was designed for quantitative studies to measure moral sensitivity in the nursing practice. It was developed and validated in Sweden, and its original version comprises questions distributed into six dimensions: interpersonal orientation, structuring moral meaning, expressing benevolence, modifying autonomy, and having confidence in medical knowledge.4

Given the previous discussion, this study is justified by the need to adapt an instrument to measure moral sensitivity in the Brazilian context, considering nurses deal with ethical problems within their professional practice. Having an adapted instrument can enable the identification of knowledge and improve the ethical dimension of nursing workers. Therefore, this study’s objective was to culturally adapt and validate the Moral Sensitivity Questionnaire among Brazilian nurses.

METHOD

This methodological study11 followed the international literature stages to culturally adapt the MSQ among Brazilian nurses.10 The author of the original instrument authorized its cultural adaptation. Ethical aspects are in accordance with the recommendations of Resolution 466/12, Brazilian National Council of Health, and the local Institutional Review Board approved the study.

The MSQ comprises 30 questions distributed into six dimensions: interpersonal orientation, structuring moral meaning, expressing benevolence, modifying autonomy, and having confidence in medical knowledge.4 The MSQ was designed to measure moral sensitivity among nurses, physicians, and students. This self-report instrument is rated on a seven-point Likert scale, ranging from 1, “completely disagree” to 7, “completely agree”.4

The MSQ was culturally adapted according to international recommendations guiding the cultural adaptation of instruments, which comprises six stages.11 These stages are intended to completely adapt the original version of instruments, namely: translation, reconciliation of translations, back translation, expert panel, pretest, and researchers’ final review.

First, two independent translators translated the instrument from English to Portuguese. One translator was already familiar with the literature in the health field. The other translator was not familiar with literature in the health field and was not informed about the study’s objective.11 The two versions were reconciled, and two other professionals back-translated the reconciled version into English.11

An expert committee appraised the back-translated version. Five professors working with ethics in the nursing field and affiliated to three public universities located in the south of Brazil independently assessed the instrument considering its concepts, redaction, comprehension level, and face validity. All the experts approved its use in research.11

The adapted version approved by the expert panel was applied to Master’s and doctoral students attending a public university’s nursing program. The items addressing moral sensitivity were verified in this pretest to ensure the instrument’s content validity.

The questionnaire was individually applied so that each participant could contribute to the study, reporting potential difficulties, strengths, the time necessary to complete the instrument, and providing suggestions.11After implementing all the procedures required to culturally adapt an instrument, the MSQ’s Brazilian final version was approved to be used among Brazilian nurses to validate its constructs and measure these workers' moral sensitivity.

The Instrument’s Brazilian version was applied among nurses from two hospitals located in the south of Brazil; a public university hospital (H1) exclusively providing care to patients covered by the Brazilian Unified Health System (SUS), and a philanthropic hospital (H2) providing care to patients paying for the treatment or covered by the SUS or a health insurance plan. The participants were recruited according to a non-probabilistic sampling. A convenience sample was composed of nurses present at the time and place of data collection and willing to participate.12

Sample size was determined with a specific tool in the Epi Info (version 7.2), considering a reliability level of 0.05%.13 The total population was composed of 141 nurses and a minimum of 106 participants was estimated.

The questionnaires were first applied in the public hospital (H1) and later in the philanthropic hospital (H2). Regardless of the work shift, each participant received an unidentified envelope with the questionnaire, which was returned later. Data collection took approximately six weeks, between August and September 2016. A total of 120 questionnaires were distributed, 60 in each hospital. A total of 47 fully answered questionnaires were returned in H1, and 59 were returned in H2, totaling 106 completed questionnaires.

After data were collected, statistical tests were performed using SPSS (Statistical Package for Social Sciences) version 22.0 to ensure the validation of the instrument’s construct. The factor analysis and Cronbach’s alpha showed that the MSQ’s Brazilian version measured the participant nurses’ moral sensitivity clearly and reliably.12

Exploratory factor analysis was used to group the constructs and later data were summarized; common factors were found among the questions. The instrument’s reliability was verified with Cronbach’s alpha, assessing the characteristics of each group of questions, and analyzing whether the questions included in the questionnaires measured the phenomenon consistently.

The principal component analysis was used as an extraction method, applying Varimax orthogonal rotation to better discriminate the variables’ pertinence to the components identified. The constructs obeyed two factors: the degree of association between the variables, found through factor loading (> 500), and subjectivity degree, that is, compliance to the theoretical framework and coherence with the factor’s remaining questions.

RESULTS

Regarding face validity, the expert panel reached a consensus in all the items, considering them pertinent and reporting their semantic, cultural, idiomatic, and conceptual equivalence. All the items were clearly formulated and understood and required only a few changes in some questions’ redaction.

The Likert scale was slightly changed, i.e., it was reduced from seven to five points to decrease the dispersion of information due to sample size. The scale now reads: 1 “Totally disagree”, 2 “Disagree more than agree”, 3 “neither disagree nor agree”, 4 “Agree more than disagree”, and “Totally agree”.

Content validity was verified with a pretest applied to 21 graduate nursing students from the Master’s and doctoral programs. The pretest confirmed the items measured the moral sensitivity construct. No changes were required, and the participants took from 8 to 30 minutes to complete it.

The culturally adapted and validated version was applied in the sample selected to verify its construct validity and measure moral sensitivity. Regarding the sample’s socio-demographic data: 106 nurses participated, 97 (91.5%) were women, and nine (8.5%) were men, aged between 24 and 64.

Of the 106 participants, 49 (46.2%) had a bachelor’s degree in nursing, 39 (36.7%) had a specialization or residency, 17 (16%) had a Master’s degree, and only one participant (0.93%) had a doctoral degree. Professional experience ranged from one month to 34 years; 9.3 years on average (SD 8.8).

In terms of construct validity, the 30 questions were submitted to exploratory factor analysis (between blocs). Eleven constructs emerged from the first analysis, which hindered categorization according to the theoretical framework. Hence, the questions with low correlations between blocs were removed, which enabled the remaining questions' grouping. The cutoff point considered for composing the constructs was factor loadings below 0.500.

After the analysis, 12 questions were excluded from the instrument due to low factor loadings, and six constructs were generated, explaining 62.50% of the variation in the original questions. It ensures an adequate degree of data synthesizing and facilitates interpretation and management. The Cronbach’s alpha confirmed the six constructs' reliability, which ranged from 0.60 to 0.67; the instrument’s alpha was equal to 0.62, which is acceptable for exploratory studies.

The questions that integrate the instrument are divided into six constructs. The first Respecting patients’ autonomy comprises q7 (Eu acredito que um bom cuidado de enfermagem sempre inclui o respeito às escolhas pessoais do paciente) [I believe that good nursing care always involves respect for patients’ personal choices], q22 (Acredito que a boa assistência de enfermagem inclua a participação do paciente) [I believe that good nursing care includes patients’ participation], q25 (Acho difícil prestar um bom cuidado de enfermagem contra a vontade do paciente) [I think it is difficult to provide good nursing care against a patient’s will], q6 (Quando eu tenho que tomar decisões difíceis em relação ao meu paciente, é importante que eu sempre seja honesto com ele) [When I have to make difficult decisions concerning a patient, it is important to always be honest with him/her]. Modified autonomy includes q15 (Eu baseio minhas decisões no conhecimento profissional relativo ao que é melhor para o paciente mesmo que ele proteste) [I ground my decisions on professional knowledge, considering what is best for patients, even if they protest], q4 (Quando é preciso tomar uma decisão que vá contra a vontade de um paciente, eu falo de acordo com o que acredito ser o melhor para ele) [When a decision that goes against a patient’s will is needed, I speak according to what I believe is best for him/her].

The Experiencing moral conflict construct, q11 (Eu frequentemente enfrento situações em que é difícil saber qual ação é eticamente correta para o paciente) [I often face situations in which it is difficult to know what is the action ethically sound for a patient], q9 (Frequentemente enfrento situações de conflito sobre como abordar um paciente) [I often face conflict situations on how to approach patients], q14 (Frequentemente enfrento situações em que é difícil permitir que o paciente possa fazer suas próprias escolhas) [I often face situations in which it is difficult to allow patients to make their own choices]. The Having confidence in medical and nursing knowledge construct is composed of the questions q28 (Eu confio em minhas próprias emoções quando tenho que tomar uma decisão difícil para o paciente) [I trust my emotions when I have to make a difficult decision for a patient] q26 (Existem situações em que há boas razões para intimidar um paciente com uma injeção caso a medicação oral seja recusada) [There are situations in which there are good reasons for threatening a patient with an injection in case oral medication is refused], q20 (Minha experiência prática é mais útil do que o conhecimento teórico em situações em que é preciso escolher sobre o que é eticamente correto) [My practical experience is more useful than theoretical knowledge in situations in which I need to choose what is ethically correct].

The Structuring moral meaning construct is composed of three questions, q10 (Eu acredito ser importante ter princípios sólidos sobre o cuidado de enfermagem prestado a pacientes) [I believe it is important to have solid principles regarding the nursing care provided to patients], q5 (Se eu perdesse a confiança de meu paciente, meu trabalho teria menos significado) [If I lost a patient’s trust, my work would lose meaning], and q18 (É a reação do paciente que me mostra o quanto tomei a decisão correta) [It is the patients’ responses that show me I made the right decision]. And finally, Teamwork has two questions, q27 (Em situações em que é difícil saber o que é eticamente adequado, eu consulto meus colegas sobre o que deve ser feito) [In situations in which it is difficult to know what is ethically appropriate, I consult with my colleagues about what should be done], and q17 (Eu confio no conhecimento de outros colegas quando não tenho certeza no que fazer) [I trust my colleagues’ knowledge when I am not sure what to do].

The factor loadings of each construct are presented in Table 1, according to factors’ formation, explained variance, and Cronbach’s alpha.

Table 1 -
Exploratory Factor Analysis (Varimax Rotation). Rio Grande, RS, Brazil, 2016. (n=106)

Indicators	Bloc	F1	F2	F3	F4	F5	F6
1. Respect for patients’ autonomy
q7	0.659	0.774	-0.057	-0.049	0.137	0.186	-0.026
q22	0.593	0.710	-0.067	0.210	-0.066	0.032	0.189
q25	0.549	0.678	-0.253	0.044	-0.148	-0.034	-0.007
q6	0.639	0.617	0.293	-0.209	-0.139	0.331	0.004
2. Modified autonomy
q15	0.754	-0.079	-0.830	0.173	0.045	0.140	0.083
q4	0.628	-0.172	0.687	-0.144	0.326	0.011	-0.017
3. Experiencing moral conflict
q11	0.720	0.111	0.013	0.834	-0.054	-0.096	0.012
q9	0.664	-0.076	0.155	0.756	0.177	0.138	-0.108
q14	0.0665	0.135	0.542	0.526	-0.244	-0.021	0.126
4. Having confidence in medical and nursing knowledge
q28	0.685	-0.024	0.207	-0.093	0.788	-0.009	0.105
q26	0.589	-0.045	0.110	0.027	0.614	-0.067	0.304
q20	0.531	-0.050	0.065	0.373	0.509	-0.010	-0.161
5. Structuring moral meaning
q10	0.668	0.217	0.100	-0.055	0.153	0.762	-0.056
q5	0.649	0.086	0.009	-0.007	-0.255	0.759	-0.028
q18	0.569	-0.003	-0.115	0.134	0.027	0.608	0.410
6. Teamwork
q27	0.668	0.242	0.022	-0.021	-0.036	0.006	0.779
q17	0.696	-0.122	-0.002	-0.106	0.318	0.073	0.751
% variance explained - rotated (62.50%)		16.383	14.166	10.995	8.277	6.840	5.844
Cronbach’s alpha (instrument: 0.623)		0.666	0.673	0.646	0.642	0.617	0.597
(*KMO=0.609)
Bartlett’s test: Chi-square= 422.467

• *Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy, F1 to F6: constructs

Like the original instrument, the adapted version presented six constructs. These constructs are composed of 18 items: Respect for patients’ autonomy (4 items); modified autonomy (3 items); experiencing moral conflict (3 items); having confidence in medical and nursing knowledge (3 items); structuring moral meaning (3 items); and teamwork (2 items). The constructs and respective meanings adopted in this study are presented in Chart 1.

Chart 1 -
Definition of the moral sensitivity constructs according to factor analysis - Rio Grande, RS, Brazil, 2016.

Construct	Definition
Respect for patients’ autonomy	Establishing a trusting relationship with patients to meet their needs.4
Modified autonomy	It refers to professionals’ decision-making, restricting a patient’s autonomy to protect a patient or others.14
Experiencing moral conflict	To express moral sensitivity in action, one needs to identify moral conflicts using intuition and perception.4
Having confidence in medical and nursing knowledge	It is a conviction that multidisciplinary knowledge is necessary when facing ethical conflicts.4
Structuring moral meaning	Refers to ways to derive moral meaning from decisions and actions aiming at the wellbeing of patients.15
Teamwork	It refers to the exchange of concepts, theories, practices between the different workers in the health staff, intending to connect different types of knowledge for the best care of patients.16

DISCUSSION

The factors involved in nurses’ moral sensitivity can provide important information regarding decision-making processes when dealing with ethical conflicts, favoring the delivery of integral care, and the development of strategies to deal with conflicts within healthcare settings.4 Therefore, the Brazilian validated version can support greater understanding regarding moral sensitivity.

The results showed that the MSQ’s adapted version is composed of six constructs, which, when compared with the original instrument's constructs, present some differences concerning the structure of results. The formation of six constructs and the instrument in general theoretically adheres to the literature addressing moral sensitivity. This Brazilian version is the first to be made available in Portuguese for hospital nurses.

The original MSQ comprises 30 questions validated in six constructs: interpersonal orientation, structuring moral meaning, expressing benevolence, modified autonomy, experiencing moral conflict, and knowledge in medical and nursing knowledge.4 The Brazilian version comprises18 questions validated in six constructs: respect for patients’ autonomy, modified autonomy, experiencing moral conflict, having knowledge in medical and nursing knowledge, structuring moral meaning, and teamwork.

The first construct of the Brazilian version had its name changed to Respect for patients’ autonomy. The name of this construct in the original version is interpersonal orientation. The four questions in this construct address decision-making and “good” nursing care, making it clear that respect for patients’ autonomy is essential in both cases.

This construct was pertinent and showed that free decision-making allied with respect for patients’ autonomy is indispensable in this context. It became clear that, within the healthcare field, patients are entitled to either accept or refuse therapeutic procedures proposed by healthcare workers.17

In this context, nurses can seek elements that facilitate bonding, interactions and care actions intended to advocate for the patients’ autonomy.18 Autonomy, a right of every human being, is expressed in the ability to act and make decisions that are based on one’s values, considering what is best for oneself.19

The modified autonomy construct appeared directly related to its equivalent subscale in the original MSQ. It maintains the original subscale's name and presents questions that involve decision-making, mainly when nurses act according to what they believe to be best, even if they have to act against a patient’s will.4

As a health staff member, nurses have specific characteristics that facilitate actions and interactions with the multi-professional team and patients and their families, grounding their care practice on humanization and the profession’s ethical principles.20 However, there are certain situations in which, even being aware of a patient’s rights and will, nurses are supposed to comply with the standards imposed in the work environment.20

The experiencing moral conflict construct showed that the validated items are equivalent to the original instrument items, except for two questions that were excluded due to low factor loadings. This construct’s items concern the high frequency in which nurses face moral conflicts in their work routine and difficulties identifying how to act appropriately. The literature confirms the consistency of this construct considering that moral conflicts are constant in professional practice.21

Moral distress is part of many health workers’ practice and is mainly related to structural conditions and the scarcity of human and material resources, causing many workers to feel demotivated, discouraged, anguished, or impotent. On the other hand, moral distress also leads to the development of coping mechanisms such as dialoguing and sharing difficult situations with team members, favoring approximation among these professionals.22

Having confidence in medical and nursing knowledge also maintained the same name given to its equivalent subscale in the original questionnaire. It addresses the importance of the knowledge and opinion of multi-disciplinary teams when facing a conflict situation in which it is difficult to identify the ethically sound solution.23

The multidisciplinary work presents numerous challenges, and some problems emerge regarding communication, interpersonal relationships, work overload, and the fact that some professions are underappreciated, among others. However, it is vital to trust the team and jointly make decisions when facing ethical conflicts.24

Structuring moral meaning maintained the name of its equivalent subscale in the original version. It comprises three questions concerning the loss of meaning of nursing work when a patient’s trust is lost, i.e., when nurses realize that a given decision was not the best. In some cases, workers need to perceive small details, read between the lines, but only intuition will show whether a choice is the right one.25

Finally, the teamwork construct focuses on the critical role of multi-disciplinary teams within health services. Its questions make it clear that relying on other professionals is a common practice, and exchanging knowledge results in improved care delivery, whether workers share responsibilities or help solve conflicts when decision-making is always a challenge.26

Concerning the instrument’s reliability, the results revealed parameters that are expected for exploratory studies, especially when compared to the validation of the original instrument. Therefore, the validated Brazilian version is reliable and can be used in future research.4 The Cronbach’s alpha of the MSQ Brazilian Version was equal to 0.62, while the coefficients of the six constructs ranged between 0.60 and 0.67, acceptable for exploratory studies.

This study’s limitations include the fact it addresses the specific population of nurses working in two hospitals in one Brazilian region. Thus, other researchers are suggested to apply this instrument among nurses experiencing other contexts, verifying different situations that may affect these professionals’ moral sensitivity, and compare to the results presented here.

CONCLUSION

This study’s results show that the Brazilian version of the Moral Sensitivity Questionnaire can contribute to a better understanding of factors that involve decision-making in the face of ethical conflicts. The instrument showed to be valid and reliable to be applied among Brazilian nurses. Factor analysis identified six constructs that explain moral sensitivity as an element that supports ethical decision-making when facing conflicts.

REFERENCES

• 1. Bayakara ZG, Demir SG, Yaman S. The effect of ethics training on students recognizing ethical violations and developing moral sensitivity. Nurs Ethics [Internet]. 2015 [cited 2019 Mar 20];22(6):661-75. Available from: http://journals.sagepub.com/doi/pdf/10.1177/0969733014542673
  » http://journals.sagepub.com/doi/pdf/10.1177/0969733014542673
• 2. Boonyamanee B, Suttharangsee W, Chaowalit A, Parker ME. Exploring moral sensitivity among Thai psychiatric nurses. Songklanagarind J Nurs [Internet]. 2014 [cited 2019 Mar 20];34:35-43. Available from: http://www.nur.psu.ac.th/journal/file/98file2733.pdf
  » http://www.nur.psu.ac.th/journal/file/98file2733.pdf
• 3. Yildirim SKG, Ozden D, Çinar Z. Moral distress in Turkishintensive care nurses. Nursing Ethics [Internet]. 2017 [cited 2019 Mar 20];24(2):209-224. Available from: https://journals.sagepub.com/doi/pdf/10.1177/0969733015593408
  » https://journals.sagepub.com/doi/pdf/10.1177/0969733015593408
• 4. Nora CRD, Zoboli ELCP, Vieira MM. Moral sensitivity in primary health care nurses. Rev Bras Enferm [Internet]. 2017 [cited 2019 Mar 20];70(2):308-16. Available from: http://www.scielo.br/pdf/reben/v70n2/pt_0034-7167-reben-70-02-0308.pdf
  » http://www.scielo.br/pdf/reben/v70n2/pt_0034-7167-reben-70-02-0308.pdf
• 5. Luz KR, Vargas MAO, Schmidtt, PH, Barlem ELD, Tomaschewski-Barlem JG, Rosa LM. Ethical problems experienced by oncology nurses. Rev Latino-Am Enfermagem [Internet]. 2015 [cited 2019 Mar 20];23(6):1187-94. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692015000601187
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692015000601187
• 6. Oliveira MAN, Rosa DOS. Conflicts and ethical dilemmas experienced by nurses in peri operative care. Science Care and Health [Internet]. 2015 [cited 2019 Mar 15];14(2):1149-56. Available from: http://periodicos.uem.br/ojs/index.php/cienccuidsaude/article/view/19423/14709
  » http://periodicos.uem.br/ojs/index.php/cienccuidsaude/article/view/19423/14709
• 7. Ramos FRS, Vargas MAO, Schneider DG, Barlem ELD, Scapin SQ, Schneider AMM. Ethical conflict as a trigger for moral suffering: survey of Brazilian nurses. Rev Enferm UERJ [Internet]. 2017 [cited 2019 Mar 20];25:e22646. Available from: https://doi.org/10.12957/reuerj.2017.22646
  » https://doi.org/10.12957/reuerj.2017.22646
• 8. Schaefer R, Zoboli ELCP, Vieira M. Moral distress in nurses: a description of the risks for professionals. Texto Contexto Enferm [Internet]. 2018 [cited 2019 Mar 20];27(4):e4020017. Available from: http://www.scielo.br/pdf/tce/v27n4/0104-0707-tce-27-04-e4020017.pdf
  » http://www.scielo.br/pdf/tce/v27n4/0104-0707-tce-27-04-e4020017.pdf
• 9. Nora CRD, Zoboli ELCP, Vieira M. Ethical problems experienced by nurses in primary health care: integrative literature review. Rev. Gaúcha Enferm [Internet]. 2015 [cited 2019 Mar 20];36(1):112-21. Available from: http://www.scielo.br/pdf/rgenf/v36n1/pt_1983-1447-rgenf-36-01-00112.pdf
  » http://www.scielo.br/pdf/rgenf/v36n1/pt_1983-1447-rgenf-36-01-00112.pdf
• 10. Schallenberger CD, Tomaschewski-Barlem JG, Barlem ELD, Rocha LP, Dalmolin GD, Pereira LA. Moral sensitivity components identified among nurses from Intensive Care Units. Rev Bras Enferm [Internet]. 2019 [cited 2019 Mar 20];2(Suppl 10):4-11. Available from: http://www.scielo.br/pdf/reben/v72s1/pt_0034-7167-reben-72-s1-0002.pdf
  » http://www.scielo.br/pdf/reben/v72s1/pt_0034-7167-reben-72-s1-0002.pdf
• 11. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of crosscultural adaptation of self-report measures. Spine [Internet]. 2000 [cited 2019 Mar 20];25(24):3186-91. Available from: https://www.researchgate.net/publication/12203631_guidelines_for_the_process_of_cross-cultural_adaption_of_self-report_measures
  » https://www.researchgate.net/publication/12203631_guidelines_for_the_process_of_cross-cultural_adaption_of_self-report_measures
• 12. Cohn EG, Jia H, Larson E. Evaluation of statistical approaches in quantitative nursing research. Clin Nurs Res [Internet]. 2009 [cited 2019 Mar 20];18(3):223-41. Available from: http://journals.sagepub.com/doi/pdf/10.1177/1054773809336096
  » http://journals.sagepub.com/doi/pdf/10.1177/1054773809336096
• 13. Hill MM, Hill A. Investigação por questionário. Lisboa (PT): Editora Sílabo; 2012.
• 14. Lútzen K, Nordin C. Modifying autonomy - a concept grounded in nurses’ experiences of moral decision making in psychiatric practice. J Med Ethics [Internet]. 1994 [cited 2019 Mar 20];20:101-7. Available from: https://doi.org/10.1136/jme.20.2.101
  » https://doi.org/10.1136/jme.20.2.101
• 15. Han SS, Kim J, Kim YS, Ahn S. Validation of a Korean version of the moral sensitivity questionnaire. Nurs Ethics [Internet]. 2010 [cited 2019 Mar 20];17(1):99-105. Available from: https://doi.org/10.1177/0969733009349993
  » https://doi.org/10.1177/0969733009349993
• 16. Backes DS, Carpes AD, Piovesan C, Haeffner LSB, Büscher A, Lomba L. Multi-professional teamwork in health: from conception to the challenge of its practice. Disciplinarum Scientia Sér Ciênc Saúde [Internet]. 2014 [cited 2019 Mar 20];15(2):277-89. Available from: https://www.periodicos.unifra.br/index.php/disciplinarums/article/viewfile/1093/1037
  » https://www.periodicos.unifra.br/index.php/disciplinarums/article/viewfile/1093/1037
• 17. Lima MLF, Rego STA, Siqueira-Batista R. Decision-making process in end-of-life care. Rev Bioét [Internet]. 2015 [cited 2019 Mar 20] 23(1):31-9. Available from: https://doi.org/10.1590/1983-80422015231043
  » https://doi.org/10.1590/1983-80422015231043
• 18. Felix ZC, Batista PSS, Costa SFG, Lopes MEL, Oliveira RC, Abrão FMS. Nursing care in terminality: compliance with principles of bioethics. Rev Gaúcha Enferm [Internet]. 2014 [cited 2019 Mar 20];35(3):97-102 Available from: https://doi.org/10.1590/1983-1447.2014.03.46405
  » https://doi.org/10.1590/1983-1447.2014.03.46405
• 19. Valcarenghi RV, Lourenço LFL, Siewert JS, Alvarez AM. Nursing scientific production on health promotion, chronic condition, and aging. Rev Bras Enferm [Internet]. 2015 [cited 2019 Mar 20];68(4):618-25. Available from: https://doi.org/10.1590/0034-7167.2015680419i
  » https://doi.org/10.1590/0034-7167.2015680419i
• 20. Gaspar RB, Silva MMda, Zepeda KGM, Silva IR. Nurses defending the autonomy of the elderly at the end of life. Rev Bras Enferm [Internet]. 2019 [cited 2019 Mar 20];72(6):1639-45. Available from: https://doi.org/10.1590/0034-7167-2018-0768
  » https://doi.org/10.1590/0034-7167-2018-0768
• 21. Oliveira MAN, Rosa DOS. Conflitos e dilemas éticos vivenciados pelo enfermeiro no cuidado perioperatório. Ciênc Cuid Saúde [Internet]. 2015 [cited 2019 Mar 20];14(2):1149-56. Available from: https://doi.org/10.4025/cienccuidsaude.v14i2.19423
  » https://doi.org/10.4025/cienccuidsaude.v14i2.19423
• 22. Oliveira CA, Oliveira DCP, Cardoso EM, Aragão ES, Bittencourt MN. Sofrimento moral de profissionais de enfermagem em um centro de Atenção psicossocial. Ciênc Saúde Coletiva [Internet]. 2020 [cited 2019 Mar 20];25(1):191-8. Available from: https://doi.org/10.1590/1413-81232020251.29132019
  » https://doi.org/10.1590/1413-81232020251.29132019
• 23. Caetano PS, Feltrin JO, Soratto J, Soratto MT. Nurse´s behavior in the wake of ethical and bioethical conflicts in the family heath strategy. Saúde e Pesquisa [Internet]. 2016 [cited 2019 Mar 20];9(2):349-60. Available from: https://doi.org/10.177651/1983-1870.2016v9n2p349-360
  » https://doi.org/10.177651/1983-1870.2016v9n2p349-360
• 24. Santos KCB, Diniz ASS, Nogueira JS, Rolim ILTP, Sardinha AHL. Comunicação e relacionamento interpessoal no centro cirúrgico: aplicação da metodologia da problematização. Rev. Elet Acervo Saúde [Internet]. 2019 [cited 2019 Mar 20];24:e698. Available from: https://doi.org/10.25248/reas.e698.2019
  » https://doi.org/10.25248/reas.e698.2019
• 25. Lútzen K, Nordin C. Structuring moral meaning in psychiatric nursing practice. Scand J Caring Sci [Internet]. 1993 [cited 2019 Mar 20];7:175-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8108620
  » https://www.ncbi.nlm.nih.gov/pubmed/8108620
• 26. Santos JLG, Lima MADS, Pestana AL, Colomé ICS, Erdmann AL. Strategies used by nurses to promote teamwork in an emergency room. Rev Gaúcha Enferm [Internet]. 2016 [cited 2019 Mar 20];37(1):e50178 Available from: https://doi.org/10.1590/1983-1447.2016.01.50178
  » https://doi.org/10.1590/1983-1447.2016.01.50178

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Moral Sensitivity among nurses facing ethical problems in hospital facilities, presented to the Programa de Pós-Graduação em Enfermagem, Universidade Federal do Rio Grande, in 2016.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of the Universidade Federal do Rio Grande, Opinion report N^o: 1631193, CAAE 56665016.5.0000.5324.

Publication Dates

• Publication in this collection
  05 May 2021
• Date of issue
  2021

History

• Received
  25 Sept 2019
• Accepted
  08 June 2020