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On-line version ISSN 1518-8345
Rev. Latino-Am. Enfermagem vol.14 no.4 Ribeirão Preto July/Aug. 2006
Ethical events in nursing: daily activities of nurse managers and nursing ethics committee members1
Ocurrencias éticas de enfermería: el cotidiano de los enfermeros gerentes y miembros de la comisión de ética de enfermería
Genival Fernandes de FreitasI; Taka OguissoII; Miriam Aparecida Barbosa MerighiIII
This study aimed to understand the meaning of nurses' actions related to ethical occurrences involving nursing professionals. Data were collected through interviews with nurse managers and members of a Nursing Ethics Committee who experienced the phenomenon. Data were analyzed in the framework of social phenomenology. The nurses' experiences gave rise to the following categories of meaning, as these professionals seek: the humanization of nursing care; continuous improvement of the care process; professional credibility; patients' satisfaction; demystification of the fear of punishment; partnership in the educational process; respect for ethical secrecy and expectation related to the event being forwarded to the Nursing Ethics Committee. The social typification was described at the end. Nurses' actions in cases of ethical events attract the interest of nursing professionals, who want to ensure a risk or damage-free care and to promote the valuation of these professionals.
Descriptors: ethics, nursing; organization and administration; education, nursing; ethics
El objetivo de este estudio fue comprender el significado de las ocurrencias éticas involucrando a profesionales de enfermería. Los datos fueron obtenidos por medio de entrevistas con enfermeros gerentes y enfermeros miembros de la Comisión de Ética de Enfermería que pasaron por el fenómeno. Los datos fueron analizados según la perspectiva de la fenomenología social. Las experiencias de los enfermeros posibilitaron desvelar las siguientes categorías concretas del significado del vivido, pues ellos buscan: la humanización de la atención; la mejoría continua del proceso de cuidar, la credibilidad profesional; la satisfacción de la clientela; las demistificación del miedo de la punición, el compartir en el proceso educativo; el respeto al sigilo ético y la expectativa relacionada al posible envío de la ocurrencia a la Comisión de Ética. La tipificación fue descrita al final. Las acciones de los enfermeros en las ocurrencias éticas despiertan interés de los profesionales de enfermería, que desean garantizar una atención libre de riesgos/daños y promover la valorización de esos profesionales.
Descriptores: ética de enfermería; organización y administración; educación en enfermería; ética
Whether as nursing professionals, managers or faculty, every day, we are faced with ethical events. In these situations, we seek to get involved and discuss these occurrences with the respective professionals, whether in the Nursing Ethics Committee or at the clinic or unit where the event occurred, using the knowledge acquired throughout our professional training and activities. Thus, with a view to guaranteeing a nursing care free from risk or damage caused by negligence, lack of expertise or imprudence committed by nursing professionals, we believe it is fundamentally important to understand the world of ethical events, as well as ways of seeing and coping with them, based on the daily experience of these professionals as nurse managers (NM) or members of a Nursing Ethics Committee (NEC).
Ethical occurrences are harmful events caused by nursing professionals during their professional exercise and related to an inadequate attitude towards a colleague, client or the place of work. These events can entail some kind of harm or damage to clients or to the involved professionals themselves, whether due to a lack of attention, skill, knowledge, zeal or to omission, that is, when professionals do not act or do not do something they should and, thus, cause risk or damage to another person(1).
Nursing actions are intrinsically linked with professional accountability when they cause harm or damage to a patient/client. On the other hand, multiple factors can contribute to risks or damage in the care process. In this sense, when errors occur involving nursing professionals, greater emphasis is given to blaming the guilty one than to analyzing and improving the processes that resulted in those harmful events. Hence, out of fear of punishment, professionals are afraid of communicating errors and, consequently, opportunities to learn from their own errors may not be exploited(2).
Some researchers have investigated different dimensions of professionals' and health institutions' responsibility in cases of harmful events involving clients(1-2). However, these studies did not respond to our inquiries about nurses' motivations to act in relation to ethical occurrences in their daily reality, thus making impossible a better understanding of the meanings these professionals attribute to their actions in these events. Therefore, this research was justified by the need we felt to understand the phenomenon of ethical events in nursing, based on the experiences of nurse managers (NM) and nursing members (NE) of ethics committees, aimed at getting to know and understanding the meaning of nurses' actions in view of ethical events in nursing.
With a view to reaching a broader understanding of ethical events involving nursing professionals from the perspective of nurses who share and undergo these experiences through interpersonal relations, we adopted the sociological phenomenology of Alfred Schütz. We believed this reference framework would allow us to unveil the phenomenon, in view of the experiences and actions of NE and NM.
Perceiving the intentionality of NE and NM who experience ethical events, we attempted to understand how the experiences of acting on ethical occurrences are manifested in their daily reality. We did not limit ourselves to the perception of the individual project, but looked at what intentionality reveals to the group of nursing professionals involved in this phenomenon.
Social phenomenology is not oriented towards single acts, individual behaviors, restricted to self-conscience, but to the understanding of what constitutes a determined social group, which experiences a typical situation. Thus, the daily world is not individual but intersubjective, in which we share with our peers, with one common world to all of us(3).
Intersubjectivity reveals itself in the reciprocity of motives and perspectives. Thus, the reaction of one individual provokes the reaction of another in view of a given situation, in which one experiences the common situation from the perspective of the other and vice-versa. This constitutes a we-relation. In turn, this is expressed in the other person's mutual conscience through each person and constitutes a generally sympathetic participation in one another's life, even if only during a certain period of time. This we-relation emerges by capturing the other person's existence in face to face interactions(4).
Another fundamental concept in Schütz' theory refers to human action, which can be purely interior (thought) or exteriorized by body movements, modifying something in the world. Human behavior is focused on based on a project man aims to carry out(5-6).
The motive for consists in a state of things - the objective one intends to achieve through the action; that is, the orientation towards the future action and motive why is related to past experiences, with available knowledge(7).
Next, we will discuss the methodology developed to achieve this study.
DEVELOPING THE METHODOLOGICAL TRAJECTORY
We defined the following research inclusion criteria: participate in the Nursing Ethics Committee as a full or substitute member and possess experience in the reception and follow-up of ethical events forwarded to this organ; having experienced, as a nurse head or manager, ethical occurrences involving nursing staff. In order to establish "rapport" and introduce the theme to the study subjects, we posed the following questions:
- NE: How do you act in relation to ethical events in a NEC? What makes you act when confronted with ethical events? What do you expect through these actions?
- NM: What is it like for you to act in relation to ethical events involving nursing staff? What makes you act when confronted with ethical events? What do you expect through these actions?
Study participants were NE and NM from a private hospital in the city of São Paulo, Brazil. The study was approved by the Research Ethics Committee of the study institution.
We established a relation of closeness and empathy with each collaborator. Thus, we explained the reasons why we had contacted them and the study objectives, and then invited them to participate by means of an interview. After obtaining their free and spontaneous manifestation, we asked participants whether we could use a recorder. Moreover, each participant received time to read and was asked to sign the Free and Informed Consent Team.
We attempted to offer a favorable environment, allowing each participant to talk freely about the proposed questions, clearly stating the guiding questions and letting collaborators reflect and declare what they were thinking at that time.
The number of participants was not determined. Interviews stopped when we perceived the repetitiveness of the motives that impulse subjects' actions in relation to ethical occurrences. In total, ten interviews were held with NM and NE.
CONSTRUCTING CONCRETE CATEGORIES AND THE EXPERIENCED TYPE
The organization and categorization of our results allowed us to construct a typology of experiences, in accordance with models proposed by nurse researchers who used Sociological Phenomenology(8-11). For this purpose, we carried out the following steps:
- reading the testimonies to grasp the subjects' motivated experience;
- identifying the concrete categories that covered the subjects' actions in relation to ethical nursing events;
- grouping discourse extracts, that is, related action aspects that are significant with respect to the phenomenon of ethical occurrences that involve nursing professionals;
- establishing the meaning of the social act of acting in relation to these events, based on what was typical in participants' discourse, in order to reach the typology of subjects' experiences.
Concrete categories related to NE's and NM's motivation for action
NM's and NE's motivations to act converged in the following categories:
Participants considered it was necessary to act in relation to ethical events in nursing with a view to guaranteeing humanized care, that is, based on respect and on the dignity of human beings. This is shown by the following extracts:
By acting in relation to ethical events, I attempt to advise the involved professional, that, if he wants the patient to be well taken care of or if he wants to be taken care of well, there is no way of not being committed to care, to what he does and how he acts (NM4).
I hope we will learn to work with the events so as to seek the humanization of nursing care, respect for human beings' rights and dignity (NE2).
NM and NE consider it is important to act in relation to ethical events in order to guarantee clients' satisfaction about whether their needs are attended to, as shown by the following excerpts:
By working on ethical events, I hope to contribute to the satisfaction of nursing clients, the valuation of nursing service, this institution (...) (NE1).
(...) that is what I expect from my actions in relation to ethical occurrences, that is, I hope our client is receiving the best possible care for his case (NM3).
Demystifying the fear of punishment
Subjects want their actions to contribute to extinguish the fear of punishment when some nursing professionals are forwarded to the Nursing Ethics Commission. They state that:
(...) I hope this, that people learn from each situation and that the event and a punitive tone are not too emphasized (NM3).
(...) We also need to take away that stigma of punishment, which unfortunately still exists. The NEC should attract the attention of nurse heads, so that denouncing a professional is not a form of punishment, but of guidance (NE3).
NM and NE hope their activities in relation to ethical events will result in credibility for nursing professionals among clients and other health professionals. This is shown by the following discourse extracts:
The patient must be respected and, if something wrong happens, he needs to be informed, but we first need to prevent damage to this patient from happening (NM4).
It is comforting to know that you are acting so as to value and dignify the profession, attempting to strengthen nursing professionals' actions inside the institution because, when you work in relation to ethical occurrences, this makes the group of nursing professionals be considered more seriously and also guarantees support to the professional if he is being accused unfairly (NM3).
Partnership in the education process
The nurses believe it is important for the NEC, continuing education, nursing service managers and nursing professionals to be partners in education activities related to ethical events, as shown by the following excerpts:
(...) I hope our action will contribute to continuing education as well. That is what I think: that is what we have done in the sector I am in charge of and also when we forward an event to the NEC, because that is a way to make this situation visible to everybody (NM3).
In my opinion, in daily reality, each nurse should guide, indicate where the flaw is, accompany persons and give advice. It is really educative work (...) (NE4).
Continuous improvement of the care process
Various statements indicated the need for continuous improvement of the care process as a fundamentally important element to act in relation to ethical events in nursing:
(...) When I act in relation to an ethical event, it's to achieve a change and improvement in the work environment and in people's relations (NM3).
(...) By seeking updated knowledge, these nurses feel secure about offering quality nursing care to clients and about using the available human resources and material to guarantee care quality (NE1).
The categories of humanization, continuous improvement of the care process, credibility, demystifying the fear of punishment, clients' satisfaction and partnership in the education process join most motives into points of convergence that appeared in NE's and NM's discourse.
The subjects revealed their concern about guaranteeing a humanized care, concretized in respect for clients, their dignity and human integrality as active subjects in the care process. Thus, the humanization of care represents a strong motive for guaranteeing the right to a dignified nursing care that is safe for clients.
NM and NE also see providing for continuous improvements of the care process as a horizon, which requires investments and changes in the dynamics of work, in the technical and scientific training of nursing professionals, in order to minimize ethical events that are harmful to clients and prevent their recurrence.
Credibility is an important motive why for NE and NM to act in relation to ethical events in nursing. They aim for clients to have confidence in nursing professionals and, thus, they justify their preoccupations with orienting them, whenever possible, informing clients/families and the medical team about the ethical event in nursing. By acting this way, these nurses hope that other professionals and clients/families value nursing team actions in relation to the ethical occurrence and the measures taken to minimize the negative consequences of the event.
Another category is clients' satisfaction, revealed because it drives NE's and NM's actions and reveals these social subjects' commitment to achieve this satisfaction, as a goal for nursing professionals. By coping with ethical events in nursing, they attempt to get closer to this goal of satisfying the needs of clients attended by the nursing team.
Demystifying the fear of punishment indicates that NE and NM acknowledge that fear of punishment exists, but both groups feel the need to overcome it by disseminating the functions of the NEC and its guidelines to professionals, in view of the ethical event or its prevention. In this perspective, by acting in relation to ethical occurrences, these nurses hope to put an end to this stigma of punishment. Their expectation is in line with another study according to which nursing professionals are afraid to notify errors and, consequently, do not exploit opportunities to learn from their own mistakes(2).
The category of partnership in the education process highlights that NE and NM also think about developing movements in partnership with continuing education and with nursing professionals, nurse managers and the NEC, with a view to everybody's commitment to this education and prevention process related to ethical events, by sharing the NEC's and nurse heads/managers' guidelines, by support, communication and reflection in relation to the professional who committed an error.
The NE's and NM's discourse also contains reciprocal perspectives towards their actions. Some NE expect NM to be trained to decide and forward certain ethical events to the NEC. NM, on the other hand, project their activities in relation to forwarding an ethical occurrence and expect NE to respect secretary, in order to safeguard the involved professional's image, avoiding future discrimination or defamation.
CONSTRUCTION OF THE EXPERIENCED TYPE
According to social phenomenology, ideal experienced types are schemes to interpret the social world, which are part of our background of knowledge about the world and have a meaningful value. We always take elements of these types in interpersonal relations(12).
The categories that emerged from subjects' discourse allowed us to construct the experienced type related to their experiences with ethical events. Our study indicated one common experienced type. This is understandable as these subjects are inserted in the same social group and have similarly experienced the motives why, based on the same context of meanings in these experiences.
Thus, NE and NM are professionals who, through their actions in relation to ethical events, aim for the humanization and continuous improvement of the care process. They work towards the credibility of nursing professionals. They want to demystify the fear of punishment among nursing professionals involved in ethical events. They attempt to achieve clients' satisfaction about care delivery. They want to close partnerships with continuing education and the NEC in the education process.
By unveiling the meanings of typified actions shared by the study subjects, we were able to understand that it is essential for the health institution to be a partner and for all professionals to be committed to this process, with a view to preventing ethical events, primarily those most harmful to clients. In this perspective, understanding the actions of NE and NM in relation to ethical occurrences revealed that they believe in closing partnerships for a permanent and long-term education process about these events, involving NE, nurse managers and other nursing professionals.
This study also indicated the need to take away the fear of punishment in forwarding professionals to the NEC. NE and NM expect and aim for the goals of nursing services and health institutions to contemplate and allow for the construction of a participatory, dialogue and support process, based on reflection and responsibility of the professional who committed an ethical event.
The educative and management actions NM and NE proposed in relation to ethical occurrences are meaningful and important with a view to humanized, safe and efficient nursing care that is free from expectable risks. Moreover, this study allowed us to understand the need for these actions to be non-punitive, as educative attitudes seem to be wiser and more effective actions in management practice related to ethical events in nursing.
By acting in relation to ethical occurrences, NE and NM aim to continuously improve the care process and clients' satisfaction. In their opinion, this may be possible through partnerships with continuing education of nursing professionals and the work of the NEC by guiding professionals instead of punishing them. Hence, these nurses - who are part of the same social group, have converging expectations about motivations for actions related to ethical events. By their commitment to the care process, they hope to contribute to the benefit of clients and aim to be socially recognized and professionally valued.
The NE's and NM's experiences also disclosed that all nurses need to cope with ethical events in daily reality, make decisions, guide and forward nursing professionals to the NEC whenever necessary. Therefore, they expect equity in deciding on ethical occurrences, so that decisions may result in improved care and, consequently, benefit the social group.
The comprehensive phenomenological branch of social action, which guided this study, allowed us to foresee new horizons for ethical events that involve nursing professionals, with a view to awaking to the relevance of these events, as well as to individual and institutional responsibilities, so that all professionals take on the commitment of expanding their knowledge in order to guarantee a care that is free from any risk or damage to clients.
In summary, this research gave us a closer look at the experiences lived and pictured by the subjects of the social action. They revealed projects to construct knowledge for a care practice based on the actions triggered by ethical events and involving the responsibilities of nursing professionals as well as health care institutions.
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Recebido em: 5.7.2005
Aprovado em: 24.3.2006
1 Study extracted from Doctoral Dissertation