Ethical problems experienced by nurses in the Family Health Strategy

Abstract

This study aimed to identify the ethical problems experienced by nurses in the Brazilian Family Health Strategy. It is an integrative literature review carried out between March and April 2018 in four databases, by cross-referencing the following descriptors: “ethics,” “bioethics,” “nursing,” and “Family Health Strategy.” After applying the inclusion and exclusion criteria, eight articles remained. The subsequent analysis identified four categories: ethical problems related to users, the team, the organization of health service, and strategies adopted by nurses to face ethical problems. We concluded on the urgent implementation of emancipatory educational processes that enable health professionals to build knowledge and develop competences to identify and manage problems involving ethical issues.

Nursing; Family Health Strategy; Primary health care; Ethics; Bioethics; Ethics, nursing

Resumo

O objetivo deste trabalho foi identificar problemas éticos vivenciados por enfermeiros na Estratégia Saúde da Família por meio de revisão integrativa realizada entre março e abril de 2018 em quatro bases de dados. Foram utilizados os seguintes descritores, combinados entre si: “ética”, “bioética”, “enfermagem” e “Estratégia Saúde da Família”. Após aplicados os critérios de inclusão e exclusão, restaram oito textos, de cuja análise emergiram quatro categorias: problemas éticos na relação com usuário; na relação com a equipe; na relação com a organização do serviço de saúde; e estratégias adotadas por enfermeiros no enfrentamento desses problemas. Conclui-se que é necessário implementar processos educativos emancipatórios que possibilitem aos profissionais da saúde construir saberes e desenvolver competências para identificar questões éticas e conduzir soluções.

Enfermagem; Estratégia Saúde da Família; Atenção primária à saúde; Ética; Bioética; Ética em enfermagem

Resumen

Este trabajo tuvo como objetivo identificar los problemas éticos vivenciados por enfermeros en la Estrategia de Salud Familiar. Se trata de una revisión integrativa realizada entre marzo y abril del 2018 en cuatro bases de datos. Se utilizaron los descriptores siguientes, combinados entre sí: “ética”, “bioética”, “enfermería” y “Estrategia de Salud Familiar”. Una vez aplicados los criterios de inclusión y exclusión, restaron ocho textos, de cuyo análisis surgieron cuatro categorías: problemas éticos en la relación con el usuario; en la relación con el equipo; con respecto a la organización del servicio de salud; y estrategias adoptadas por los enfermeros en el afrontamiento de dichos problemas. Se concluye que es necesario implementar procesos educativos emancipatorios que permitan a los profesionales de la salud construir saberes y desarrollar competencias para identificar cuestiones éticas y conducir soluciones.

Enfermería; Estrategia de Salud Familiar; Atención primaria de salud; Ética; Bioética; Ética en enfermería

Since its implementation in 1994, the Family Health Strategy (FHS) has been reorganizing the care practice by reinforcing the fundamental characteristics of primary care. Considered as the health system articulation element and preferred gateway, the FHS focuses on the individual, the family, and the community, based on social control, intersectorality, territoriality with separate clientele and work focused on health surveillance¹ .

The FHS practices are made possible by its teams, which are composed by at least a doctor and a nurse – preferably specialized in family and community health –, a nursing assistant or technician and a community agent. The team may also include an agent to combat endemic diseases and oral health professionals, such as a dental surgeon – also preferably specialized in family health – and an oral health assistant or technician² .

Nurses have an important role in changing the care practices of the Brazilian Unified Health System (SUS) towards comprehensive care³ . However, the daily life of this professional in the FHS is marked by activities that make up the dynamics of the health service and the work advocated by the care model, in a context where ideologies and management strategies reinforcing the hegemonic paradigm prevail⁴ .

As FHS nurses are directly involved with both organizing the work, as well as the patient and family members, they often face ethical problems involving users and the health team⁵ . In this context, the professionals’ unpreparedness, along with macro-political aspects, such as scarcity of financial, human, and material resources, can aggravate conflicts and influence their resolution⁶ .

However, several everyday situations, despite involving ethical issues, do not generate major conflicts. In such situations, lacking awareness of latent problems can compromise the quality of health care and the relationship between professionals and patients. Aware of this, we aimed to identify ethical aspects of the FHS nurses’ practice.

Method

We conducted an integrative literature review, which allows deepening the understanding on a specific phenomenon by summarizing multiple studies⁷ ,following six steps: 1) identifying theme and research question; 2) establishing inclusion and exclusion criteria; 3) selecting studies; 4) categorizing selected works; 5) analyzing and interpreting the results obtained; and 6) presenting information/synthesis of knowledge⁸ . The following question guided our study: “What does the scientific literature say about ethical problems experienced by nurses in the FHS?”

The research began by consulting the Health Sciences Descriptors (DeCS) to identify the appropriate terminology for the topic. Controlled keyword were selected in Portuguese, English and Spanish, and combined with the Boolean operator “and”: “ ética, ” “ethics,” “ ética ”; “ bioética, ” “bioethics,” “ bioética ”; “ enfermagem,” “nursing,” “ enfermería ”; and “ Estratégia Saúde da Família ,” “Family Health Strategy,” “ Estrategia de Salud Familiar. ” Finally, a reverse search was also carried out from the list of references of the selected texts.

The survey was carried out between March and April 2018 in the following databases: Latin American and Caribbean Health Sciences Literature, Medical Literature Analysis and Retrieval System Online/PubMed, Nursing Database and Scientific Electronic Library Online.

Online studies in Portuguese, English or Spanish were included, without time limits. Unavailable articles, experience reports, monographs, dissertations, theses, editorials, news articles, short-term analyzes, theoretical discussions of concepts, non-original articles (reviews, comments) and secondary studies (bibliometric, bibliographic, integrative or systematic review) were excluded. Finally, we read in full the selected articles ( Figure 1 ).

Figure 1
Selection of articles included in the integrative review

After the reading, we classified the documents according to authorship, title, objectives, research location, year of publication, main results, method used, conclusions and journal. The data were stored in a Microsoft Excel spreadsheet and submitted to analysis to identify points of convergence and divergence between the articles, as well as relationships between findings and research questions. The most relevant results of this integrative review are summarized in Chart 1 and in the ^Appendix.

Chart 1
Ethical problems with users, team, and organization of the service

Subcategories	Ethical problems
Users
Communication	Information to users Privacy Confidentiality Secrecy Omission of information
Autonomy	Users’ autonomy Nurses’ autonomy
Respect	Nurse’s respect for users User’s respect for nurses
Team
Information	Confidentiality Secrecy Omission of information
Inter-professional relationship	Respect among team members Communication between the team Collaboration between professionals
Academic background	Professionals’ unpreparedness to work in the FHS
Organization of the health care service
Physical structure	Precarious physical resources
Organizational structure	Absence of support for conflict resolution
Human resources	Work overload Lack of time to provide services

Results

The eight selected studies⁵ , ⁹ - ¹⁵ were published between 2004 and 2016 – five between 2004 and 2011; three in 2015 and 2016 – and half of them were developed in the state of São Paulo, Brazil. The main results refer to common conflicts of daily life, which often go unnoticed, although they contradict ethical and moral precepts and system recommendations, compromising the quality of care.

Present in six studies, the qualitative approach prevailed as the methodological design. Regarding the conclusions, conflicts were presented as risk situations for the attention and care, identifying the need to expand the collective dialogue and develop new investigations. As for the journals, most articles were published in nursing journals (^Appendix).

The analysis identified four categories regarding: 1) ethical problems related to users; 2) ethical issues involving the health team; 3) the organization of the healthcare service; and 4) strategies adopted by nurses to face ethical issues. The first three categories are divided into subcategories, according to Chart 1 .

Ethical problems related to users

The ethical problems experienced by nurses in their relations with users referred to communication, autonomy, and respect. There was a constant violation of secrecy, with patient information being revealed among the health team⁵ , ¹¹ , ¹³ and even to other users⁵ , ¹³ , ¹⁴ . A common ethical dilemma was the challenge of establishing limits in the relationship between professional, patient and family⁹ , ¹¹ , ¹² . We also found the health professional’s disrespect towards the patient⁹ , ¹¹ , ¹² , usually motivated by prejudice, as well as issues with giving information for decision making, underestimating the subjects’ autonomy⁹ , ¹⁰ , ¹² .

Users also showed disrespect towards nurses, refusing to: follow directions⁹ , ¹⁰ , ¹² , ¹⁴ , perform complementary tests¹² , receive information about treatment⁹ , ¹⁰ , ¹² , ¹⁴ or wait for consultation at the health center¹³ . Another situation that often creates ethical conflicts, especially with the patient’s family⁹ , ¹⁰ , is requesting procedures to minors without authorization or knowledge from parents or legal guardians⁹ , ¹⁰ , ¹¹ .

Another challenge is prescribing expensive drugs – especially when there are more affordable drugs with similar efficacy –, making its acquisition impossible for the patient⁹ , ¹¹ , ¹² . In other cases, nurses omit information⁵ , ⁹ , ¹¹ , ¹² on the health status¹² and patrimonial, physical, or psychological violence suffered by patients⁵ . This problem stems from the professional’s lack of both preparation and knowledge regarding how to proceed in such situations⁵ , ¹¹ .

Ethical problems related to the team

The team’s ethical conflicts relate to information, interprofessional relationship and academic background. The review found that medical prescriptions were questioned by colleagues⁹ , ¹⁰ , ¹² and medical confidentiality violated by the sharing of information about users and family members⁹ - ¹⁴ .

Situations related to unpreparedness to work in the health service⁹ , ¹⁰ , ¹² , ¹⁴ and the challenge of delimiting the responsibilities of each professional were quite frequent, aggravating other problems⁹ , ¹⁰ , ¹² , ¹³ . As for the relationship between the team, lack of both companionship and respect, added to deficiencies in communication and collaboration⁹ , ¹² , ¹⁴ were understood as the source of ethical problems, hindering the organization of activities and spaces⁹ , ¹² , ¹³ , ¹⁵ .

Ethical problems related to the organization of the healthcare service

Ethical conflicts with management were related with physical and organizational structure and human resources. The most frequent complaints were lack of both support to discuss and resolve ethical dilemmas, and transparency by the FHS management in solving problems with employees, besides precarious conditions⁹ , ¹⁰ , ¹² , ¹⁴ , ¹⁵ . Nurses also reported difficulties in preserving the patients’ privacy due to structural deficiencies in health units⁹ , ¹⁰ , ¹² .

Other ethical problems experienced by nurses were: too many families assigned for each team⁹ , ¹² , implying work overload; little time to provide care to users¹⁴ ; difficulty in accessing laboratory tests⁹ , ¹⁰ , ¹² ; health units’ precarious conditions for emergency care; and lack of resources for removal services¹⁰ , ¹² , ¹⁵ .

Strategies adopted by nurses to face ethical problems

Nurses discuss cases in team meetings, sharing information and looking for solutions together⁵ , ¹⁴ . Other resources used are: stimulating dialogue and affection between those involved in the conflict; participation of the team coordination to address problem solving¹³ ; and assistance with bibliographic material (scientific articles, professional code of ethics and other documents) or consultants¹⁴ . In some situations, nurses appeal to Brazilian social support networks, such as the Guardianship Council, the Public Prosecutor’s Office, the Social Action Foundation, the Older adults Protection Network, the Municipal Council for the Rights of Older Adults⁵ and the Social Assistance Reference Center¹⁴ .

Discussion

Ethical issues have been the subject of investigations, discussions, and debates, especially regarding health services, in which there are constant violations. Among the issues faced by FHS nurses, the sharing of confidential patient information among the team or with other patients stands out. This situation violates ethical precepts and constrains those involved, thus damaging the link established between users and the health services.

The Code of Ethics for Nursing Professionals, approved by the Resolution 564/2017 of the Brazilian Federal Nursing Council (Cofen), establishes in the caput of its article 52 that health workers must keep confidentiality about having knowledge of a fact due to its professional activity, except in cases provided for by law or court order, or with written consent of the person involved or their representative or legal guardian ¹⁶ .

The FHS is considered a model for reorganizing primary care because it develops actions aimed at health promotion and protection, disease prevention, diagnosis, treatment, recovery, and rehabilitation focusing on patients and their family. To achieve such goals, a good relationship among all involved is essential. But in practice, the health professional’s disrespect towards patients is evident, disregarding their autonomy and right to decide.

Disrespect threatens the bonding relationship and co-responsibility essential to care¹⁰ . Autonomy, in turn, refers to the individuals’ ability to decide what is good for them and what they understand by well-being, according to their expectations, values, needs, priorities and beliefs. This is what guarantees the patients’ freedom, preventing them from being vulnerable to professionals¹⁷ .

By maintaining close contact and sharing responsibilities with patients, the nurse ensures autonomy and the right to decide, guaranteeing the user’s right to self-determination and free consent. As such, effective communication, mutual respect, consensus, and synergy between the parties are essential, instead of merely overlapping knowledge.

On the other side of the relationship, disrespect towards the professional is identified by patients who, for example, refuse to follow the nurse’s prescriptions or to wait for care at the health service. This conflict stems from communication failures, especially due to the lack of both information and the user’s understanding. Thus, nurses must establish bonds with patients and instruct them, reducing incidents of ethical problems and improving the conduct of the therapeutic processes⁶ .

A situation that also creates conflicts in the FHS is assisting minors without their legal guardians’ consent. However, based on the principle of autonomy, adolescents can be cared for alone, if they wish. Guaranteeing the right to privacy is essential to improve quality of care, promote health and prevent injuries, and thus the professional must respect the minor’s decision and choices whenever they have the capacity to do so¹⁸ .

Another problem detected was the insensitivity of some professionals when prescribing high-cost drugs, while others are cheaper and of similar efficacy. Regarding this issue, we must remember that nurses in primary care, supported by the municipal manager and guided by care protocols, can prescribe medications. One of the articles reviewed, developed in São Paulo/SP with 17 nurses from family health teams, presented divergent results from the current study, emphasizing the professionals’ concern regarding the users’ social and economic conditions¹¹ . The research stated that this concern seems to indicate the overcoming of the biological perspective of care, allowing dialogue about values and concepts and co-responsibility for the patient’s health¹¹ .

Omitting information to users about their health status proved to be another major ethical problem. This may result from training centered on the biomedical model, with a fragmented view of the health-disease process¹⁹ , leading to the conservative and paternalistic paradigm. To overcome this obstacle, health services must value a new professional profile that meets the actual demands of the population⁶ .

Unpreparedness to work in the health center and difficulty of defining responsibilities among the staff also appeared as permanent sources of problems. Working with professionals without adequate qualification prevents nurses from performing their work in ideal conditions, bringing discomfort and suffering²⁰ . The difficulty of defining roles and functions is partly due to integrating new professionals and innovating the assistance proposals. In such context, permanent health education is the best alternative to address and solve the problem¹³ .

The difficulty of communication and interaction between the health team can be explained by the fragmentation of work – generating isolated and juxtaposed interventions –, by the turnover of professionals in different spaces, the hierarchical structure of the service and the great demand for care. This situation can compromise the quality of care even in a proposal such as the FHS, which aims to be interdisciplinary and focus on humane care²¹ .

The lack of strategies and tools to support professionals in problem solving is another recurring issue. To solve it, systematic training is needed, focusing on knowledge, attitudes and practices that foster critical reflection on ethical problems, preparing the professional to detect conflicts present in daily life and, thus, modify their care practice. This learning process requires small groups and a connection between theory and practice by sharing experiences²² .

The structure of health centers also causes conflicts, as the nursing team is unable to ensure the patients’ privacy – a problem beyond the attitude of professionals, as it concerns the architecture of the environments. Given the conditions of the units, the professionals’ concern in preserving the physical and moral privacy of users and families becomes a source of stress¹⁰ . Therefore, the institutions’ physical facilities must undergo periodical analysis and adapt to the profile of the enrolled population and the type of procedures to be performed²³ .

Ethical conflicts with the management result from issues such as an excess of families served by the same team and poor working conditions. This lack of organization has been hampering performance and preventing the consolidation of the principles of SUS and FHS, reliant on the focus on access and care and also on the participation of leaders, managers, professionals, technicians, academics, and politicians. Only engaging all these actors we may build and consolidate a structuring, universal and ethical service²⁴ , which identifies the real needs of the population and enables actions to solve the most frequent problems, ensuring quality of care.

Team meetings, the use of bibliographic documents and the request for support from other institutions are some of the strategies used by professionals to conduct reflection and discuss dilemmas of the health unit. Recognizing these strategies is essential to face situations of ethical conflict²⁵ , ²⁶ .

Finally, we must emphasize that this research was limited by the reduced number of empirical studies on the topic developed in primary care. This indicates a gap in scientific production and the impossibility to generalize the results of this review to all health care scenarios, as the analyzed bibliography deals specifically with the FHS.

Final considerations

The results showed several ethical problems present in the FHS, such as breach of confidentiality and secrecy of information, disrespect between professionals and users, poor working conditions, unpreparedness, and fragility of the relationship between the team. Such issues are often part of everyday life, making them difficult to recognize; however, failure to perceive them impairs care and implies breaking the bond with the patient. Therefore, institutions must implement emancipatory processes of permanent and continuing education that enable professionals to build knowledge and develop skills to identify ethical issues and solve them.

We expect that the knowledge produced by this investigation will stimulate changes in nursing practice towards an evidence-based practice that promotes citizenship and emancipates all involved in the process. Considering that the integrative literature review is only one of many possible methods to investigate this phenomenon, we recommend conducting further studies from other theoretical and methodological alternatives, in other health care settings – primary, secondary and tertiary – and with other informants, such as users, family members and professionals.

Appendix

Classification of papers

Authors and year of publication	Article title and journal	Objective(s)	Research location (Brazilian state) and method	Main results	Conclusions
Zoboli, Fortes; 20049	“Bioética e atenção básica: um perfil dos problemas éticos vividos por enfermeiros e médicos do Programa Saúde da Família, São Paulo, Brasil”; Cadernos de Saúde Pública	Identify ethical problems experienced by nurses and doctors of the Family Health Program (FHP).	São Paulo. Descriptive research with a qualitative approach, with 17 nurses and 16 doctors from Health Centers (UBS). To collect data, the authors conducted semi-structured interviews. After transcribing the recorded statements, they carried out thematic categorical analysis.	Ethical problems are part of the routine of primary health care. These problems are not always seen as dilemmas or issues deserving of media attention.	The difficulty of identifying ethical problems in primary health care puts the FHP’s bonding relationship at risk.
Silva, Zoboli, Borges; 200610	“Bioética e atenção básica: um estudo exploratório dos problemas éticos vividos por enfermeiros e médicos no PSF”; Cogitare Enfermagem	Identify ethical problems and the frequency with which FHP nurses and doctors experience them.	São Paulo. Quantitative, exploratory study developed at UBS. Included 24 nurses and 22 doctors, totaling 46 participants. The authors collected data through a structured and self-administered questionnaire.	Ethical problems involve users and their families, professionals, and the organization of the health system.	As they are everyday ethical problems, they appear subtly in primary care, to the point of going unnoticed, making it difficult to change the teams’ attitude.
Zoboli; 200711	“Enfermeiros e usuários do Programa Saúde da Família: contribuições da bioética para reorientar esta relação profissional”; Acta Paulista de Enfermagem	Identify ethical problems experienced by nurses in primary care to improve the professional-user relationship.	São Paulo. Descriptive research with qualitative approach, and thematic categorical analysis. Seventeen nurses from family health teams participated in the investigation.	It is difficult to establish limits in the professional-patient relationship. The authors observed conflicts between the team and users, besides professional neglect in patient and family care.	Consider and specify principles of autonomy, non-maleficence, justice, and beneficence can contribute to the construction of citizenship and health promotion.
Lima and collaborators; 200912	“Problemas éticos na atenção básica: a visão de enfermeiros e médicos”; Cogitare Enfermagem	Identify and verify the frequency with which nurses and doctors in FHS, UBS and School Health Centers experience ethical problems.	São Paulo. Quantitative and qualitative research with 33 doctors and 30 nurses. Semi-structured interviews facilitated collecting information. To organize the data, the authors performed content analysis using an instrument that identifies ethical problems in primary care.	Ethical problems arise in everyday situations of primary care and were similar in the three scenarios investigated.	It is important to collectively elaborate guidelines to establish relationships based on citizenship and the emancipation of the subjects, whether they are users, professionals, or managers.
Przenyczka and collaborators; 20115	“Conflitos éticos da enfermagem na atenção primária à saúde e estratégias de enfrentamento”; Ciência, Cuidado e Saúde	Identify ethical conflicts experienced by nursing professionals in a health unit with FHS and discuss the coping strategies used.	Paraná. Qualitative study with 13 nursing professionals from a health unit. The authors collected data using individual interviews recorded on audio.	Violation of professional secrecy and violence against old adults were the main conflicts experienced. As a coping strategy, educational activities were developed that enabled constructive dialogues. Everyone participated, indicating interest in the theme.	Nursing professionals benefited from the coping strategy, better understanding ethical conflicts. However, further discussion is needed, as it is a comprehensive topic with several implications.
Siqueira-Batista and collaborators; 201513	“(Bio)ética e Estratégia Saúde da Família: mapeando problemas”; Saúde e Sociedade	Address the main (bio)ethical problems identified by FHS workers in Viçosa, state of Minas Gerais, a medium-sized municipality in the Zona da Mata Mineira.	Minas Gerais. Qualitative research with 73 professionals from 15 FHS teams, who answered a semi-structured questionnaire. The content analysis technique helped researchers organize the findings.	Most professionals showed difficulty in identifying (bio)ethical problems in their work, among which stand out: inequality of access to health services; teaching-work-community relationship; secrecy and confidentiality; and conflicts between staff and users.	The identification and adequate approach to (bio)ethical conflicts in the FHS is still incipient. Further research is needed to establish theoretical references, improve the professionals training, and develop methods for decision making.
Caetano and collaborators; 201614	“Conduta do enfermeiro frente aos conflitos éticos e bioéticos em área vulnerável na ESF”; Saúde e Pesquisa	Identify the conduct of FHS nurses in ethical and bioethical conflicts in caring for socially vulnerable families.	Santa Catarina. Qualitative, descriptive, exploratory study. The authors collected data using semi-structured interviews with six FHS nurses who work in vulnerable areas. The authors used content analysis to organize the findings.	To resolve conflicts, one must use clear and accessible language, discuss cases with the multidisciplinary team, work in a network, establish links with the community and maintain ethical conduct.	Nursing professionals must promote dialogues about conflicts and ethical and bioethical dilemmas, aiming to qualify and humanize care, with resoluteness in the service network.
Cardoso and collaborators; 201615	“Sofrimento moral na Estratégia de Saúde da Família: vivências desveladas no cotidiano”; Revista da Escola de Enfermagem da USP	Understand the experiences of moral suffering in the daily life of the FHS.	Minas Gerais. Case study with qualitative approach. Semi-structured interview answered by 28 professionals from family health teams. The researchers used observation, projective technique, and content analysis to organize the findings.	Routine aspects of the health service lead professionals to face situations that contradict their ethical precepts and compromise the quality of work, creating moral distress.	FHS workers must expand their discussions on ethics to minimize suffering and develop professional practice in line with personal ethical values.

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• ¹¹
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Publication Dates

• Publication in this collection
  26 June 2020
• Date of issue
  Apr-Jun 2020

History

• Received
  12 Feb 2019
• Reviewed
  3 Jan 2020
• Accepted
  23 Jan 2020