ORIGINAL RESEARCH

Ethical conflict as a trigger for moral suffering: survey of Brazilian nurses

Flávia Regina Souza Ramos^I; Mara Ambrosina de Oliveira Vargas^II; Dulcinéia Ghizoni Schneider^III; Edison Luiz Devos Barlem^IV; Soliane Quitolina Scapin^V; Ana Maria Masiel Schneider^VI

^I PhD in Nursing. Nursing Professor at the Federal University of Santa Catarina. Brazil. E-mail: flavia.ramos@ufsc.br
^II PhD in Nursing. Professor at the Federal University of Santa Catarina. Brazil. E-mail: ambrosina.mara@ufsc.br
^III PhD in Nursing. Professor at the Federal University of Santa Catarina. Brazil. E-mail: dulcineia.schneider@ufsc.br
^IV PhD in nursing. Professor at the Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: ebarlem@gmail.com
^V Nursing Graduate at the Federal University of Santa Catarina. Florianópolis, SC, Brazil. E-mail: solscapin@gmail.com
^VI Specialist in Adult Intensive Care. Florianópolis, Santa Catarina, Brazil. E-mail: aninha_masiel@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.22646

ABSTRACT

Objective: to examine moral suffering triggered by situations of conflicts experienced in the daily work of Brazilian nurses. Method: survey of 1050 Brazilian nurses by applying an open questionnaire in October 2013. The project was approved by the research ethics committee of the Rio Grande Federal University (Nº 144/2013). The 2,304 situations pointed out by the participants were submitted to thematic analysis, giving rise to nine categories, two of which are addressed in this article. Results: two initial categories – conflicts and professional relationships – were identified and, when aggregated, produced the subcategories conflict and professional relations with the health team and with the user and family. Conclusion: nurses experience multiple situations in their daily work, which may constitute reasons for the process of moral suffering.

Keywords: Moral; ethic; conflict; nursing.

INTRODUCTION

The conflict arises when there is a need to choose between situations that can be considered incompatible, between people or groups, being perceptible and constant. ^1-3. In the health care area, conflicts are manifested in innumerable ways among professionals. They are manifested in relations of insubordination, or by lack of respect, integration, and collaboration, or by abusive relationships, disputes between teams, stress of the professionals, in relationships with users/family and in expectations with oneself^2,4-6.

Nurses are among the professionals directly involved in conflict situations, as they occupy management and team leadership positions. These situations are common in their daily work routine, and thus, they need to experience and interact with the conflicts in the best possible way, seeking alternatives to solve them. That is, managing conflicts is a challenge for these professionals².

In addition, conflicts directly affect the quality of care provided to health service users. It is understood that nurses must learn to manage conflicts in an efficient and resolute manner among health professionals, community members, and users, so that the quality of care provided is consistent with the ethical principles and guidelines of the Brazilian Unified Health System (SUS)⁷. However, although nurses are educated and exposed to the nursing values and the nursing duties throughout their academic career and in the exercise of their professional activities, they are especially likely to experience situations of ethical conflict and to examine them inappropriately. And, to the extent that these conflicts are inadequately managed, they can trigger moral suffering (MS)⁸.

Thus, the objective of this study was to analyze the Brazilian Nurses' Health, triggered by the situations of conflicts experienced in the daily work.

LITERATURE REVIEW

MS is understood as a situation in which the person knows what is right and what should be done, but is prevented from doing so for some reason, whether it is individual, institutional or social^9,10. And considering the extent of the causes, the severity of the consequences and the subjective and personal character of the phenomenon, the MS became the object of analysis in different realities, countries and types of care units where nurses work^11-15.

Still, studies indicate the identification of higher levels of MS among those involved in direct patient care compared to physicians. In this sense, differences among professionals refer to higher scores of MS among nurses and other non-medical professionals (in relation to physicians), a relation inversely associated with age for other health professionals and directly associated with years of experience only for nurses^11-15.

METHODOLOGY

It is a survey, that is, an empirical study based on the collection and quantification of data to understand situations and circumstances of a given population, using the questionnaire as an instrument.

The study was developed with Brazilian nurses working in several settings, from basic to high complexity care, through the application of an open survey, which first presented the concept of MS and then asked participants to cite up to five causative situations of MS that were experienced by them, important in terms of intensity and frequency. The profile data collected from the participants was not analyzed in this clipping.

The survey was applied to nurses who performed specialization, in distance learning mode, during a face-to-face meeting, concurrent in the capitals of the 27 federative units of Brazil, in October 2013. About 1050 nurses were present at the meeting and answered the questionnaire after being informed about the project and signing the Term of Free and Informed Consent. The project was approved (opinion No.144/2013) by the Research Ethics Committee of the Federal University of Rio Grande, associated with the Multicentric Project that integrated this stage of the study, and followed the guidelines established by Resolution 466/12 of the National Health Council.

The total of 2,304 situations pointed out by the participants was published in an Excel spreadsheet, and its contents were submitted to thematic analysis. Initially, a group of researchers classified the similar contents and distributed it into nine categories. Of the most relevant categories in the number of citations, two were articulated by their interrelation and importance to the understanding of the MS problem and chosen for analysis in this article, namely: professional relationships (679 excerpts) and conflicts (427 excerpts).

To give greater uniformity and reliability to the process, the categorization involved the group of researchers, from reading situations, formulating themes, codes, and keywords, until there was no new themes rising. Only after the construction of the category and subcategory framework, the remainder of the data processing was continued, by pairs, due to the large quantity of data. Collectively, there were also the stages of deepening relations between themes and categories and the conformation of thematic syntheses. The researchers were based on the theoretical framework of the MS¹⁰.

RESULTS

In this manuscript, the two initial categories (conflicts and professional relations) are discussed, which after analysis were configured around the central object conflicts, with two subcategories, relationships with the health team and with the user/family, as shown below.

Relationships with the health team

In this subcategory, the various potential conflict situations generating the MS process were gathered, the following were reported: depreciation and professional discrimination; the dispute and the lack of communication and companionship between work teams; the disregard of the physicians towards other members of the team; the lack of opportunity for dialogue with the managers, mutual disrespect between the health professionals and the disrespectful and abusive treatment by the bosses and between teacher and students. Situations of insubordination by professionals and inadequate conduct among nurses themselves were also identified. Finally, among the results, there were evidences of occurrences of moral harassment.

Relationships with the user/family

In this subcategory, the antagonisms between the demands of the users and of the service, and between the demands of the professional and the user are expressed, and the antagonism of beliefs is described. In this direction, situations of suspension and postponement of procedures without acceptable justifications have been reported; the professional being threatened and assaulted by a problem that cannot be solved; perceiving themselves pressured by users to provide care for which there are no institutional conditions; witnessing disrespect, non-acceptance, maltreatment or authoritarianism on the part of the professionals in the relationship with the user; perceiving themselves as impotent to intervene out of respect for the autonomy of the patient and family in a situation of non-cooperation and adherence to care; recognizing insufficiencies and ineffectiveness in the information, in the service or referral of users, due to an inadequate relation between supply versus demand.

There were also reports of occurrences in the Psychosocial Care Centers (CAPS). In these cases, the professionals report that they are often held accountable by users of the health system for the unavailability of the medications they need.

In addition, the violence is reported by professionals who work in the Mobile Emergency Care Service (SAMU), the Emergency Care Unit (UPA), in the Emergency Room, and in the Intensive Care Unit; being that the most exposed people would be the elderly and the children, that is, aggression and abuse are the main reasons for care in these health care contexts. And, in the public health strategy (FHS), outpatient clinics and basic health units, professionals identify situations of sexual violence against children, often involving family members and sexual violence against women.

Finally, the professionals who work in the FHS, point out the disrespect to the patient's autonomy, insofar as the team or one of its members reports the diagnosis to the family, contrary to the patient's request. But, regardless of the context of health care, the participants of the research indicate the inadequacy of information and the omission of the truth to the patients and their families about their health condition and the exams and the procedures performed as intervention. Even in the oncology department, professionals report that they find themselves lying to the patient or to the caretaker saying that the doctor is not present (because he/she does not want to attend), especially when the patient is terminally ill.

DISCUSSION

The conflict is a part of the ethical dilemma, and health teams are not prepared to conduct its management. The ethical dilemma is intrinsic to the nurses' daily work, precisely because, when acting as a mediator of the solution, they search immediately and, often without prudence, the decision-making. Therefore, interpersonal relationships are of great importance in the context of the nursing work, and the ineffective communication causes nurses, directly linked with the staff and the patients, to experience conflicts in ethically difficult situations, and which demand their performance as mediators of these problems¹⁶.

Regarding the conflicting relationship between the nurse and the medical professional, it is evident that there are situations of injustice, disrespect, persecution at work and psychological pressure. As these two professional categories are primarily responsible for patient care, there is a power dispute between them, which may unbalance the situation and generate ethical problems, affecting the level of stress and job dissatisfaction¹⁷. It is considered that, even if one could consider the autonomous professional exercise of nursing in relation to medicine, society still maintains a hierarchy between these two professional categories, considering nursing subordinated to medicine ¹⁷. The meanings of maintaining this hierarchy are complex and enable a social, cultural and economic logic of structuring the health care. However, teamwork presupposes harmonious relationships between its members in which each one is responsible for their actions and all should revere the patient's well-being^18-20.

Thus, in this study, situations where nurses have their behaviors or skills depreciated were listed, and they recognize making inappropriate or unsafe care and decision-making due to a lack of institutional structure or material conditions. In this sense, frequent conflicts restrict the possibilities of the best performance and autonomy of the nurse, and lead to the distance between what should be and what can be done in the concrete reality¹⁸.

Harassment is also presented as one of the results of this study, whether it comes from persecution at work, disrespect between staff and between bosses, discrimination, among other situations. Harassment is the exposure of the workers to humiliating and embarrassing situations, which are repetitive and prolonged, during the working day, and relative to the exercise of the labor functions¹⁹.

In the analysis of the subcategory entitled relationship with the user/family, first, it is argued that the conflicts restrict the possibilities of the best performance and autonomy of the nurse, and lead to the distance between what should be and what can be done in the concrete reality. In this perspective, it is necessary to adopt actions that minimize the differences and bring people together, placing the user at the center of their care process, collaborating to a care model in which the forms of therapist-user/nurse-user relationship are configured as a space of active and critical interaction in the search for a new practice. However, when it comes to the act of caring, nursing professionals are based on their beliefs and values that are determinant points of behavior and their life habits, which build the foundations of their personalities²⁰. In this sense, there are professionals with different profiles, whose behaviors interfere in the way of caring for the health system users.

It was also observed that the beliefs of each person and or group of belonging shape what might constitute conflicts. The patient's need to undergo a blood transfusion, contrary to the guidelines of their religious belief is an exemplary situation. There are controversies regarding this conduct that limits the autonomy of the patient in favor of the fundamental values established by a society that puts the defense of life in the first place. In the hierarchy of values, the religious and spiritual values proceed the others; however, this hierarchy of values constantly oscillates, to the detriment of other social values that come up²¹.

Situations reported in another study address the maltreatment, and inadequate care by the health professionals to the clients. It must be stressed that respect for individuals must always be emphasized, regardless of their social and economic conditions; humanized professionals are more concerned with the person²². The goal is always to consider that the interpersonal relationships of nurses/users are a dynamic process, with manifest and non-manifest behaviors, verbal and nonverbal, and being attentive to these behaviors, to, then, offer a planned and humanized nursing care²⁰.

In addition, there are factors that generate conflicts between health professionals and users, inadequate infrastructure, lack of materials and equipment and human resources, insufficient supply of specialized care and the organization of work, which can increase the workload. Situations such as these cause conflicts for both the service provider professional and the service user, as both parties do not feel that their rights are recognized. This causes discontent among health professionals because they must work in precarious conditions of service, which leads to the rendering of inappropriate services; and, therefore, the dissatisfaction of the users of the service occurs, because they do not have guaranteed access to quality care^5,17.

Paradoxically, even if the nurse situates by exemplifying the situations of non-acceptance of the family/companion, the omission or insufficiency of information to the user, and the impotence regarding domestic/family violence, such as conflicts that trigger MS within themselves; even if this conflict is expressed in an ambiguous and polarized relationship with themselves - between the expectation of being able to do and the evaluation of their own conduct -, the nurses express themselves. And here, expressing themselves means the possibility of wondering about what you see and what you experience. In this perspective, a study indicates that negative actions have consequences for themselves (professionals), for the patients and their families, such as the prolongation of death, the unworthy death, quantity versus quality of life, inadequate care, late treatment, prolonged hospitalization, disrespect and false hope²³.

Exploring the fact that the nurse is responsible for the uninterrupted care and is involved in close relationships with the users/relatives, even if related to the frequency and complexity of the ethical and moral issues to which they are exposed, it may highlight another position for the nurse. That is, a favorable position, which leads them to perceive the weaknesses and potentialities of the users' beliefs. Thus, the defense of the users/family is also expressed in the different ways the nurse denounces the aggravations to which they are subject in the social and health context. Therefore, the composition of health teams by professionals from different training areas, who are willing to clarify possibilities for the patient and his/her family in facing the health-illness process, which is a difficult moment in their lives, alleviates the suffering of all, including the team itself. In fact, the attributes of care relationships are re-signified, emphasizing ethical values such as trust and autonomy²⁴.

CONCLUSION

The nurse experiences multiple situations in their daily work, which may constitute a reason for the MS process. Moral harassment was presented as one of the results of the study, resulting from persecution at work, disrespect between the team and between bosses, discrimination, depreciation of their work and their potential autonomy, among other situations. A conflictual relationship with the medical professional, resulting from power disputes and maintaining a status quo of this medical professional, is perpetuated.

Also, situations in which the nurse recognizes making inadequate or unsafe care and decision-making procedures due to a lack of institutional structure or material conditions are listed. Conflict relations are aggravated by the lack of materials, equipment, and personnel, increasing the workload, generating difficulties, especially in interpersonal interactions, which reflects in all the spheres of care.

In the nurse/user relationship, it was considered that the beliefs of each person and group of belonging shape the conditions that can generate conflicts. Therefore, nurses need to adopt actions that minimize the differences and bring people together, placing the user at the center of the care process. Finally, it is pointed out that nurses need to always manifest themselves in the patient's defense, denouncing the grievance to which they are subjected in the context of health.

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