ORIGINAL RESEARCH

Relationship between length of service and ethics violations in nursing

Adaiele Lucia Nogueira Vieira da Silva^I; Mariluci Camargo Ferreira da Silva Candido^II; Sebastião Junior Henrique Duarte^III; Ana Tania Lopes Sampaio^IV; Regina Maria dos Santos^V

^I Nurse. PhD student, Universidade Federal de Mato Grosso do Sul. Brazil. E-mail: adaiele@hotmail.com
^II Nurse. PhD in Psychiatric Nursing. Professor at the Federal University of Mato Grosso do Sul. Brazil. E-mail: mcfsc@uol.com.br
^III Nurse. PhD in Health Sciences. Professor at the Federal University of Mato Grosso do Sul. Brazil. E-mail: sjhd.ufms@gmail.com
^IV Nurse. PhD in Education. Professor at the Federal University of Rio Grande do Norte. Brazil. E-mail: anatsampaio@hotmail.com
^V Nurse. PhD in Nursing. Associate Professor IV of the Federal University of Alagoas. Brazil. E-mail: relpesantos@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.23058

ABSTRACT

Objective: to examine the relationship between length of service and ethics violations by nursing personnel involved in complaints filed with the Mato Grosso do Sul Regional Nursing Council (COREN/MS). Method: this retrospective, descriptive, documentary study examined complaints filed with the COREN/MS, from 2003 to 2013. The study was approved by the research ethics committee. Results: 111 complaints were filed from 2003 to 2013, relating mostly to mid-level workers (54.6%). Personnel with 1-5 years of training were involved in more ethics complaints (44.7%). Conclusion: ethics complaints involved predominantly newly-graduated nurses, indicating that further bioethics research is imperative in Brazilian nursing training, both to learn the real situation and to provide input to nursing teams' decision-making.

Descriptors: Nursing; bioethics; nursing education; education institutions.

INTRODUCTION

The nursing staff needs to reconcile, in their professional practice, knowledge, technical skills and a solid ethical-moral foundation, in addition to being aware of their professional responsibilities, especially in the face of ethical issues and occurrences.

It is emphasized that ethical occurrences are understood as harmful events caused by nursing professionals during their daily practice, resulting in harmful outcomes for both the client and co-workers, as well as for the institution, or the nursing professional itself.¹

The ethical infractions committed by nursing professionals, in addition to all their legal implications,² also violate the doctrinal principles of the Unified Health System (SUS – "Sistema Único de Saúde", in Portuguese), which demands comprehensive, equitable and universal care and assistance, principles dear to all who fought for a fairer and more resolute health system.^1,3

It is essential that the nursing professional becomes aware of the legal framework of their profession from the beginning of their formation, being the responsibility of the pedagogical project of the course chosen to address theoretical contents and practical experiences that lead to the consolidation of an ethical and safe attitude for oneself and for the others. The increasing mediatic dissemination of nursing ethical occurrences led to the following question: is there any relation between the time of professional exercise and the ethical occurrences?

In view of the above, the present study had the objective of analyzing the relationship between professional exercise time and ethical occurrences with members of the nursing team involved in delations registered at the Regional Nursing Council of Mato Grosso do Sul (COREN / MS – "Conselho Regional de Enfermagem de Mato Grosso do Sul", in Portuguese).

LITERATURE REVIEW

Regarding the training, the current National Curricular Guidelines of the Nursing Undergraduate Program (DCNs – "Diretrizes Curriculares Nacionais", in Portuguese), issued in November 2001, point to a generalist, humanist, critical and reflective formation; determining the qualification of the student for the exercise of the profession, based on scientific and intellectual rigor and based on ethical principles. It recommends a training in which the professional has the ability to act, with a sense of social responsibility and commitment to citizenship, acting as promoter of the comprehensive health of the human being.⁴

The National Curriculum Guidelines for the Professional Education at the Technical Level determine some general professional skills, one of which is to interpret and apply standards of professional practice and ethical principles ruling the conduct of the health professional.⁵

In Brazil, although the policies pursued by the Ministry of Education and Culture (MEC) and the Ministry of Health seek to guarantee references to the ethical and bioethical issues underlying the professional practice, evidencing its importance in the development of the skills and competences of the nursing team, there is still widespread dissemination of the violation of ethical and bioethical principles through the media. ⁶

Considering the understanding that every ethical occurrence implies non-observance of a bioethical principle, the mainstream bioethics, discussed in this study, defends the existence of four fundamental principles, these being: non-maleficence, beneficence, autonomy and justice.⁷

METHODOLOGY

This is documentary, descriptive and retrospective research, whose primary sources were the complaints filed to COREN/MS, with a temporal clipping from 2003 to 2013. The inclusion criteria adopted were: the complaints should be available in the COREN/MS computerized system; processes should be closed and archived. The documents that were not available in electronic registries were excluded from the study. The data collection was carried out from November 2013 to January 2014. The findings were analyzed from February 2014 to November 2014.

In this study, it was sought to respect ethical principles, keeping the anonymity and confidentiality of those involved. The research was carried out after the approval of the Research Ethics Committee of the Federal University of Mato Grosso do Sul, with Opinion No. 438.302/2013.

It should be emphasized that, first, the research project was presented to the COREN/MS Counselors, explaining the objectives and methods of the study. With the approval of COREN/MS and the Ethics Committee, the study was initiated.

For the internal and external critical analysis of the documents, an instrument was built based on the experience of the researchers, taking as reference the documentary analysis method. The external critical analysis attested the authenticity, origin and custody of the documents; and the internal critical analysis evidenced the content of the documents, with respect to the its components. The variables found were: category of the professionals involved in ethical occurrences, training time up to the date of the occurrence, and bioethical principle involved.

The descriptive analysis of the data was carried out, which were treated with statistical resources as simple frequency and percentage. The results were presented with the support of tables and discussed with the literature produced on the topic. A total of 111 reports of ethical occurrences registered in COREN/MS were analyzed, involving 68 nurses, 41 nursing technicians and 41 nursing assistants.

RESULTS AND DISCUSSION

The data show that mid-level professionals were the ones most involved in ethical occurrences in Mato Grosso do Sul, which may be associated with the largest contingent of them in the State, as described in Table 1.

Table 1: Distribution of nursing professionals involved in ethical occurrences with COREN/MS, according to the professional category. Campo Grande – MS, Brazil, 2014.

The increasing number of cases of ethical occurrences can be explained by several factors that involve them, from low pay, work overload, stress, inadequate working conditions, to professional training. Nevertheless, all these situations do not exempt the responsibility of the professionals of guaranteeing to the person, family and collectivity nursing care free of damages due to malpractice, negligence or recklessness.^8-12

The number of nursing and technical courses has been growing in recent years,⁶ many without proper supervision. Therefore, it is highlighted the importance to discuss and reflect on the training and preparation of the nursing team to confront the most diverse ethical conflicts related to professional practice.¹³

The findings showed that 82 (54.6%) nursing professionals, involved in the 111 reports, were technicians and nursing assistants. Data from COREN/MS indicate that mid-level professionals constitute a group of 12,873 professionals,¹⁴ being the largest contingent of nursing professionals in the state. Despite the significant figures, it is known that the poor training and the low remuneration of these professionals, whose consequence is reflected in the need of exercising double work shifts, undoubtedly corroborate to the incidence of ethical occurrences. ¹⁵

Thus, the increasing number of open positions for the professionalization in the nursing area, without the increase in the supply of new jobs in the same proportion, has generated what can be described as structural unemployment, since the supply-demand relationship does not occur in the same extent. As a consequence, the large availability of manpower promotes the increase of precarious work conditions. Thus, the worker ends up undergoing worse working conditions as a means of staying in employment, thus ensuring their income.^16,17

The current way of offering courses without the monitoring of their quality can be a risk, it is added that in the area of health what is put at risk is the life of the population.¹⁸ In this sense, studies point to the need for regulation and establishment of quality parameters so that there is not only a quantitative increase in the open positions, but also a quality training, with professionals who intervene positively in the current models of healthcare.^18,19

Regarding the time elapsed, from the conclusion of the course to the date of ethical occurrence, the data showed that 13 (8.7%) occurrences happened with professionals who had less than one year of experience in the profession. Perhaps this situation can be explained by the fact that during the probationary period or when the professional is newly hired, in addition to being more attentive, they are also under constant supervision and accompaniment of another health professional, in many cases of the nurse responsible for the unit.^1,2

Considering those involved, there was a predominance of working time between 1 and 5 years, from the completion of the course to the date of the occurrence, with 67 (44.7%) workers. See Table 2.

Table 2: Distribution of the professionals involved in ethical occurrences, according to category and time of training. Campo Grande – MS, Brazil, 2014.

Attention should be drawn to the involvement of professionals with less than one year of experience in ethical infractions, because even with the low percentage, they are newly graduated, assuming that their technical-scientific and ethical knowledge should be fresher in memory and in care practices.

Considering the predominance of working time from 1 to 5 years, 67 (44.7%), this finding evidences that the knowledge of the values and ethical principles that guide the professional exercise have not been apprehended as it should in the school, in addition to refer to the importance of the training, improvement or retraining actions to update the knowledge acquired in professional training, especially regarding bioethics.

A study conducted in 16 undergraduate nursing courses at federal universities has shown that in only 50% of the institutions, the bioethical discipline or thematic is given directly. And the theme was treated as a complementary topic of other disciplines and not as a central focus in the teaching-learning process.^20-22

The discussion of issues involving the training of nursing professionals is challenging, given the inexpressive number of publications on the subject, especially in the training of mid-level professionals.^20-22 It is perceived that the bioethical principles of the non-maleficence, beneficence, autonomy and justice⁷have not received a prominent position in the training of nursing professionals.^20-25

Faced with the bioethical principles violated, it is necessary to be aware that it is enough to violate one of them for all to be implicated, since the relations between these principles are visceral.^7,23

The principles of the non-maleficence and justice were the most violated by nursing professionals, with working time between 1 and 5 years, as can be seen in Table 3.

Table 3: Distribution of the professionals involved in ethical occurrences, according to the bioethical principle infringed and training time. Campo Grande – MS, Brazil, 2014.

It is important to highlight that all the four principles were violated, with a predominance of the group with experience time between 1 and 5 years of activity in the profession, according to Table 3.

The violation of the principle of autonomy is an intriguing fact, since it indicates the violation of one of the most widely debated bioethical principles; respect for the autonomy of the patient, in the face of their health-illness process, refers to telling the truth, respecting privacy, protecting confidential information, obtaining consent for interventions, and helping them make important decisions.⁸

This data indicates that the individuals are prevented from making decisions regarding their health care, totally countering the conceptual bases of autonomy, because in the health services, users should be consulted about their desires, options and plans, based on clear and accessible information about the health-illness process experienced by them.

The results show the need to discuss the training of nursing professionals in the professional and bioethical ethical context.²⁶

Thus, understanding these principles is fundamental for nursing, because the provision of healthcare requires the application of the principles of bioethics during the care provision, whether in respect to the individuality of the patient, by providing risk-free and harmless healthcare while meeting the needs of each individual or by providing information on the care to be provided to both patient and family, giving them the right to exercise autonomy - to accept or refuse the therapeutic proposals.²⁷

CONCLUSION

The study of the relation between the ethical occurrence and the training time showed that professionals with less experience (less than 1 year) were not the most involved in ethical occurrences. However, the predominance of ethical problems among professionals with 1 to 5 years of experience raises questions about their training: How are nursing professionals being prepared for the job market? Is the nursing team prepared to come across ethical issues and the dilemmas of the profession, avoiding or minimizing their grievances?

The violation of the principles of beneficence and non-maleficence indicates acts of negligence, malpractice and/or recklessness, which leads to the reflection of the professional training as recommended in the DNCs.

Another aspect to be considered is the professor's education in nursing, that is, who educates the educators? How are the professors being trained? Are the methodologies and content addressed in the training compatible with the paradigm of ethical healthcare? What criteria and parameters are being used to evaluate nursing courses and professors?

Finally, there are several questions that point to the need for greater supervision of professional training courses by the responsible bodies, higher or medium level, guaranteeing the quality of teaching, in addition to prepare the future nursing worker for the exercise of the profession, providing them with subsidies to deal with all the dilemmas inherent to their daily practice.

Such reflections reinforce the need to research more about bioethics in Brazilian nursing education, both to know the real situation and to provide subsidies for nursing team decision-making in the face of ethical dilemmas.

There are several factors underlying the ethical occurrences in the professional practice of nursing. The technical and scientific training must be linked to an appropriate ethical guidance, which in addition to humanizing care and respecting the rights of patients also favors the recognition of professional responsibilities, rights and duties.

REFERENCES

1.Oguisso T, Schmidt MJ. O exercício da enfermagem: uma abordagem ético-legal. 3ª ed. at. ampl. Rio de Janeiro: Guanabara Koogan; 2013.

2.Ministério da Saúde (Br). Abc do SUS: doutrinas e princípios. Brasília (DF): Ministério da Saúde. [citado em 15 set 2017] Disponível em http://www.pbh.gov.br/smsa/biblio grafia/abc_do_sus_doutrinas_e_pri ncipios.pdf .

3.Oguisso T, Freitas GF. Brazilian nursing history on the shoulders of giants. Int. nurs. rev. [Internet]. 2015; [cited 2017 Dec 07]. 62(1):75-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25475384 . DOI: https://doi.org/10.1111/inr.12154 .

4.Conselho Nacional de Educação (Br). Câmara de Educação Superior. Resolução CNE/CES N. 3, de 07 de novembro de 2001. Institui as Diretrizes Curriculares Nacionais do Curso de Graduação em Enfermagem. Diário Oficial da República Federativa da União. Brasília, 09 nov. 2001. Seção 1, p.37.

5.Ministério da Educação (BR). Educação Profissional: Diretrizes Curriculares Nacionais para a Educação Profissional de Nível Técnico. Brasília (DF): Ministério da Educação; 2000.

6.Teixeira E, Fernandes JD, Andrade AC, Silva KL, Rocha MEMO, Lima RJO. Panorama dos Cursos de Graduação em Enfermagem no Brasil na década das Diretrizes Curriculares Nacionais. Rev. bras. enferm. (Online). 2013[citado em 05 maio 2017]. 66(esp):102-10. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672013000700014 .

7.Beauchamp TL, Childress JF. Princípios de ética biomédica. 2ª ed. Tradução de Luciana Pudenzi. São Paulo: Edições Loyola; 2011.

8.Novaretti MCZ, Santos EV, Quitério LM, Daud-Galloti RM. Sobrecarga de trabalho da enfermagem e incidentes e eventos adversos em pacientes internados em UTI. Rev. bras. enferm. (Online). 2014; 67(5):692-9.DOI: http://dx.doi.org/10.1590/0034-7167.2014670504 .

9.D'Aquino FFR, Juliani CMCM, Lima SAM, Spiri WC, Gabriel CS. Drug-related incidents in a hospital: input to improving management. Rev. enferm. UERJ. 2015; 23(5):616-21.

10.Lima CSP, Barbosa SFF. Occurrence of adverse events as indicators of quality of care in an intensive care unit. Rev. enferm. UERJ. 2015; 23(2):222-8. DOI: https://doi.org/10.12957/reuerj.2015.6076 .

11.Moreira IA, Bezerra ALQ, Paranaguá TTB, Silva AEBC, Azevedo Filho FM. Health professionals' knowledge regarding adverse events in the intensive care unit. Rev. enferm. UERJ. 2015; 23(4):461-7.

12.Conselho Federal de Enfermagem. Resolução COFEN nº 311, de 8 de fevereiro de 2007. Aprova a reformulação do Código de Ética dos Profissionais de Enfermagem. Código de ética dos profissionais de enfermagem. [Internet]. Brasília (DF): CDFEn; 2007 [citado em 20 set 2017]. Disponível em: http://novo.portalcofen.gov.br/resoluo-cofen-3112007_4345.html .

13.Nora CRD, Deodato S, Vieira MMS, Zoboli ELCP. Elementos e estratégias para a tomada de decisão ética em enfermagem. Texto & contexto enferm. 2016; 25(2):e4500014. DOI: http://dx.doi.org/10.1590/0104-07072016004500014 .

14.Conselho Regional de Enfermagem de Mato Grosso do Sul. Ofício Gabinete COREN-MS nº 273 de 21 de março de 2012. Campo Grande (MS): COREN/MS; 2012.

15.Marin MJS, Dias MUSS, Tonhom SFR, Michelone AP, Bernardo MCM. Estudantes de curso Técnico em Enfermagem e sua motivação para o trabalho em enfermagem. Rev. eletrônica enferm. [Internet] 2014 [citado 05 set 2017]. 16(2):401-7. Diponível em: https://revistas.ufg.emnuvens.com.br/fen/article/view/20827/17265. DOI: 10.5216/ree.v16i2.20827.

16.Ribeiro AC, Souza JF, Lima JL. A precarização do trabalho no SUS na perspectiva da enfermagem hospitalar. Cogitare enferm. 2014; 19(3): 569-75. DOI: http://dx.doi.org/10.5380/ce.v19i3.33034 .

17.Fernandes JD, Teixeira GAS, Silva MG, Florêncio RMS, Silva RMO, Santa Rosa DO. Expansão da educação superior no Brasil: ampliação dos cursos de graduação em enfermagem. Rev. latinoam. enferm. (Online). [Internet] 2013 [citado em 05 fev 2017]. 21(3):670-8. Disponível em: http://www.revistas.usp.br/rlae/article/view/75972/79502 . DOI: http://dx.doi.org/10.1590/S0104-11692013000300004.

18.Vieira AL, Silva GTR, Fernandes JD, Silva ACAB, Santana MS, Santos TBS. Des-interesse no ensino profissionalizante na produção do Seminário. Rev. bras. enferm. (Online). 2014; 67(1): 141-8. DOI: http://dx.doi.org/10.5935/0034-7167.20140019 .

19.Silva KL, Sena RR, Silveira MR, Tavares TS, Silva PM. Desafios da formação do enfermeiro no contexto da expansão do ensino superior. Esc. Anna Nery Rev. Enferm. 2012; 16 (2):380- 7. DOI: http://dx.doi.org/10.1590/S1414-81452012000200024 .

20.Rates CMP, Pessalacia JDR, Mata LRF. Enfermagem brasileira frente às questões bioéticas: revisão integrativa. Rev. enferm. Cent.-Oeste Min. 2014; 4(1):1036-47. DOI: http://dx.doi.org/10.19175/recom.v0i0.567 .

21.Silva AC, Silva GT, Silva RM, Vieira SL, Santana MS. Secondary professional education: characterization of scientific production in graduate studies. Acta paul. enferm. 2013; 26(5):499-505. DOI: http://dx.doi.org/10.1590/S0103-21002013000500015

22.Couto Filho JCF, Souza FS, Silva SS, Yarid S, Sena ELS. Survey of bioethics teaching in Nursing Courses of Brazilian Federal Universities. Rev. bioét. (Impr.). 2013;21(1): 173-9. DOI: http://dx.doi.org/10.1590/S1983-80422013000100021 .

23.Silva ALNV da, Silva MCF da, Duarte SJH, Santos MS dos. Complaints filed against nursing professionals: Mapping a Brazilian reality. Nursing Ethics [Internet] 2016 [cited 2017 Sep 10]; 8(23). Available from: http://journals.sagepub.com/doi/abs/10.1177/0969733015587777. DOI: https://doi.org/10.1177/0969733015587777

24.Laukkanen L, Leino-Kilpi H, Suhonen R. Ethical activity profile of nurse managers. J. Nurs. Manag. [Internet] 2015 [cited 2017 Sep 15]. 24(4). Available from: http://www.ncbi.nlm.nih.gov/pubmed/26597499 . DOI: 10.1111/jonm.12348

25.Emran SAN. The four-principle formulation of common morality is at the core of bioethics mediation method. Med. health care philos. [Internet] 2015 [cited 2017 Dec 10]. 18(3):371-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25424703 .

26.Mendonça FAC, Menezes MV, Amorim SC, Morais FDM, Feitosa EMN, Lacerda CMM. Processo ético de enfermagem no estado do Ceará: reflexão para prática profissional. Enferm. foco. 2017; 8 (2): 77-81. DOI: https://doi.org/10.21675/2357-707X.2017.v8.n2 .

27.Silva ALNV, Candido MCFS, Duarte SJrH, Santos RM. Violations and ethical incidents committed by nursing professionals: an integrative review. Rev. enferm. UFPE on line. 2015;9(1):201-11. DOI: https://doi.org/10.5205/1981-8963-v9i1a10326p201-211-2015 .