Moral distress among nursing professors: The exercise of parrhesia.

BACKGROUND: Mismatch between the perception of one's moral duty and one's real social contribution may trigger moral distress, especially when no specific resistance strategies are used to counteract morally distressing situations. Considering a philosophical-ethical conception, individuals need to first reflect upon themselves to later turn to the world and confront their current situation in order to change it. OBJECTIVES: To understand moral distress experienced by nursing professors teaching in higher education institutions and the use of parrhesia as a coping strategy. METHOD: This qualitative exploratory-descriptive study addressed 33 nursing professors working in Brazilian federal public universities using an open-ended question form. Data were collected between June and December 2018 and analyzed using discursive textual analysis. ETHICAL CONSIDERATIONS: The Institutional Review Board at the Federal University of Rio Grande approved this study. FINDINGS: Three categories emerged: performance of nursing professors and potentially distressing situations, the experience of moral distress, and parrhesia as a strategy to deal with moral distress. Nursing professors face situations that cause moral distress in the context of higher education, however, those who adopt parrhesia as a coping strategy find it easier to express their beliefs from the perspective of moral duty, even in the face of conflicts. CONCLUSION: When the nursing professors in this study acknowledge elements in the power structure that hinder their actions, they express parrhesia, as an essential virtue in an attempt to modify unsymmetrical power relations that can trigger moral distress.

Moral distress and professors of nursing: A cluster analysis.

BACKGROUND: Professors of nursing sometimes experience specific situations in their daily practice that conflict with their values and ethical principles and may culminate in moral distress. Moral distress occurs when one is prevented from acting according to his or her knowledge or values, or what one considers to be ethically sound. OBJECTIVES: To identify the profile of professors of nursing through grouping sociodemographic characteristics and intensity of moral distress. METHOD: Cross-sectional and exploratory study addressing 373 nurses teaching in Brazilian federal public higher education institutions. Data were collected from June to December 2018 through email, using the Google Docs tool. A moral distress scale directed to nurse educators was used. Data were analyzed using descriptive statistics, variance analysis, and cluster analysis. ETHICAL CONSIDERATIONS: The Institutional Review Board at the Federal University of Rio Grande approved this study. FINDINGS: Initially, four clusters emerged for each variable predicting the profile of Brazilian professors of nursing: sex; whether the individual worked in a graduate program; age; experience in years in their respective higher education institution; and intensity of moral distress. The profile of Brazilian professors of nursing was represented by the largest cluster, 36.5% (n = 136), composed of women working in graduate programs, aged 37 years old on average, having worked in their respective institutions for approximately 5 years, and presenting a moderate intensity of moral distress. CONCLUSION: Assigning individuals into groups facilitates seeing similarities among the predictors that compose the profile of Brazilian professors of nursing, thus recognizing those workers experiencing moral distress in their daily work routine. In addition, this study's results are expected to encourage reflection on the planning of efficacious interventions directed to the context of education and health.

Moral distress in undergraduate nursing students.

BACKGROUND: Moral distress is considered to be the negative feelings that arise when one knows the morally correct response to a situation but cannot act because of institutional or hierarchal constraints. OBJECTIVES: To analyze moral distress and its relation with sociodemographic and academic variables in undergraduate students from different universities in Brazil. METHOD: Quantitative study with a cross-sectional design. Data were collected through the Moral Distress Scale for Nursing Students, with 499 nursing students from three universities in the extreme south of Brazil answering the scale. The data were analyzed in the statistical software SPSS version 22.0, through descriptive statistical analysis, association tests (t-test and analysis of variance), and linear regression models. ETHICAL CONSIDERATIONS: Approval for the study was obtained from the Research Ethics Committee at Universidade Federal do Rio Grande. FINDINGS: The mean intensity of moral distress in the constructs ranged from 1.60 to 2.55. As to the occurrence of situations leading to moral distress in the constructs, the frequencies ranged from 1.21 to 2.43. The intensity level of moral distress showed higher averages in the more advanced grades of the undergraduate nursing course, when compared to the early grades of this course (between 5 and 10 grade, average = 2.60-3.14, p = 0.000). CONCLUSION: The demographic and academic characteristics of the undergraduate nursing students who referred higher levels of moral distress were being enrolled in the final course semesters, were at a federal university, and had no prior degree as an auxiliary nurse/nursing technician.

Applicability of the adapted Moral Distress Scale in the context of nursing in hemato-oncology services. / Aplicabilidade da Moral Distress Scale adaptada no cenário da enfermagem em hemato-oncologia.

OBJECTIVE: To verify the applicability of the adapted Moral Distress Scale in the nursing setting of the hemato-oncology sector of a university hospital. METHOD: Cross-sectional study conducted with 46 nursing workers of a university hospital in the southern region of Brazil with data collected between December 2014 and March 2015 by means of the adapted Moral Distress Scale. Factor analysis, Cronbach's alpha, and descriptive statistics were used to analyze the data. RESULTS: Factor analysis resulted in a group of 26 questions validated based on three factors: Lack of Competence in the Team, Denial of the Nursing Role as the Patient's Advocate, and Disrespect for the Patient's Autonomy. Cronbach's alpha of the instrument was 0.98. CONCLUSION: This study showed that the adapted Moral Distress Scale is an appropriate instrument for the identification of moral distress in nursing workers in the hemato-oncology area.

Actions for health advocacy and user empowerment by nurses of the Family Health Strategy. / Ações de advocacia em saúde e empoderamento do usuário por enfermeiros da Estratégia Saúde da Família.

OBJECTIVE: To understand the actions for health advocacy and user empowerment developed by nurses of the Family Health Strategy in Brazil. METHOD: A qualitative study carried out with nurses working in the Family Health Strategy in a city in the South of Brazil. Participants were selected by non-probabilistic, snowball sampling. Data was collected from a semi-structured interview guide, recorded, transcribed and analyzed through discursive textual analysis. RESULTS: Fifteen (15) nurses participated in the study. Three categories emerged: user participation; health environments; health advocacy actions related to the multiprofessional team. CONCLUSION: The closer relationship that the Family Health Strategy enables between the multiprofessional team, users and the community promotes health advocacy practices, while user empowerment favors autonomy in health care, encouraging a healthier life and enabling them to intervene in the health decisions of the local community.

Psychic workload in the process of work of maternity and obstetric centers nurses. / Cargas de trabalho psíquicas no processo de trabalho de enfermeiros de maternidades e centros obstétricos.

OBJECTIVE: To identify the psychic workload present in the work process of nurses working in Maternity and Obstetric Centers. METHOD: A descriptive qualitative study developed with 14 nurses working in obstetric centers and maternity units of two hospitals. The data were collected through a semi-structured interview, developed from October of 2015 to January of 2016, and exploited based on Content Analysis. RESULTS: The results were grouped into two categories: the nurses' working process and their psychic workload; and the maintenance of (in)appropriate practices such as psychic workload, demonstrating that the psychic workload is materialized in multiple elements of the work process, passing through assignments, interpersonal relationship and maintaining inadequate pipelines. CONCLUSIONS: It was identified that the psychic workload in the nurses' work process in the studied context is related to the perpetuation of dehumanized practices and to the challenge of maintaining humanized practices.

Productivity versus workloads in the nursing working environment.

Objective To analyze the association between the productivity loss of nursing workers and workloads in a teaching hospital. Method Descriptive study with a quantitative approach, conducted with nursing workers. A structured data collection instrument and the Work Limitations Questionnaire were used. Data analysis was performed using descriptive and analytical statistics, with the Kruskal Wallis test and the Spearman rank correlation. Results A total of 211 nursing workers participated in the study. They had an average of 6.38% of lost productivity; 75% of nursing technicians showed 9.57% of productivity loss, followed by nurses (8.75%) and nursing aides (8.50%). The units presenting the highest productivity loss were surgical clinic (8.81%), and medical clinic (8.58%). The rate of productivity loss was significantly associated with chemical loads (p=0.044) and with mechanical loads (p=0.041). Conclusion Workers presented productivity loss and work limitations associated with workloads, which shows they have difficulty performing the activities in part of the work time.

Constructing a theoretical model of moral distress.

Moral distress has been characterised as one of the main ethical problems affecting nurses in all health systems, and has been depicted as a threat to nurses' integrity and to the quality of patient care. In recent years, several studies tried to investigate moral distress, its causes and consequences for health professionals, clients and organisations. However, such studies are considered controversial and vulnerable, mainly because they lack a solid philosophical and empirical basis. The present article aimed at elaborating a theoretical model for moral distress, considering the process of moral deliberation, spaces of power and resistance and patient advocacy, and sought to carry out a reflection that culminated with the creation of a broader concept of moral distress.

[Nursing Actions in practicing inpatient advocacy in a Burn Unit]. / Ações dos enfermeiros no exercício da advocacia do paciente internado em um centro de queimados.

OBJECTIVE: Understanding nursing actions in the practice of inpatient advocacy in a burn unit. METHOD: A single and descriptive case study, carried out with nurses working in a referral burn center in southern Brazil. Data were collected through focus group technique, between February and March 2014, in three meetings. Data was analysed through discursive textual analysis. RESULTS: Three emerging categories were identified, namely: (1) instructing the patient; (2) protecting the patient; and (3) ensuring the quality of care. CONCLUSIONS: This study identified that the nurses investigated exercised patient advocacy and that the recognition of their actions is an advance for the profession, contributing to the autonomy of nurses and the effectiveness of patients' rights and social justice.

[Nursing beliefs and actions in exercising patient advocacy in a hospital context]. / Crenças e ações de enfermeiros no exercício da advocacia do paciente no contexto hospitalar.

OBJECTIVE: Analyzing beliefs and actions of nurses in exercising patient advocacy in a hospital context. METHOD: A quantitative cross-sectional exploratory and descriptive study, conducted with 153 nurses from two hospitals in southern Brazil, one public and one philanthropic, by applying Protective Nursing Advocacy Scale - Brazilian version. Data were analyzed using descriptive statistics and analysis of variance. RESULTS: Nurses believe they are advocating for patients in their workplaces, and agree that they should advocate, especially when vulnerable patients need their protection. Personal values and professional skills have been identified as major sources of support for the practice of advocacy. CONCLUSION: Nurses do not disagree nor agree that advocating for patients in their working environments can bring them negative consequences. It is necessary to recognize how the characteristics of public and private institutions have helped or not helped in exercising patient advocacy by nurses.

[Nurses, nursing technicians and assistants: who experiences more moral distress?]. / Enfermeiros, técnicos e auxiliares de enfermagem: quem vivencia maior sofrimento moral ?

OBJECTIVE: To identify the frequency and intensity of moral distress experienced by nurses, technicians and nursing assistants who worked in hospitals in the South of Rio Grande do Sul State. METHOD: A survey research was conducted with 334 nursing workers from three institutions, through a questionnaire of moral distress. Constructs were validated through factorial analysis and Cronbach's alpha: lack of competence of the working team, disrespect to the patient's autonomy, insufficient working conditions and therapeutic obstinacy. RESULTS: With descriptive statistics and analysis of variance, it was found that nurses and nursing assistants have higher perception of moral distress when compared to nursing technicians. Organizational questions and ways of communication influence lower perception of moral distress. CONCLUSION: Implementation of actions to favor coping, decision making and autonomy exercise from those workers.

[Nursing undergraduate education in relation to the death-dying process: perceptions in light of the complex thinking]. / Formação do enfermeiro em relação ao processo de morte-morrer: percepções à luz do pensamento complex.

The objective of this study was to perceive the death-dying process from the perspective of nursing students. This is an exploratory, descriptive and qualitative research study. Data were collected between June and July 2013, from three focus groups with six nursing students at a University Center located in the central region of Rio Grande do Sul, Brazil. The meetings were organized with an approach to increase discussions about the death-dying process from the perspective of the complex thinking. Data were analyzed by means of the Strategic Focal Analysis, and three categories were created: Death: a process of rupture or continuity?; Recognizing weaknesses in the undergraduate educational process; and Outlining strategies to broaden academic discussions. It is possible to conclude that the death/dying process is minimally discussed in undergraduate courses, and when it is discussed, it happens in a fragmented and disjunctive manner, without integrating it into the human living process. Descriptors: Death. Education, nursing. Attitude to death.

Moral distress: challenges for an autonomous nursing professional practice.

Constantly experiencing limiting situations that hinder a professional practice coherent with its principles - of autonomy and advocacy of users' interests -, and often conditioned to experience moral distress, the nursing profession plays a prominent role in the current health model because it has the characteristic of managing the care rendered to users in a perspective of social inclusion, both in the basic health network and in hospitals. Aiming at carrying out a reflection on the nursing practice and the difficulties present in its work routine, and considering its characteristics as a profession, this article sought to make a reflection between the practice of nursing and the numerous moral challenges imposed by the routine, resulting, in many cases, in a value crisis that can reverberate directly on the quality of the service rendered, and in abandonment of the ideals of advocacy for users.

Association between Moral Distress and Burnout Syndrome in university-hospital nurses.

OBJECTIVE: to analyze the association between moral distress and Burnout Syndrome among nurses in a university hospital. METHOD: descriptive, analytical study conducted with 269 nurses working in a university hospital located in Rio Grande do Sul, Brazil. Data were collected in person in 2019 by previously trained collectors. A sociodemographic and employment questionnaire, the Brazilian Scale of Moral Distress in Nurses and the Maslach Burnout Inventory were applied. Descriptive and analytical statistical analysis was used. RESULTS: an association was identified between moral distress intensity and frequency and its dimensions with Burnout Syndrome and its dimensions. Nurses with low professional achievement and high emotional exhaustion showed a higher prevalence of moral distress. CONCLUSION: an association between moral distress and Burnout Syndrome, as well as between their dimensions, was evidenced. The results suggest the need to investigate urgent interventions to mitigate the situations and manifestations of moral distress and Burnout Syndrome by developing strategies for workers' health.

Ethical issues experienced by nurses during COVID-19 in university hospitals.

OBJECTIVE: To identify the ethical issues experienced by nurses in the care for patients with COVID-19 and the factors that influence their occurrence. METHOD: This is a cross-sectional, quantitative study, carried out between February and May 2022 with 101 nurses from two university hospitals, through the socio-occupational Ethical issues Experienced by Nurses in Emergency Questionnaire, adapted and validated for Brazilians. Descriptive statistical analysis, Pearson's correlation test and linear regression were performed, adopting p-value. RESULTS: Ethical issues related to concern and stress in caring for infected patients were evidenced, being influenced by perception of social stigmatization (p = .003) and perception of hospital measures (p = .000). Agreement with infection control measures (4.46) and perception of hospital measures against COVID-19 (3.26) were factors with the highest mean between the constructs. CONCLUSION: Nurses are faced with ethical issues in the face of concern and stress in caring for patients with COVID-19, who are affected by social issues and assistance. It is essential to support them, promoting their mental and social well-being to deal with new emergency situations.

Burnout, ethical climate and work organization in covid-19 intensive care units: mixed method study.

OBJECTIVES: to analyze the association between burnout and the perception of the ethical climate in nursing professionals in the covid-19 Intensive Care Unit and the relationship with the organization of work from the perspective of managers of these units. METHODS: mixed method study conducted in three university hospitals in southern Brazil from December 2021 to March 2022. A cross-sectional study was developed with 110 nursing professionals, followed by an exploratory-descriptive study through semi-structured interviews with six managers. Descriptive and analytical statistics and discursive textual analysis were used. RESULTS: the prevalence of burnout was 10% and the perception of negative ethical climate was 24.5%. The association between burnout and ethical climate revealed overload and fatigue during working hours, related to tension, fear, and stress that emerged from the consequences of the organization and relations of work in the covid-19 Intensive Care Unit. CONCLUSIONS: there was an association between burnout and ethical climate and elements of the work organization.

[The experience of moral distress in nursing: the nurses' perception]. / Vivência do sofrimento moral na enfermagem: percepção da enfermeira.

With the objective to understand the nurses' perception of moral distress, as well as its frequency and intensity, this study used a survey utilizing a six-point Likert scale, with 124 nurses working in hospitals in southern Brazil in 2008. Using a self-administered questionnaire and factorial analysis, four constructs were identified and validated. The final results were obtained through three different analyses: 1) descriptive statistical analysis; 2) analysis of variance; and 3) multiple regression. The construct that showed the highest intensity of perception regarding moral distress was the lack of competency in the work team (4.55), followed by the nurse's denial of their role as patient advocate (4.30), therapeutic obstinacy (3.60) and disrespecting the patient's autonomy (3.57). Regarding the perception of the frequency of moral distress, once again, the highlighted construct was the lack of competency within the work team (2.42), followed by therapeutic obstinacy (2.26), the nurse's denial of their role as patient advocate (1.71) and disrespecting the patient's autonomy (1.42).

[Option and evasion of a bachelor's degree programme in nursing evaded students' perception]. / Opção e evasão de um curso de graduação em enfermagem: percepção de estudantes evadidos.

Qualitative study, developed in a Federal University in southern Brazil aiming to know the motives for choosing and evading a Bachelor's degree programme in Nursing, in the evaded students 'perception. The data were collected through a questionnaire sent by e-mail to 19 evaded students. The 9 questionnaires that returned were submitted to Qualitative Textual Analysis, and two categories emerged motives to opt for the nursing programme and motives to evade from the nursing programme. The results showed that the option for the programme is associated to personal vocation, perception of Nursing as a profession of care, and its closeness to the health area. Evasion seems to be related to passing the first option of undergraduate programme, ignorance about the profession, financial difficulties, and professional depreciation. We demonstrated that greater emphasis should be put on promoting knowledge about the nursing work, areas of activity and attributions.

Clustering the engagement of Brazilian nurses in political advocacy.

OBJECTIVES: to analyze the level of nurses' engagement in political advocacy by performing cluster analysis. METHODS: observational study, with a quantitative approach. A total of 184 nurses working in primary, secondary, and tertiary care in a city in the south of Brazil completed the Policy Advocacy Engagement Scale. Data analysis consisted of descriptive statistics, cluster analysis, analysis of variance, and chi2. The Institutional Review Board approved the study. RESULTS: four differentiated clusters were found according to professional experience, level of healthcare complexity, and unit. The cluster analysis revealed that patient advocacy for community-based obtained the highest mean, indicating that political advocacy is effective in organizational environments and that professional qualification favors greater engagement in political advocacy. CONCLUSIONS: the results reveal that nurses play an active role in political advocacy, seeking to promote positive changes in health, especially those working in tertiary care, the nurse group that obtained the highest means.

The performance of nursing students in a tele-health service during the COVID-19 pandemic.

OBJECTIVE: To identify the experiences of nursing students working in a telehealth service to fight the COVID-19. METHOD: Qualitative, exploratory, and descriptive study, addressing 31 undergraduate nursing students at a Federal University located in the extreme south of Brazil. Data were collected in October 2020 using an online questionnaire. Textual discourse analysis was used to interpret data. RESULTS: The students identified facilities, weaknesses, and potentialities of a telehealth service, verifying that it is a strategy that favors the development of skills and competencies during the training of students and to fight the COVID-19 pandemic. CONCLUSION: The results reveal the students' experiences in a telehealth service designed to fight the COVID-19, showing the importance of including this service in the routine of healthcare services.