Ethical infractions committed by nursing professionals received by the nursing ethics committee: integrative review

Abstract

Objective

To identify, analyze, and characterize the incidents committed by nursing professionals received by the Nursing Ethics Committee.

Methods

Integrative review conducted according to the methodology defined by the Manual for Evidence Synthesis from the Joanna Briggs Institute and registered on the Open Science Framework platform. Databases searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE via PubMed^®), Web of Science, SciVerse Scopus (SCOPUS), Latin American and Caribbean Literature in Health Sciences (LILACS) and Nursing Database (BDENF) via Virtual Health Library (VHL). Studies entirely published in Portuguese, English, or Spanish (2018-2023) were included. Data management was carried out with Rayyan^®.

Results

A growing interest in infractions in complaints attributed to nursing professionals, which were accepted by the Nursing Ethics Committee in the professional context of the health area and expressed by predominant publications in the last five years, was verified.

Conclusion

Mid-level professionals were the most reported, with a greater participation of Nursing Assistants. Negligence and Illegal Exercise of Profession were the criminal types of ethical infractions with the highest incidence. Nursing Ethics Committees, followed by victims’ families, Regional Nursing Councils, victims, and nurses were the main categories of complainants of ethical violations. Verbal Warning was the most prevalent type of penalty applied.

Ethics, nursing; Nurse practitioners; Ethics committees; Legal process; Brazil

Resumo

Objetivo

Identificar, analisar e caracterizar as ocorrências cometidas por profissionais de enfermagem acolhidas pela Comissão de Ética de Enfermagem.

Métodos

Revisão integrativa conduzida conforme a metodologia definida pelo Manual for Evidence Synthesis do Joanna Briggs Institute e registrada na plataforma Open Science Framework. Bases de dados pesquisadas: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System on-line (MEDLINE via PubMed®), Web of Science, SciVerse Scopus (SCOPUS), Literatura LatinoAmericana e do Caribe em Ciências da Saúde (LILACS) e Base de dados de Enfermagem (BDENF) via Biblioteca Virtual em Saúde (BVS). Incluídos estudos publicados integralmente em português, inglês ou espanhol de 2018 a 2023. Gerenciamento dos dados realizado com o Rayyan®^.

Resultados

Verificado um crescente interesse pelas infrações em denúncias imputadas a profissionais de Enfermagem acolhidas pela Comissão de Ética de Enfermagem no contexto profissional da área da saúde, expressas pelas publicações predominantes nos últimos cinco anos.

Conclusão

Profissionais de nível médio foram os mais denunciados, com maior participação de Auxiliares de Enfermagem. Negligência e Exercício Ilegal da Profissão foram os tipos penais de infração ética com maior incidência. As categorias dos denunciantes de infração ética foram as Comissões de Ética de Enfermagem, seguidas pelos familiares das vítimas, Conselhos Regionais de Enfermagem, vítimas e enfermeiros como denunciantes principais. Advertência Verbal foi o tipo de penalidade aplicada com maior prevalência.

Ética em enfermagem; Profissionais de enfermagem; Comissão de ética; Processo legal; Brasil

Resumen

Objetivo

Identificar, analizar y caracterizar infracciones cometidas por profesionales de enfermería admitidas por la Comisión de Ética de Enfermería.

Métodos

Revisión integradora llevada a cabo de acuerdo con la metodología establecida por el Manual for Evidence Synthesis del Joanna Briggs Institute y registrada en la plataforma Open Science Framework. Búsqueda en las siguientes bases de datos: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System on-line (MEDLINE vía PubMed®), Web of Science, SciVerse Scopus (SCOPUS), Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS) y Base de Datos de Enfermería (BDENF) a través de la Biblioteca Virtual en Salud (BVS). Se incluyeron estudios publicados con texto completo en portugués, inglés o español de 2018 a 2023. La gestión de los datos se realizó con Rayyan®^..

Resultados

Se verificó un creciente interés por las infracciones en denuncias imputadas a profesionales de enfermería admitidas por la Comisión de Ética de Enfermería en el contexto profesional del área de la salud, demostrado mediante las publicaciones predominantes en los últimos cinco años.

Conclusión

Los profesionales de nivel medio fueron los más denunciados, con una mayor participación de auxiliares de enfermería. Los tipos penales de infracción ética con mayor incidencia fueron negligencia y ejercicio ilegal de la profesión. Las categorías de los denunciantes de infracciones éticas fueron las Comisiones de Ética de Enfermería, seguidas de los familiares de las víctimas, Consejos Regionales de Enfermería, víctimas y enfermeros como denunciantes principales. La advertencia verbal fue el tipo de penalidad aplicada con mayor prevalencia.

Ética en enfermería; Enfermeras practicantes; Comités de ética; Proceso legal; Brasil

Introduction

Nursing is considered the art and science of care and was initially practiced by lay voluntary people linked to religious motivation. Its professionalization emerged in England, in the second half of the 19^th century, with Florence Nightingale when hospital reorganization began under the impact of imperialist wars. She played a crucial role in assisting wounded individuals during the Crimean War. She is recognized as a pioneering British nurse. Her contributions were significant to the advancement of nursing practices and the global dissemination of high standards of hospital hygiene. Her legacy endures as a pivotal figure in the history of modern nursing, notable for her dedication to health care and the substantial improvements she introduced to conditions of care during and after the conflict.(¹)

In Brazil, Nursing was regulated as a profession by Law 2,604 (1955), which states in the first article: “Nursing is free throughout the national territory if the provisions of this law are observed”.(²) Law 7,498, which regulates the practice of nursing and provides other measures, was published in 1986, and nursing is exclusively practiced by Nurses, Nursing Technicians, Nursing Assistants, and Midwives if their respective qualification degrees are respected.(³) The representative bodies of these professional categories, the Federal Nursing Council (COFEN), and the Regional Nursing Councils (COREN) were created by Law 5,905 (1973).(⁴) Among other functions, COFEN is responsible for elaborating the Code of Ethics for Nursing Professionals (CEPE) and amending it when necessary, in agreement with COREN, which is responsible for supervising professional practice.(⁵,⁶)

The first Code of Ethics for Nursing Professionals (CEPE; published in 1975) brought together norms, principles, rights, and duties guiding professional practice. However, with the socio-economic, political, and cultural transformations that occurred over time, updates to CEPE were necessary considering the need for Nursing assistance to the population, culminating in the current CEPE (COFEN Resolution 564/2017).(⁶)

The ethical and moral formation of individuals is crucial for the development of professional ethics. This construction of values, originating in family, educational, and social contexts, influences moral consciousness throughout life. These ethical foundations, which have been internalized over time, directly impact professional conduct in the workplace. The integration of personal ethics with professional ethics facilitates decision-making, respect for professional standards, and the promotion of interpersonal relationships based on integrity. Thus, ethical and moral formation not only reflects the integrity of individuals, but is based on universal principles and concepts, such as respect for life, dignity, and human rights without discrimination of any kind.(⁷)

In November 2018, COFEN approved Resolution 593/2018 establishing the obligation to create and operationalize Nursing Ethics Commissions (CEEs) across Brazilian territory as entities representing the Regional Councils in the Nursing Services of institutions. It established the obligation to create and operate the CEE in institutions with at least 50 nursing professionals in their team of collaborators.(⁸)

The elected or designated members of the CEE must carry out their activities in an honorific character, providing activities relevant to the nursing service of the institution to which they belong and to COREN of the State of São Paulo following the COREN-SP Decision, PLENARY 014/2018. They must maintain their autonomy and impartiality, safeguarding secrecy and discretion on matters linked to the ethical and disciplinary conduct of nursing professionals, being responsible for forwarding them to the Continuing Education Sector for prevention, education, and guidance actions on ethical issues experienced in everyday life.(⁹,¹⁰) Ethical and disciplinary infraction comprises action, omission, or collusion that implies disobedience and/or non-compliance with the provisions of CEPE, as well as non-compliance with the rules of the COFEN/CORENs system (COFEN Resolution 564/2017).(⁴,⁶)

Over the years, nursing has gained increasing space in the health field, playing a fundamental role in the care and promotion of quality of life and well-being. In the Brazilian context, nursing stands out as the largest health category in the country, highlighting its importance and significant contribution to the national health system. The continuous advancement and recognition of nursing reflect not only the evolution of the profession but also its undeniable relevance in providing health services to the Brazilian population. Thus, she has assumed much more responsibility for the actions or omissions of professionals who expose the nursing team to greater risks in the context of ethical and legal issues. Failure to comply with COFEN’s laws and resolutions leads these professionals to ethical and legal infractions related to rights, duties, and prohibitions established by CEPE.(⁵,⁶,¹¹-¹⁸)

The knowledge of nursing professionals about the law that regulates the Nursing Practice and CEPE (as a normative instrument that directs their practice to different areas of activity) is fundamental for ethical action, free from malpractice, imprudence, and negligence, thus complying with the foundations and guiding principles of an ethical and safe professional practice, ensuring quality assistance with respect for human dignity.(¹²-¹⁸)

Therefore, we conducted an integrative review of the literature considering the importance of nursing professionals understanding the legislation that regulates the exercise of their profession. In this context, we sought to identify, analyze, and characterize the occurrences committed by nursing professionals that were accepted by the Nursing Ethics Committee (level of the professional reported, criminal types of ethical infractions, categories of complainants, and type of penalty applied).

Methods

This bibliographic study of the Integrative Literature Review type was conducted in six steps as follows: 1) Identification of the topic and selection of the research question, 2) Establishment of inclusion and exclusion criteria, 3) Pre-selection and selection of studies of interest, 4) Categorization of selected studies, 5) Analysis and interpretation of results, and 6) Review/Synthesis of knowledge.(¹⁹) The objective of the review was divided into two questions: 1- “What are the infractions in the complaints attributed to nursing professionals received by the Nursing Ethics Committee?” and 2- “What can be inferred from these infractions?” They were developed based on the PICo strategy,(²⁰)in which P corresponds to the population (Nursing Professionals), I corresponds to the phenomenon of interest (Ethics Committee) and Co corresponds to the context (Ethical Infractions).

The searches were conducted in the period Jan-Jul 2023. Studies fully published in Portuguese, English, or Spanish in the period 2018-2023 were the inclusion criteria.

The summary published in 2018 “Infractions committed by nursing professionals investigated by the nursing ethics committee: integrative review of the literature” was published in the period 2003-2017.(²¹)

Editorials, dissertations, theses, reflections, literature reviews, gray literature, and duplicate studies were excluded. Records on specific and multidisciplinary nursing bases were maintained. The databases were accessed through the CAPES Journal Portal, and the search steps (identification, screening, eligibility, and inclusion) were independently performed by two reviewers.

The databases searched were the following: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE via PubMed^®), Web of Science, SciVerse Scopus (SCOPUS), Latin American and Caribbean Literature in Health Sciences (LILACS), and Nursing Database (BDENF) via Virtual Library in Health (VLH).

To conduct the searches, controlled and uncontrolled descriptors were selected after consulting the controlled vocabularies, Descriptors in Health Sciences (DeCS), and Medical Subject Headings (MeSH). The subjects and synonyms used to structure the search strategy were as follows: Nursing Professionals, Ethics Committee, Ethics in Nursing, Codes of Ethics, Ethical Occurrences, Ethical Nursing Processes, and Brazil along with the following keywords: Nursing Professionals, Ethics Committee, Nursing Ethics, Codes of Ethics, Ethical Occurrences, Ethical Nursing Processes, and Brazil. To expand the recruitment of references, a personalized search strategy was used to meet the particularities of each database. In each of them, the Boolean operators “OR”, “AND”, and “NOT” were used.

Search strategies

The searches were independently performed by two reviewers. In each database, the standard search strategy together with authors was adopted, maintaining standardization and adequacy for each of the other databases searched, which were as follows:

1. Cumulative Index to Nursing and Allied Health Literature (CINAHL) via (EBSCO): (“Ethics Committee”) AND (“Codes of Ethics”) AND (“Nursing Professionals”) AND (“Ethics in Nursing”) AND (“Brazil”) AND (“Ethics Committee) OR (“Codes of Ethics”) OR (“Nursing Professionals”) OR (“Ethics in Nursing”) AND (“Brazil”);

2. Medical Literature Analysis and Retrieval System Online (MEDLINE) accessed via the National Library of Medicine (PubMed): (“Ethics Committee”) AND (“Codes of Ethics”) AND (“Nursing Professionals”) AND (“Ethics in Nursing”) AND (“Brazil”) AND (“Ethics Committee ”) OR (“Codes of Ethics”) OR (“Nursing Professionals”) OR (“Ethics in Nursing)” AND (“Brazil”);

3. Web of Science: (“Ethics Committee”) AND (“Ethics in Nursing”) AND (“Ethical Occurrences”) AND (“Ethics Committee”) OR (“Ethics in Nursing”) OR (“Ethical Occurrences”) OR (“ Ethical Nursing Processes”) AND (“Nursing Professionals”);

4. SciVerse Scopus (SCOPUS): Ethics Committee OR Nursing Ethics OR Ethical Occurrences AND Nursing Ethical Processes AND Nursing Professionals;

5. Latin American and Caribbean Literature in Health Sciences (LILACS): (“Ethics Committee”) OR (“Nursing Ethics”) OR “(Ethical Occurrences”); (“Ethical nursing processes”) AND (“Nursing Professionals”);

6. Nursing Database (BDENF) via Virtual Health Library (VHL): (“Ethics Committee”) OR (“Nursing Ethics”) OR “(Ethical Occurrences”); (“Ethical nursing processes”) AND (“Nursing Professionals”).

This integrative review was conducted according to the methodology defined by the Manual for Evidence Synthesis from the Joanna Briggs Institute (JBI)(²²,²³)prepared and registered on the Open Science Framework (OSF; https://doi.org/10.17605/OSF.IO/53U8R ) platform to ensure transparency of the review.

The searches were performed in the period 24 Jan-06 Jul 2023 and data management was carried out using the Rayyan^® software.

Of the 350 articles selected by the search strategy, 336 articles were included to select the reading of titles and abstracts after excluding 14 duplicate articles. After applying the eligibility criteria, a sample of nine studies was obtained. Figure 1 shows the path taken for identification, screening, eligibility, and inclusion based on Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).(²⁴)

Figure 1
Flowchart of the integrative review search strategy. Flow diagram (PRISMA 2020) for new systematic reviews including searching databases, registries, and other sources

The instrument validated by Ursi(²⁵)was used to collect the selected articles and modified to meet the study objectives (^{Appendix 1}). Due to the bibliographic nature of the research, appraisal by the Research Ethics Committee was not necessary. However, the ethical and legal aspects regarding the authorship of the articles were maintained. Furthermore, no author involved in the study is linked to any funding institution; thus, no conflict of interest exists.

Results

The available evidence on infractions in complaints attributed to nursing professionals, which were accepted by the nursing ethics committee, was extracted from the final sample of nine articles(²⁶-³⁴)(Chart 1). As expressed by predominant publications in the last five years, a growing interest in infractions in complaints attributed to nursing professionals, which were accepted by the CEE in the professional context of the health area, was verified.(²⁶-³⁴) Regarding the design, documentary research approaches(²⁹-³²)and exploratory-descriptive,(²⁶-²⁹,³¹,³³)retrospective,(²⁶-²⁷,³¹,³³)and cross-sectional,(²⁶,³¹)studies with quantitative(²⁷,²⁹,³²)and quantitative-qualitative(²⁸,³⁴)approaches predominated Studies performed in the State of São Paulo by Mattozinho and Freitas(²⁸,²⁹)and in Mato Grosso do Sul by Silva et al.(³⁰,³³)have highlighted the topic. Articles presenting processes and complaints to the Regional Nursing Councils in Brazil were selected. The analytical reading of the nine articles selected for this review made it possible to diagnose four main aspects related to the complaints: I- Professional nursing categories reported; II- Categories of complainants of ethical violations; III- Criminal types of ethical infractions accepted by the CEE, and IV- Types of penalties applied by the Regional Nursing Councils and/or Federal Nursing Council.

Discussion

Nursing professional categories reported

Two aspects are highlighted when data on the professionals involved in ethical infraction reports are observed. Their level of training is the most relevant. The findings in the articles analyzed show that mid-level professionals, technicians,(²⁶,³¹,³³-³⁴)and nursing assistants(²⁹-³⁰,³²-³⁴)are the most reported, and incidents involving nursing assistants are the most prevalent. In general, the rate of infractions committed by such assistants was greater than 40,0%,(²⁹,³⁰,³²,³⁴)and the proportion of complaints among nursing assistants and technicians was identical in only one of the surveys.(³³)

In health institutions, nursing professionals with secondary education are generally the largest contingent. His contact with patients is more frequent, and this would be the first explanation for the greater number of involvement reports. In addition, it is common for nursing assistants without the necessary training to feel compelled to carry out procedures that should be carried out by nurses or technicians.

However, one of the studies identified nurses as the most reported category, followed by nursing technicians and assistants,(²⁷)diverging from most of the studies analyzed here.(²⁶,³¹,³³-³⁴) Nurses have a greater professional responsibility (Law 7,498/86),(³)covering activities ranging from assistance, through management and planning, to responsibility for the nursing team. This may explain the result found.

In the articles analyzed, professionals with less experience and at the beginning of their careers were prevalent. In the article by Silva et al. (2020),(³⁰)the lack of experience related to complaints is evident: 41.2% of the 17 nurses involved in infractions were young professionals (20-30 years old). Lack of experience can be a reason for errors in conduct. On the other hand, younger professionals should have a more recent understanding of the ethical values and principles that guide professional practice as they completed their training more recently. However, the opposite is observed, indicating that training on this subject is still deficient in the nursing area, also showing the need for constant training and improvement.

Categories of complainants of ethical violation

Complainants are a theme to highlight. Some of the articles analyzed here investigated this theme, but different data were shown. Ues et al. (2022)(²⁶)stated that few family members made complaints. Differently, other articles showed that most of the complainants were relatives of victims.(²⁷,³¹,³²) Many processes were opened at the request of other nurses; in the study by Silva et al. (2020),(³⁰)this type of complaint reached 64.7%, versus 35.3% of complaints made by other people. Complaints made by nurses were cited in the article by Silva and Freitas (2018)(³²)as being the second most frequent complaints.

Four articles mentioned processes that were opened at the request of representative bodies in the area of nursing, such as the Regional Nursing Councils in Brazil.(³⁰-³²,³⁴) These data show the importance of the actions of these regulatory bodies for supervision and professional improvement in the area.

Regarding the categories of complainants of ethical violations, studies agree that Nursing Ethics Committees,(²⁶,³⁰-²¹,³⁴)followed by victims’ families,(²⁶-²⁷,³¹-³²)Regional Nursing Councils in Alagoas and Mato Grosso do Sul,(²⁷,³⁰)victims,(²⁷,³²)and nursing professionals(²⁷,³⁰)were the main ones.

Criminal types of ethical infractions accepted by nursing ethics committees

In the selected articles, illegal exercise of the profession and duties that are not the responsibility of nursing teams were the most cited infractions.(²⁶-³⁰) Among the causes of such occurrences, we highlight the reduction in nursing staff in health institutions.(²⁶,²⁸,³³,³⁴) Exposure to an unhealthy environment encourages nursing professionals to participate in activities that are beyond their competence, despite the potential care denial established in the Code of Ethics for Nursing Professionals.(⁶,²⁶-³⁴)

The insufficient number of professionals can also result in other types of infractions, such as acts of negligence, malpractice, and imprudence highlighted in all articles analyzed.(²⁶-³⁴) In an article, the principles of non-maleficence and justice were the most violated.(³³)In the study by Fernandes et al.(²⁷)(2022), negligence was the most reported infraction (more than 25% of cases). In a qualitative study, Mattozinho and Freitas (2021)(²⁸)listed some complaints about abandonment and mistreatment of incapacitated people that may be related to negligence acts. In their quantitative study, where “negligence” was the most prevalent category (40.2% of cases), this diagnosis becomes clearer.(²⁹) Among cases of negligence, Pereira et al. (2020),(³¹)bring together errors such as a procedure that poses a risk to physical or moral integrity, failure to monitor the patient during physical activity, abandonment of duty or failure to monitor the patient during the duty, failure to check medication (occurred individually in all items and at all times of each item of this medical prescription), and use of inappropriate medication and/or diet. In this article by Pereira et al. (2020),(³¹)this type of behavior was the most prevalent (26.7% of cases).

Silva-Santos et al. (2018)(³⁴)also found reports of errors linked to negligence, such as incorrect use of medication or treatment, action, and access route or medication dose. Possible causes were enumerated/listed from the theory of human error: undersizing of nursing workers, work intensity, lack of supervision of the work of technicians and assistants, curtailment of labor rights, absence of supplies and equipment, inadequate storage of medicines, and absence of continuing education.

Not only do material conditions make a poor working environment but human relationships sometimes affect it too. The study by Fernandes et al. (2022),(²⁷)found 30 cases (among 68 complaints analyzed) linked to interprofessional relationships such as moral harassment, abuse of power, verbal and physical aggression, insubordination, persecution, and prejudice. These and other behaviors that appear in the complaints violate the CEPE articles (COFEN Resolution 564/2017), mainly those related to duties, responsibilities, and prohibitions to which the nursing team is subject.(⁶,³⁰) Again, these elements highlight the insufficient training of these professionals who show that they are unaware of the legislation that governs their professional activities.

According to recent studies,(²⁶-³⁴)highlighting that unethical practices have been identified (including conduct prohibited under the protection of criminal law) among categories of nursing professionals is crucial.(³⁵) This finding is a substantial indication that requires attention, reinforcing the need for further investigations for a comprehensive approach and reduction in such behaviors.

Nursing professionals played a crucial role, especially during the COVID-19 pandemic when their constant interaction with patients and pressure in the work environment significantly increased. This context makes health professionals (as well as health students) especially vulnerable to mental health problems such as anxiety, depression, burnout syndrome, and other disorders. The resulting physical and psychological exhaustion directly affects the work performed. Highlighting the importance of taking care of the mental health of these professionals becomes a crucial intervention, not only to prevent and manage ethical problems but also to ensure a healthy working environment, especially in challenging times during and after the pandemic.(²⁸,³⁴,³⁶-³⁷)

The literature highlights the ethical responsibility of nursing professionals to protect patients from unnecessary risks, whereas employer institutions are legally obliged to ensure safe working conditions. Compliance with COFEN resolution 293/2004 (which was replaced by COFEN resolution 543/2017) is essential to ensure adequate sizing of nursing staff. These conditions are also defended by syndicates, including overloading of tasks, working double shifts, inadequate remuneration, and persistent shortages of material and human resources. Supervision by syndicates, inspection bodies, and the Ministry of Labor is crucial to ensure compliance with these guidelines.(²-³,⁵-⁷,²⁶-³⁴,³⁸)

Types of penalties applied by the Regional Nursing Councils and/or Federal Nursing Council

Regarding the types of penalties mentioned in the studies in this review, verbal warnings prevail,(⁶,²⁶-³⁴)showing a tendency towards a more educational and non-punitive nature of the sentences applied by the Regional Nursing Councils. Revocation or loss of the right to practice nursing was mentioned in only three articles, and this responsibility is legally and exclusively the responsibility of the Federal Nursing Council.(⁶,²⁹,³⁰,³²) In the infraction cases analyzed by Mattozinho and Freitas (2021),(²⁸)the “perception of the illicit act” was raised by the reported professionals. In addition, recognizing the error committed shows the importance of reflecting on one’s professional conduct and the consequent need to acquire knowledge for better decision-making.(²⁸) Responsibility for ethical incidents related to criminal offenses in nursing practice is not limited to the individuals who perpetrated them. There is co-responsibility between individuals and the social community. This scenario emphasizes the need for more educational and less punitive interventions, combined with the urgency of implementing continuous training programs not only for the nursing team but also for the interdisciplinary and/or multidisciplinary team.(²⁸)

Other types of penalties, such as fines and censorship, appeared in the processes analyzed in the objects of this research.(²⁶-³⁴) Conciliation between the parties and signing of conduct adjustment terms (CATs) were also mentioned.(²⁶)

The review of ethical infractions committed by nursing professionals can raise awareness of ethical issues in nursing and promote debate about how to deal with ethical conflicts related to professional practice. This will allow consolidation of the existing knowledge, highlight areas where further research is needed, and provide information to improve professional ethics with insights into effective strategies for prevention and intervention in cases of ethical violations by nursing professionals. This information can be valuable to improve the education and training of these professionals and guide not only clinical practice but also the development of health policies. This is especially important in the case of ethics violations, in which professional ethics are primordial to the quality of patient care.(²⁶-³⁴)

The availability and accessibility of infraction records were limitations of the study on ethical infractions committed by nursing professionals accepted by the nursing ethics committee. The quantity and quality of data available for analysis vary depending on how records are kept and the disclosure policy of healthcare institutions. Furthermore, the accuracy and consistency of the information contained in the records may also influence the validity of the results obtained in the integrative review. The representativeness of the sample may be another potential limitation as ethical violations may be underreported or not reported in some situations. This may affect the generalizability of the findings to the population of nursing professionals as a whole.

Conclusion

The infractions in the complaints attributed to nursing professionals confirm that mid-level professionals were the most reported, with a greater participation of nursing assistants. Negligence and illegal exercise of the profession were the criminal types of ethical infractions with the highest incidence. The Nursing Ethics Committees, followed by victims’ families, Regional Nursing Councils, victims, and nurses were the main categories of complainants of ethical violations. Verbal warning was the most prevalent type of penalty applied. Recent studies using ethical infraction types as an approach to collect data on categories of nursing professionals in publication databases are scarce. New publications should increase scientific knowledge, paving the way for future investigations. Other methods of synthesis of evidence, such as scoping review and analysis of multiple data sources may be included.

Chart 1
Summary of studies on ethical violations found in complaints against nursing professionals received by Nursing Ethics Committees (CEE) in Brazil

Title / Authors / Year of publication / Reference number / Journal	Objectives	Methodology	Main Results Found
1- Ethics in nursing: categorization of legal processes Ues, Pereira, Bastos, Ribeiro, Silva, Campos, et al. (2022)(26) Brazilian Journal of Nursing (REBEn)	Categorize the factual elements of the nursing ethical-disciplinary processes in the State of Goiás.	Transversal and retrospective study based on secondary data obtained from ethical-disciplinary processes filed at COREN in Goiás (GO; 2010-2019).	The largest number of cases was initiated in the period 2013-2014, most frequently in the capital of Goiás. Most of them came from Nursing Ethics Committees and ex-officio complaints. Nursing technicians at the beginning of their careers (age range: 31-40 years old) were the most reported professionals. Exercising duties that are not nursing competencies was the most common type of complaint.
2- Characterization of ethical nursing processes in the State of Alagoas. Fernandes, Vasconcelos, Santos, Rodrigues, Souza, Miranda. (2022)(27) Cogitare Enfermagem	To analyze the infringements related to the opening of disciplinary ethical processes against nursing professionals in Alagoas, SE, Brazil.	This is a documentary from an exploratory and retrospective study with quantitative analysis, performed at COREN in Alagoas (SE; from Nov. 2020 to Jan. 2021).	Nursing was the most affected category, with 63 (49.2%) complaints. Regarding training time, five (3.90%) reported professionals had 1-10 years. Many ethical processes (68) were analyzed (2009-2020). The infringements referring to interprofessional relationships (37.0%) and negligence (21.0%) were highlighted; verbal warning (42.2%) was the most applied penalty and the Regional Nursing Council of Alagoas (27.9%) was the main complainant.
3- Analysis of ethical processes: criminal types in nursing practice Mattozinho, Freitas. (2021)(28) Acta Paulista de Enfermagem	To identify criminal types in nursing practice and the existence of factors related to professional conduct in ethical incidents involving criminal types in the analysis of statements contained in ethical processes judged at COREN/SP.	Exploratory-descriptive study with a quantitative-qualitative approach, in ethical processes containing illegal ethical acts considered criminal types. Data were collected in the ethical-professional nursing processes judged by COREN/SP (2012-2013).	The criminal types highlighted in the analysis were the following: abandonment of incapable persons; misappropriation; sexual harassment; fraud; illegal exercise of profession; illegal practice of medicine; ideological falsehood; loss, evasion or destruction of book or document; document forgery; falsification, corruption, adulteration or alteration of a product intended for therapeutic or medicinal purposes; theft; murder; bodily injury; mistreatment; embezzlement; drug trafficking; use of false documents, and vilification of a corpse. Seven thematic categories emerged from the statements: later repentance; perception of the illicit act; factors related to working conditions; psychological and/or social factors; financial factors; non-observance of responsibility, and duality.
4- Criminal types in professional nursing practice: quantitative approach Mattozinho, Freitas. (2021)(29) Acta Paulista de Enfermagem	To describe ethical nursing incidents involving criminal types in ethical processes (EPs) judged by COREN in São Paulo (SP).	Descriptive study with a quantitative approach. The sample consisted of documents about 169 professionals judged in 2012 and 2013 at COREN/SP for incidents involving criminal types.	Mid-level professionals were the most involved (71.0%), with a greater participation of Nursing Assistants (46.1%). A higher prevalence of beginners was detected in professional practice. The occurrences described as criminal types were as follows: murder; bodily injury; abandonment of an incapable person; mistreatment; injury; theft; misappropriation; fraud; vilification of a corpse; rape; sexual importunity; sexual harassment, forgery; corruption; adulteration or alteration of a product intended for therapeutic and medicinal purposes; illegal practice of medicine; falsification of public documents; use of false documents; ideological falsehood; embezzlement; loss, withdrawal or destruction of a book or public document, and misdemeanors relating to the organization of work as an illegal exercise of a profession. The majority of incidents were procedural, resulting in death or bodily injury, with a greater incidence of negligent acts. As for incidents of an attitudinal nature, the illegal exercise of a profession had the highest incidence, followed by document forgery. As a result of the trials, 63.3% of the professionals involved were found guilty and a warning (21.5%) was the most frequently applied penalty.
5- Characterization of Ethical Processes established against Nursing Professionals da Silva, Duarte, Candido, Mendez, Machado, dos Santos, et al. (2020)(30) Nursing	To characterize the ethical processes established at COREN in Mato Grosso do Sul (MS).	This was an exploratory, descriptive, and documentary study. The variables analyzed were the complainant person, reported professional, outcome of the ethical process, articles infringed, and penalties applied. The research was approved by the CEP of the Federal University of Mato Grosso do Sul (Opinion 438.302).	Ethical processes (34) were analyzed (2003-2013). COREN/MS was the main complainant (47.0%) and nursing assistants (44.0%) were the majority of those reported. Penalties were applied in 11 cases; the infringed articles pointed out that non-compliance with professional duties and responsibilities (and therefore a violation of bioethical principles) occurred in addition to carrying out prohibited practices. Verbal warning (81.0%) was the most frequently applied penalty.
6- Ethical violations in nursing care for the elderly people Pereira, Sousa, Moraes Filho, Guilhem, Lemes, Oliveira. (2020)(31) Nursing in Focus	To analyze the ethical nursing processes judged by COREN (Federal District) involving elderly people	This was a descriptive cross-sectional study of retrospective document analysis. Eighteen ethical processes were analyzed regarding complainant persons, the profile of the professional reported, characterization of the complaints, age of the victim, locations and types of health institution with the highest number of ethical incidents, the main articles of the Code of Ethics violated and the penalties applied in the final decision of the Council.	Ethical infractions were mostly committed by nursing technicians with few years of registration due to negligence against elderly people (60-70 years old) in the care provided at home.
7- Professional negligence: analysis of the ethical lawsuits of nurses judged by COREN-SP (2001-2010) da Silva e Freitas. (2018)(32) O Mundo da Saúde	This article is the result of a study about the negligence committed by nursing professionals in the exercise of their function and aimed to identify and classify the cases of professional negligence judged by the CRE of São Paulo from 2001 to 2010.	This is a documentary, exploratory, and descriptive study of a quantitative nature performed at COREN/SP, the body responsible for supervising professional practice.	The research base data was composed of 482 ethical processes concluded in the period 2001-2010. Lawsuits of negligence (68) were identified. Precarious care was the type of negligence with the highest percentage (51.5%); the adults (30.8%), elderly (30.2%), and children (29.6%) groups were victims of neglect. Negligence caused damage to patients in 92.9% of the cases analyzed. The nursing assistant was the category that most committed negligence (46.5%) and the hospital institution was the place with the highest incidence (84.6%). Surgical medical clinics were the most frequent clinical specialty (34.3%). The complaints were originated at COREN-SP (52.7%). The trials resulted in 37.9% of convicted professionals.
8- Relationship between professional practice time and ethical occurrences in nursing da Silva, Candido, Duarte, Sampaio, dos Santos. (2018)(33) UERJ Nursing Journal	To analyze the relationship between time spent in the profession and ethical incidents of nursing professionals involved in complaints registered at COREN (Mato Grosso do Sul, MS).	This was a documentary, descriptive and retrospective research, in which complaints registered at COREN/MS, in the period 2003-2013, were analyzed. This research was approved by the CEP.	Complaints (111) involving 68 nurses, 41 technicians, and 41 nursing assistants were analyzed. Professionals with 1-5 years of training were the group most involved in ethical incidents (44.7%). The data showed that mid-level professionals (27.3%) for nursing technicians and (27.3%) nursing assistants were those who were most involved in ethical incidents, totaling (54.6%), followed by higher-education professionals for nurses (45.3%).
9- Error-producing conditions in nursing staff work Silva-Santos, Araújo dos Santos, Alves, Silva, Costa, Melo. (2018)(34) Brazilian Journal of Nursing	To analyze errors made by nursing workers subject to ethical-disciplinary processes.	This was a documentary, exploratory, and quantitative-qualitative research. Information was collected in 13 COREN-BA ethical-disciplinary processes (1995-2010). They had errors committed by nursing workers as the subject of the complaint. Quantitative data was analyzed using descriptive statistics. In analyzing the qualitative data, the Human Error Theory and Sociology of Work approach was used.	‘Nursing technicians and assistants were the most reported workers. The health organization was the biggest complainant (through the coordination of the nursing service) and the day shift had the highest incidence.

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Appendix 1

Instrument for data collection validated by Ursi(²⁵)

1 – Identification
Publication Title
Title of the journal
Database
Authors	Name ______________________________________________________ Workplace _______________________________________________ Graduation _________________________________________________
Authors’ country of origin
Language
Year of publication
Study host institution	() Hospital () University () Research Center () Single institution () Multicenter research () Other Institutions () Does not identify the location
Publication Type	A – Scientific material () Textbook () Dissertation/thesis () Research Article () Proceedings/Annals () Others B – Type of scientific journal () General nursing publication () Perioperative nursing publication () Nursing publication of another specialty Which ________________________________________________ () Medical publication () Publication in other health areas Specification: _____________________________________________
2 – Introduction and Objectives
Introduction	() defines the research objective () justifies the relevance of the study () presents a review of literature related to the study topic () the theoretical framework represents the study content
Objective/research question/Hypothesis	Description ___________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ () the author clearly defines the objective of the study
3 – Methodological Characteristics
Study design	A – Studies with primary data () Quantitative approach () Experimental design (factorial design: repeated measures design; clinical trials) () Quasi-experimental design (non-equivalent control group design: time-series design) () Non-experimental design (correlational research; descriptive research () Qualitative approach () Ethnography () Phenomenology () Grounded theory () Others B – () Others. Which? _______________________________________ C – () The author clearly defines the study design
Sample	Selection: () random () convenience () other ______________ Size (no.): initial __________ final ___________________ Characteristics: age: _________ Sex: ()M ()F Race: __________ Subject inclusion/exclusion criteria: __________________________ _______________________________________________________________ _______________________________________________________________
Technique for data collection	Description ____________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ () semi-structured interview () observation () the data collection instrument was described () the instrument was subjected to validation Independent variable (intervention): _______________________________ Dependent variable: ___________________________________________ Control group: () yes () no Duration of study: _____________________________________________
Data analysis	() descriptive analysis () statistical analysis Description ____________________________________________________ _______________________________________________________________ _______________________________________________________________
4- Results
Results	Description: ___________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ () were presented in a clear and objective manner () were explored and discussed Related factors identified: ________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
5- Conclusions
Conclusions	Description: ___________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ () conclusions are justified based on the results _______________________________________________________________ What are the authors’ recommendations? __________________________ _______________________________________________________________ _______________________________________________________________

Source: Ursi, (2005).(²⁵)

Edited by

Associate Editor: Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  13 Sept 2024
• Date of issue
  2024

History

• Received
  12 Nov 2023
• Accepted
  25 Mar 2024