Association between moral distress and supporting elements of moral deliberation in nurses

Ramos, Flavia Regina Souza; Brehmer, Laura Cavalcanti de Farias; Dalmolin, Graziele de Lima; Silveira, Luciana Ramos; Schneider, Dulcinéia Ghizoni; Vargas, Mara Ambrosina de Oliveira

doi:10.1590/1518-8345.3990.3332

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Revista Latino-Americana de Enfermagem

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Original Article • Rev. Latino-Am. Enfermagem 28 • 2020 • https://doi.org/10.1590/1518-8345.3990.3332 copy

Association between moral distress and supporting elements of moral deliberation in nurses^* * Supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil, Grant # 471859/2013-3.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to identify the association between moral distress and the supporting elements of moral deliberation in Brazilian nurses.

Method:

a cross-sectional study conducted with Brazilian nurses working in health services at different complexity levels. The research protocol consisted of the Brazilian Scale of Moral Distress in Nurses, a sociodemographic and labor questionnaire, and a list of bases and ethical elements used for moral deliberation. For analysis, descriptive statistics, chi-square test, and Poisson regression were used.

Results:

1,226 nurses took part in the study. The 12 elements associated with the moral deliberation process were classified as important for nurses’ actions, especially the professional experience acquired, code of ethics/law of professional practice, and ethical and bioethical principles. The relationship of moral distress showed higher prevalence in the Beliefs, culture and values of the patient, Beliefs and personal values, and Intuition and Subjectivity elements.

Conclusion:

the results showed a balance between the subjective criteria of professional experience and the objective ones of deontology for moral deliberation.

Descriptors:
Ethics; Ethics, Nursing; Decision Making; Moral; Nursing; Stress, Psychological

Bases and ethical elements	0^* * 0 = No importance; n (%)	1^† † 1 = Low importance; n (%)	2^‡ ‡ 2 = Medium/Moderate importance; n (%)	3^§ § 3 = High importance n (%)	Absent n (%)	Total
1. Personal Beliefs and Values	99(8.2)	306(25.5)	392(32.6)	404(33.6)	25	1201
2. Patient’s beliefs, culture and values	37(3.1)	224(18.7)	488(40.7)	451(37.6)	26	1,200
3. Code of professional ethics /Professional practice law	14(1.2)	115(9.5)	378(31.3)	699(58.0)	20	1206
4. Professional experience gained	6(0.5)	76(6.3)	364(30.4)	751(62.7)	29	1,197
5. Intuition and subjectivity	84(7.0)	405(33.9)	443(37.1)	263(22.0)	31	1195
6. Ethical and bioethical principles	8(0.7)	107(9.0)	384(32.2)	692(58.1)	35	1191
7. Theoretical bases acquired in the training	15(1.3)	128(10.7)	390(32.5)	666(55.5)	27	1,199
8. Practices established in the service \/institution	12(1.0)	233(19.5)	497(41.7)	451(37.8)	33	1193
9. Practice agreed with the team	23(1.9)	200(16.8)	510(42.7)	460(38.6)	33	1193
10. Defense of interests and image of the profession	52(4.4)	236(19.8)	442(37.1)	462(38.8)	34	1,192
11. Defending the patient’s interests and needs	14(1.2)	133(11.1)	442(36.9)	610(50.9)	27	1,199
12. Defense of interests and image of the service/institution	69(5.7)	345(28.7)	474(39.5)	313(26.1)	25	1201

Bases and ethical elements		Moral distress		Total	p^* * Chi-square test
Bases and ethical elements		Low n(%)	Moderate/High n(%)
1. Personal Beliefs and Values	Low	149(37.4)	249(62.6)	1,184	0.001
1. Personal Beliefs and Values	Discharge	183(23.3)	603(76.7)	1,184	0.001
2. Patient’s beliefs, culture and values	Low	118(46.1)	138(53.9)	1,183	0.001
2. Patient’s beliefs, culture and values	Discharge	213(23.0)	714(77.0)	1,183	0.001
3. Code of professional ethics/Professional practice law	Low	70(55.1)	57(44.9)	1,189	0.001
3. Code of professional ethics/Professional practice law	Discharge	263(24.8)	799(75.2)	1,189	0.001
4. Professional experience gained	Low	59(72.8)	22(27.2)	1180	0.001
4. Professional experience gained	Discharge	271(24.7)	828(75.3)	1180	0.001
5. Intuition and subjectivity	Low	164(34.1)	317(65.9)	1,178	0.001
5. Intuition and subjectivity	Discharge	165(23.7)	532(76.3)	1,178	0.001
6. Ethical and bioethical principles	Low	66(58.9)	46(41.1)	1,176	0.001
6. Ethical and bioethical principles	Discharge	263(24.7)	801(75.3)	1,176	0.001
7. Theoretical bases acquired in the training	Low	73(52.1)	67(47.9)	1182	0.001
7. Theoretical bases acquired in the training	Discharge	258(24.8)	784(75.2)	1182	0.001
8. Practices established in the service/institution	Low	96(39.5)	147(60.5)	1,176	0.001
8. Practices established in the service/institution	Discharge	235(25.2)	698(74.8)	1,176	0.001
9. Practice agreed with the team	Low	90(41.1)	129(58.9)	1,177	0.001
9. Practice agreed with the team	Discharge	240(25.1)	718(74.9)	1,177	0.001
10. Defense of interests and image of the profession	Low	103(36.4)	180(63.6)	1,175	0.001
10. Defense of interests and image of the profession	Discharge	227(25.4)	665(74.6)	1,175	0.001
11. Defending the patient’s interests and needs	Low	82(56.9)	62(43.1)	1,182	0.001
11. Defending the patient’s interests and needs	Discharge	249(24.0)	789(76.0)	1,182	0.001
12. Defense of interests and image of the service/institution	Low	132(32.4)	275(67.6)	1,184	0.019
	Discharge	202(26.0)	575(74.0)	1,184	0.019

Variables		RPb^† † RPb = Gross regression;	CI 95%	p	RPaj^‡ ‡ RPaj = Adjusted regression (all variables)	95% CI	p
1. Personal Beliefs and Values	High	1.087	1.051-1.124	<0.001^* * Significant value at the 0.05 level;	1.017	0.982-1.054	0.341
1. Personal Beliefs and Values	Low	1	1.051-1.124	<0.001^* * Significant value at the 0.05 level;	1	0.982-1.054	0.341
2. Patient’s beliefs, culture and values	High	1.150	1.102-1.200	<0.001^* * Significant value at the 0.05 level;	1.044	0.996-1.094	0.070
2. Patient’s beliefs, culture and values	Low	1	1.102-1.200	<0.001^* * Significant value at the 0.05 level;	1	0.996-1.094	0.070
3. Code of professional ethics/Professional practice law	Discharge	1.210	1.137-1.286	<0.001^* * Significant value at the 0.05 level;	1.025	0.960-1.095	0.463
3. Code of professional ethics/Professional practice law	Low	1	1.137-1.286	<0.001^* * Significant value at the 0.05 level;	1.025	0.960-1.095	0.463
4. Professional experience gained	Discharge	1.379	1.276-1.490	<0.001^* * Significant value at the 0.05 level;	1.198	1.071-1.340	0.002^* * Significant value at the 0.05 level;
4. Professional experience gained	Low	1	1.276-1.490	<0.001^* * Significant value at the 0.05 level;	1	1.071-1.340	0.002^* * Significant value at the 0.05 level;
5. Intuition and subjectivity	Discharge	1.063	1.030-1.096	<0.001^* * Significant value at the 0.05 level;	1.017	0.984-1.051	0.323
5. Intuition and subjectivity	Low	1	1.030-1.096	<0.001^* * Significant value at the 0.05 level;	1	0.984-1.051	0.323
6. Ethical and bioethical principles	Discharge	1.243	1.163-1.328	<0.001^* * Significant value at the 0.05 level;	1.038	0.950-1.134	0.406
6. Ethical and bioethical principles	Low	1	1.163-1.328	<0.001^* * Significant value at the 0.05 level;	1	0.950-1.134	0.406
7. Theoretical bases acquired in the training	Discharge	1.185	1.118-1.256	<0.001^* * Significant value at the 0.05 level;	1.001	0.941-1.065	0.963
7. Theoretical bases acquired in the training	Low	1	1.118-1.256	<0.001^* * Significant value at the 0.05 level;	1	0.941-1.065	0.963
8. Practices established in the service/institution	Discharge	1.089	1.045-1.135	<0.001^* * Significant value at the 0.05 level;	0.984	0.940-1.030	0.481
8. Practices established in the service/institution	Low	1	1.045-1.135	<0.001^* * Significant value at the 0.05 level;	1	0.940-1.030	0.481
9. Practice agreed with the team	Discharge	1.101	1.054-1.150	<0.001^* * Significant value at the 0.05 level;	1.013	0.964-1.063	0.616
9. Practice agreed with the team	Low	1	1.054-1.150	<0.001^* * Significant value at the 0.05 level;	1	0.964-1.063	0.616
10. Defense of interests and image of the profession	Discharge	1.067	1.027-1.108	0.001^* * Significant value at the 0.05 level;	0.972	0.933-1.012	0.171
10. Defense of interests and image of the profession	Low	1.067	1.027-1.108	0.001^* * Significant value at the 0.05 level;	0.972	0.933-1.012	0.171
11. Defending the patient’s interests and needs	Discharge	1.230	1.161-1.304	<0.001^* * Significant value at the 0.05 level;	1.114	1.035-1.199	0.004^* * Significant value at the 0.05 level;
11. Defending the patient’s interests and needs	Low	1	1.161-1.304	<0.001^* * Significant value at the 0.05 level;	1	1.035-1.199	0.004^* * Significant value at the 0.05 level;
12. Defense of interests and image of the service/institution	Discharge	1.038	1.005-1.073	0.023^* * Significant value at the 0.05 level;	0.973	0.939-1.007	0.119
	Low	1	1.005-1.073	0.023^* * Significant value at the 0.05 level;	1	0.939-1.007	0.119

Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br

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[1] Corresponding author: Laura Cavalcanti de Farias Brehmer E-mail: laura.brehmer@ufsc.br

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Association between moral distress and supporting elements of moral deliberation in nurses* * Supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil, Grant # 471859/2013-3.

Objective:

Method:

Results:

Conclusion:

Association between moral distress and supporting elements of moral deliberation in nurses^* * Supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil, Grant # 471859/2013-3.