Nursing ethical issues occurring within the State of Sao Paulo: factual description

Abstract

Objective

To describe ethical issues occurring in nursing ethical cases (NECs) judged by the Nursing Council of Sao Paulo (Coren/SP).

Methods

Retrospective quantitative study, performed at the Coren/SP. The sample size consisted of 399 documents of nursing professionals obtained in 254 NECs judged in 2012 and 2013. Data was collected through an instrument, which were tabulated and analyzed through descriptive statistics.

Results

The category of nursing assistants (46.12%) was the most involved in the cases, with higher prevalence of beginners in the professional exercise, mean age of 36 years. Most issues highlighted were Iatrogenic by omission (22.6%), Iatrogenic by mistake in the administration of medicines (22.1%), crimes or criminal misdemeanor (18.0%).

Conclusion

The results were important to identify the characteristics of the issues and the professionals involved and the need to deepen the discussion on the ethical problems in everyday nursing practice.

Ethics; Nursing/ethics; Codes of ethics; Legislation, nursing; Professional review organizations

Resumo

Objetivo

Descrever ocorrências éticas de enfermagem nos processos éticos (PEDs) julgados pelo Conselho Regional de Enfermagem de São Paulo (Coren/SP).

Métodos

Estudo retrospectivo de natureza quantitativa, realizado no Coren/SP. Amostra constituída por documentos de 399 profissionais de Enfermagem obtidos em 254 PEDs julgados no período de 2012 e 2013. Utilizou-se instrumento de coleta de dados sendo tabulados e analisados por meio de estatística descritiva.

Resultados

A categoria dos Auxiliares de Enfermagem (46,12%) foi a mais envolvida nas ocorrências, com maior prevalência de iniciantes no exercício profissional, idade média de 36 anos. As ocorrências mais evidenciadas foram Iatrogenias por omissão (22,6 %), Iatrogenias por erro na administração de medicamentos (22,1%), crimes ou contravenções penais (18,0 %).

Conclusão

Os resultados foram de suma importância para identificar as características das ocorrências e dos profissionais envolvidos e com isso, a necessidade de aprofundar a discussão sobre os problemas éticos na prática cotidiana da Enfermagem.

Ética; Enfermagem/ética; Códigos de ética; Legislação de enfermagem; Organizações de normalização profissional

Introduction

As citizens, we are subject to standards of social life. It’s not different in relation to nursing professionals, who follow not only guiding norms of coexistence in his/her civilian life, but are also compelled to obey the rules inherent in professional practice.

Ethical issues while “damaging events caused by nursing professionals throughout the exercise related to improper attitude towards co-workers, patients or the institution where they work”(¹)occur daily in the professional routine, who should have knowledge on the analyses performed by the Board of Registered Nursing, in this case the Nursing Council of Sao Paulo (Coren/SP), in order to demystify the punitive aspect, as in most cases, errors are reported only when there is evidence that the patient has been harmed, making hard to critical discuss the implementation of measures for prevention and education.(²)

Living norms, both in the ethical planning of a profession or in the midst of the sparse legislation should not be conceived only as a command, but mainly in the form of maintenance of an orderly coexistence, because we assumed the existence of intersubjective relations conducted in respect for the basic principles of our existence from the intangibility of human values.(³)

Regarding professional ethics, there is a statement of the principles which should guide the professional conduct, to ensure compliance with the established norms and values.(⁴) In this sense, the Ethics Code of Nursing Professionals (ECNP) is an instrument that brings together a set of norms, moral principles and rights related to the profession and its exercise.(⁵)It has been reformulated by COFEN Resolution 311/2007,(⁶) whose applications reach all relations involving professionals registered at Nursing Councils.

The studies regarding Nursing Ethical Cases (NECs) related to Regional Councils of Nursing, COFEN(⁷) are scarce and consequently the knowledge of cases judged by Coren/SP.

Therefore, the present study aims to increase the debate about the ethical issues and, consequently, envision new possibilities of acting on this kind of phenomenon, taking into account the approach that the socialization of information can contribute to improvement of educational and preventive action in the daily work of nursing professionals.

Given the above, this study aims to describe the ethical issues involving nursing professionals reporting the ethical cases judged by Coren/SP.

Methods

This is a retrospective, exploratory-descriptive quantitative approach and documentary analysis study. The study was carried out from the analysis of documents from Coren/SP, which were obtained from the Ethics Department, linked respectively to Management and Presidency Offices. The cases were scanned to the trial phase and the nursing data in computerised system WebCoren, being accessed with password-restricted and traceable, in addition to the physical file found in the archives sector of that institution.

The cross-sectional timeframe was established for the period from January 1^st, 2012 to December 31^st, 2013, due to the facts that these are recent decisions and the organization was implemented at the beginning of 2012-2014, since the researcher is part of management and the restricted follow-up of the guidelines published by COFEN Resolution 370/2010.(⁸)

The data collection started after approval and authorization of Coren/SP of the State of São Paulo. To ensure the anonymity of the subjects and/or institutions involved, we ensured the confidentiality of information concerning names of professionals and/or workplaces, restricting any exposure or embarrassment. A consent form was not used, as we conducted a historical sources analysis under Coren’s/SP responsibility, which holds the prerogative of custody and access authorization and usage of data.

The population of 399 professionals was established from documents that were on 254 ethical cases completed in first instance on the timeframe established. The instrument of data collection, developed by the author, had the following variables: Professional category, type of incident, age group, years of professional training and training institution. Data was stored, tabulated and analyzed in Excel® through descriptive statistics.

The development of study followed national and international standards of ethics in research involving humans.

Results

Table 1 presents the Professional category by level of education, excluding midwives or nursing attendant among the ethical cases.

Table 1
Distribution of population by occupational category

Professional	Frequency	Percentage	Cumulative Percentage
Nursing Assistant	184	46.12	46.12
Nurse	142	35.59	81.70
Nursing Technician	73	18.30	100.00
Total	399	100.00

As for the types of incidents involving professionals, the analysis was divided into two groups, attitudinal and procedural.

The following cases were considered attitudinal incidents: abandonment of duty, non-compliance with the obligation of professional secrecy, failure to observe the right to autonomy, no attendance of service calls and non-compliance with ethical tools as Technical Manager, categorized as voluntary acts contrary to CEPE (AVC); abuse, embezzlement, rape, illegal practice, document forgery, identity theft, illegally exhuming a corpse, abandonment of incapable, racism, sexual harassment, sexual acts, racketeering, narcotics trafficking, larceny, categorized as crimes or misdemeanours under criminal law (MUCL); physical and verbal aggression, moral harassment and insubordination in the team relations, categorized as inter-professional relations (IPR); and physical and verbal aggression to users and family members, categorized as interpersonal relationships with users and family (IRU).

The following incident ethical cases were considered procedural: clumsiness, recklessness and administration of parenteral enteral diet, categorized as iatrogenesis of action (IA); negligence, categorized as iatrogenesis of omission (IO); error in the administration of medications, categorized as medication misuse associated with negligence, incompetence or carelessness (DI) and error in the administration of blood products, categorized as iatrogenesis with blood products (IB).

From this categorization, figure 1demonstrates the incidences complained by level of training.

Figure 1
Incident ethical cases by level of training

Most professionals were aged 31 to 40 years, 141 (35.3%), followed by the age group between 21 and 30 years, totaling 126 (31.3%) professionals.

Another study variable referred to the time of training of each professional involved in the analyzed cases. Therefore, considering the date of graduation as initial term and final term of the incident date, we found professionals who had had a degree from zero to 41 years, being the majority, 170 (42.6%), graduated in the period from 0 to 5 years, followed by 97 (24.3%) from 6 to 10 years. Analyzing by level of education, we observed that all categories maintain the same pattern. Among nurses, 74 (52.1%) professionals had their training period dating from 0 to 5 years, followed by 23 (16.2%) of 6 to 10 years. Among nursing technicians 38 (52.1%) had their training from 0 to 5 years ago, followed by 24 (32.9%) from 6 to 10 years. In relation to nursing assistants 58 (31.5%) had their training from 0 to 5 years ago, followed by 50 (27.29%) from 6 to 10 years.

From the data related to the time of training, the analysis of the type of undergraduate institution was only possible for Nurses, as we could not access accurate information from Coren/SP database for nursing assistants and technicians (Table 2).

Table 2
Nurses, according to the type of undergraduate institution

Type	Frequency	Percentage	Valid percentage	Cumulative percentage
Private	122	85.9	85.9	85.9
Public	19	13.4	13.4	99.3
Impaired	1	0.7	0.7	100.0
Total	142.0	100.00	100.00

Out of the 142 Nurses, that corresponded to 35.6% of the population of this study, 01 (0.7%) could not be identified due to incomplete data in the records.

Discussion

As shown in table 1, there has been a greater quantitative incident involving nursing assistants (46.1%). Thus, these data reveals the need to reconsider studies, such as those made by Peduzzi and Anselmi(⁹) with regard to activities that in practice these professionals develop. In this sense, Padilha et al(¹⁰) also alerted about how nursing assistants are performing activities of greater complexity, although they are often unprepared to make them.

Nurse cases accounted for 35.59% of incidents, highlighting the change in the profile of the activities of Nurses from the implementation of the Unified Health System (SUS), as well as the changes in nursing practice based on historical, political and social contexts, expanding the work of Nurses, especially in public service, generating greater accumulation of assignments.(¹¹) It is still known, that management action of the nurse is closely linked to their professional practice, thus creating, many times, the accountability for the activities performed by the nursing assistants and technicians, once focused on the implementation of the nursing care, “guided by the understanding and knowledge of the patient as a person, and their specific needs.”(¹²)

The results regarding the Professional category, in this study, converge with the results of the research conducted by Schneider and Ramos,(¹³) which was conducted in the Regional Council of Santa Catarina. This study analyzed 128 NECs, judged from 1999 and 2007, involving 172 professionals. From this quota, 66 (38.4%) were nursing assistants, followed by 61 (35.5%) Nurses. Also, a study conducted by Penna(¹⁴) analyzed 158 NECs, involving 189 professionals judged by Coren/SP, between 2001 and 2004, as it showed greater number of cases in the category of nursing assistant with 105 (55.6%), followed by the Nurse with 64 (33.9%) cases.

Regarding age group, there was higher prevalence in the age group up to 40 years with 67.9% of the population. Of these, 35.3% were 31 to 40 years. A study conducted by Mendes and Caldas(¹⁵) on ethical incidents with nursing professionals showed higher incidence in the age group of 21 to 39 years (70.5% of the ethical cases analysed).

The data related to the time of training of professionals revealed prevalence of professionals with up to 05 years of education (42.6%). In this sense, a study conducted by Silva et al ,(¹⁶) showed concern for beginners in the nursing practice, addressing aspects that influence on direct assistance to the patient, contributing to potential risks, such as: lack of skills and training for professional practice, training of generalist nurses that immediately assume patients in specialized areas, insecurity, anxiety and even anguish in providing care to patients in units of greater complexity.

In table 2, we indicate that 85.9% of nurses were from private education institutions. In the year 2012, a study on the training of nurses from private undergraduate institutions, held in the State of Minas Gerais showed change in profile of these professionals, with the finding that the students would make double shifts, being in the labor market additionally to study, as well as emphasizes ease of college access, indicating that the private schools of nursing have attracted students with scholarship offer and opening of units near borders, which certainly attracts the individual who dreams of having higher education, even with the lack of training related to primary and secondary school, thus demonstrating the ease of enrolling without any criterion.(¹⁶)

On the other hand, a study conducted on the training of undergraduate nurses from public institutions, held in the State of São Paulo, shows that the students hardly ever carry work activities, considering the fact that the course is full-time, which does not make possible to combine work and study and indicates increase in freshmen who have completed secondary education in private schools.(¹⁷)

Considering these aspects, a differentiated profile must be taken into consideration to data collection. The undergraduate training can be undermined by students who try to reconcile work and study, where factors such as tiredness and lack of free time for supplementary activities, leads to a lower performance to those who have less worries and more time available.

Some authors consider that it is necessary to continue the process of professional learning, through training in service, aiming at the training of professionals working in health, taking into account the approach with the realities of the world of work. To do so, educational activities from the needs of the institution, of the professionals and those who will be served in this context are necessary.(¹⁸)

In this sense, it is important to invest in institutional policies towards permanent education, with establishment of the real needs of the institution and the individual, respecting all the practical context and multidisciplinary approach to enhance the technical, ethical and political skills, and consequently, increasing the critical capacity of those involved.(¹⁹)

As figure 1 shows, most incidents are related to IO 90 (22.6%), followed by DI 88 (22.1%) and MUCL 72 (18.0%), being in total 139 (34.8%) cases related to attitudinal issues and 260 (65.2%) cases related to procedural issues, noting that in the analysis by level of education the incidence of cases is diverse. Consistent with this result, a study conducted by Freitas and Oguisso(²⁰) related to ethical incidents located in the city of São Paulo, for negligence, while omission iatrogenesis, was cited as the main cause of incidents in 57.33% of 114 cases conducted by nursing.

Oguisso and Zoboli(²¹) also mentioned that negligence is characterized by omission in attendance with consequent indifference of professional patient care, acting wrongly.

Incidents characterized as iatrogenics IA, IO, DI and IB were listed from Padilha(¹⁰)“considering being undesirable events by health professionals, in the case of nursing, regardless of the different concepts that allow different interpretations.”

According to Madalosso(²²) “the iatrogenesis of nursing care is related to the deprivation of care, or unsatisfactory enforcement of these that would cause inconvenience, harm or injury to the patient.”

By category, the professional Nurse presents a higher incidence in cases related to negligence. The following incidents related to malpractice or recklessness, and the expansion of the Nurse tasks, especially after the advent of SUS.

Cases related to volunteer attitudes opposing the ethics code (EC), including actions related to technical responsibility in service, were also highlighted in the results, data that bring us to think about the ignorance of the professional about all their responsibilities not only in the field but also in the management assistance, once guided, towards knowledge, attitude and practice of Systematization of Nursing Care (SNC), the conduct of the performance of the whole team, being fundamental the knowledge about their rights, duties and responsibilities, because their performance directly impacts the assistance provided, regardless of their function.(¹³)

Considering the advances in technology and legal provision of expertise in activities of greater technical complexity, this investment is required in constant training, especially given the views of this researcher, opening a large working space to the Nurse.

With regard to the nursing technician, there is a higher incidence of ethical iatrogenic drug misuse. In this respect, it should be noted that there is concern in relation to issues related to the administration of medicines, because as Cassiani and Coimbra(²³) reported, there is predominant understanding that such an action is one of the biggest responsibilities of the nursing staff that requires thought and not only practice. The data found in relation to crime cases require a specific study, not providing conjecture or value judgment now.

Regarding nursing assistants, there was a higher incidence of crime cases, demonstrating the utmost need of further study on this subject, because there are many factors influencing these incidents, and manifestation without deepening, as it can cause discomfort and even preconceptions. Incidents related to iatrogeny drug misuse and iatrogenic action, compatible with the nursing assistants’ functions, are the most common incidents, as these are prescribed procedures in the professional law.

According to Mirabete,(²⁴) the concept of crime is essentially legal, it can be considered a fact contrary to human law and is analyzed on the formal aspect, extending this definition from the perspective of analytical fact committed with guilt subject to penalty application. On the other hand, the felony is a “crime” of lower proportion, with less offensive potential, with minor penalties.(²⁵)

There is no doubt that the details of procedural issues revealed to be of the utmost importance to implementation of actions aimed at minimizing incidents of mistakes or failures, with the establishment of guidelines for primary and preventive actions, aimed at not only theoretical but especially practical activities such as those carried out in realistic simulation centers. However, one cannot overlook the findings related to attitudinal issues, both regarding action and omission, since attitudes keep strong relationship with professional principles in nursing, namely: teamwork, communication, coexistence, respect and honesty, among others. Therefore, such principles are enveloped in the essence of the human being that cares and that relates to another human being.

According to Santos and Ceolim,(²⁶) the most frequent cause of iatrogenic cases is connected to human conduct, regardless of potential situations in the workplace that can enhance any damage, with constant investigation, avoiding punitive policies on human error.

Therefore, we must spread the view in the discussions that involve the exercise of nursing care both in management and in practice, ensuring that “recovery strategies and expansion of ethics discussions throughout the training process encourage the training of ethical issues”.(²⁷)

Conclusion

Most ethical cases highlighted in this study allows us to point out the importance of investment not only in training related to procedural issues, but mainly in discussions involving the professionals attitudes (the values, behaviors, professional attitudes in the workplace, involving interpersonal relationships, among other aspects), in addition to the promotion of the integration of theoretical and practical skills with ethical values, attitudes and principles for the safe exercise of care and management practice.

Referências

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Publication Dates

• Publication in this collection
  Nov-Dec 2015

History

• Received
  18 Aug 2015
• Accepted
  16 Oct 2015