Safety of nursing professionals before ethical and bioethical problems

Abstract

The objective was to identify scientific production on the safety of primary health care nurses before ethical and bioethical issues. This is a review of papers published between January 2013 and August 2018 in the SciELO, Medline, LILACS, BDENF and Coleciona SUS databases, and Ordinances 2,436/2017 and 529/2013 of the Ministry of Health. Twenty-six articles were identified and divided into four thematic categories: occupational safety constructs and safety contexts; ethical and bioethical problems in primary health care; ethics and bioethics education: contributions to decision-making; and perspectives and decisions in experiences of ethical and bioethical problems. In conclusion, professional safety is related to the institution’s ability to establish a culture of safety; and that, before multiple and dynamic factors (personal, professional, and environmental), nurses are faced with ethical and bioethical problems that, if left unresolved, can result in moral distress and insecurity.

Primary health care; Bioethics; Ethics, nursing; Safety management; Nurses

Resumo

Teve como objetivo conhecer a produção científica sobre a segurança de enfermeiros da atenção primária à saúde perante problemas éticos e bioéticos. Trata-se da revisão de publicações indexadas entre janeiro/2013 e agosto/2018 nas bases de dados SciELO, Medline, LILACS, BDENF e Coleciona SUS; inclui as Portarias 529/2013 e 2.436/2017 do Ministério da Saúde. Foram identificados 26 artigos, divididos em quatro categorias temáticas: constructos de segurança do profissional e contextos de segurança; problemas éticos e bioéticos na atenção primária à saúde; educação ética e bioética: contribuições para tomada de decisão; e perspectivas e decisões na vivência de problemas éticos e bioéticos. Conclui-se que a segurança do profissional se relaciona com a capacidade da instituição em estabelecer uma cultura de segurança, e que, diante de fatores múltiplos e dinâmicos (pessoais, profissionais e ambientais), o enfermeiro se depara com problemas éticos e bioéticos que, quando não solucionados, podem resultar em sofrimento moral e insegurança.

Atenção primária à saúde; Bioética; Ética em enfermagem; Gestão da segurança; Enfermeiras e enfermeiros

Resumen

El objetivo fue conocer la producción científica sobre la seguridad del enfermero en la atención primaria de salud ante problemas éticos y bioéticos. Esta es una revisión de publicaciones indexadas entre enero/2013 y agosto/2018 en las bases de datos SciELO, Medline, LILACS, BDENF y Coleciona SUS; incluye la Ordenanza 2.436/2017 y la Ordenanza 529/2013 del Ministerio de Salud. Se identificaron 26 artículos, divididos en cuatro categorías temáticas: constructos de seguridad profesional y contextos de seguridad; problemas éticos y bioéticos en la atención primaria de salud; educación en ética y bioética: contribuciones a la toma de decisiones; y perspectivas y decisiones en la experiencia de problemas éticos y bioéticos. Se concluye que la seguridad del profesional está relacionada con la capacidad de la institución para establecer una cultura de seguridad y que, ante múltiples y dinámicos factores (personales, profesionales y ambientales), el enfermero se enfrenta a problemas éticos y bioéticos que, si no se resuelven, pueden derivar en sufrimiento moral e inseguridad.

Atención primaria de salud; Bioética; Ética en enfermería; Administración de la seguridad; Enfermeras y enfermeros

Nursing plays a major role in health care, and nurses must provide safe care, seeking to ensure quality of care and patient safety¹ . To this end, one needs to assess nursing care accurately and reliably, as well as create strategies to report (actual or potential) unsafe care and errors² .

Promotion of health safety culture is defined in the National Patient Safety Program as a set of individual and collective characteristics, skills, behaviors, and questionings that culminate in attitudes and practices centered on the willingness to detect and learn from errors ³ . In the scope of Primary Health Care (PHC), safe nursing practices depend on training to meet good the practices and work according to the assumptions of the Unified Health System (SUS), on the role of nursing and on the professional’s own safety⁴ .

Institutions’ and organizations’ commitment to good health practices requires knowledge of the difficulties and challenges faced daily by caregivers, since the ability to provide safe care depends on workplace safety, a fundamental human need¹ , ² . Meeting this need is increasingly important in the current scenario, in which the particularities of multiprofessional teamwork according to the expanded clinic and the diverse health demands can lead to ethical and bioethical issues that put the professional’s safety at risk⁵ .

Ethics is a knowledge intended on guiding human action with critical reflections on morality, considering the set of practices, attitudes, and values that characterize a person, the collective and the community. Ethical practice guides, proves and justifies the why of a certain attitude or behavior⁶ , ⁷ . Bioethics is related to an in-depth reflection on ethical and moral problems that emerge from human action and their consequences for society⁸ , ⁹ .

In PHC especially, ethical and bioethical impasses can result from occupational insecurity, breakdown of everyday labor and lack of comprehensive care for families – factors that lead to the need for attitudinal and cultural changes in the multidisciplinary team¹⁰ , ¹¹ . Nurses face various ethical and bioethical issues in PHC, often related to service organization, health care, and work processes. These problems may interfere with their daily practice¹² and professional safety.

A study with 15 Family Health Strategy (ESF) teams in Viçosa, Minas Gerais, identified five major groups of ethical and bioethical problems related to inequality in access to health services; to the teaching-working-community relationship; to secrecy and confidentiality; to conflicts between staff and users; to conflicts between team members ¹³ . According to this study, even if apparently more subtle, when compared to ethical and bioethical issues that take place in hospital institutions, there exists situations of moral conflicts related to the scope of PHC that erode the work process and the scope of comprehensive care promotion ¹³ .

Internationally, a study in Norway, with 25 primary care professionals, showed that 82% of respondents face ethical and bioethical problems at work frequently (daily or weekly)¹⁴ . Being closer to patients, nurses have to deal with more ethical and bioethical impasses – linked to communication, lack of resources, and professional responsibility – than other professionals.

In that same study, 65% of the professionals reported that ethical and bioethical issues are major generators of tension between professionals, users, and families and end up hindering the creation of bonds and quality of care¹⁴ . As possible solutions to such conflicts, its results point to informal discussions between team professionals, systematization of care, and acquisition of ethical and bioethical knowledge and skills. Besides, most respondents suggest the creation of a specific PHC ethics committee, capable of promoting reflection, exchange of ideas and discussions about conduct¹⁴ .

In this context, one must adopt an ethical and bioethical standpoint that allows reflecting on PHC problems and experiences, as to ensure the patient’s and nursing professional’s safety in decision-making. Consequently, one needs to create spaces for listening and discussion among the multidisciplinary team, to define, guide and solve daily problems⁹ , ¹⁰ .

Based on these reflections, this scoping review scours the knowledge produced on nurse safety and on the ethical and bioethical problems experienced in PHC to disclose and discuss the scientific production on these topics.

Method

This is a scoping review, a non-linear iterative methodology that allows reviewers to systematically and rigorously gather and synthesize multiple types of studies on a topic of interest and obtain comprehensive detailed results by following five steps: identification of the research question; identification of relevant studies; study selection; data extraction and analysis; collating, synthesis, and presentation of results¹⁵ .

It was conducted based on the participants, concept, and context (PCC)¹⁶ strategy, whereby nurses were the participants were nurses; the professional’s security when experiencing ethical and bioethical problems the concept; and PHC the context. Our research question read: “What scientific evidence on PHC nurse safety is available?”.

The literature search was carried out in the Medical Literature Analysis and Retrieval System Online (Medline), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Literature on Health Sciences (LILACS), Nursing Database (BDENF), and Coleciona SUS databases between June and August 2018.

We used the Medical Subject Headings (MeSH) descriptors with the following associations: “primary health care and ethics,” “clinical or ethics,” “professional or ethics,” “nursing [MeSH] or bioethics or ethics,” “security management and nurses.”

Inclusion criteria consisted of: articles with abstracts available in the selected databases, deriving from original research and literature reviews, published in any language, between January 2013 and August 2018. Studies with research design or objectives poorly defined, conference abstracts and proceedings, comments, opinions, previous notes, reports, dissertations, theses and monographs were excluded. The review also included Ordinances 2,436/2017⁴ and 529/2013¹⁷ of the Ministry of Health (MS), which address the research topic. Table 1 summarizes the identification and selection process of the 26 articles and two selected ordinances⁴ , ¹⁷ .

Table 1
Study identification and selection process in the database review, 2018

Articles identified in the initial search based on the established criteria (n=630) Medline: 579; SciELO: 16; LILACS: 24; BDENF: 9; Coleciona SUS: 2

Articles eliminated by title and abstract: (n=426) Medline: 400; SciELO: 0; LILACS: 20; BDENF: 6; Coleciona SUS: 0

Articles and ordinances selected for full reading and review regarding the research question (n=204) Medline: 179; SciELO: 16; LILACS: 4; BDENF: 3, Coleciona SUS: 2

Articles eliminated after full reading and reviewing answers to the research questions (n=169) Medline: 169; SciELO: 0; LILACS: 4; BDENF: 3; Coleciona SUS: 0

Articles selected for the final sample (n=28) Medline: 10; SciELO: 16; LILACS: 0; BDENF: 0; Coleciona SUS: 2 (Ordinances 2,436/2017 and 529/2013)

Articles were classified by two researchers according to evidence-based practice. After reading and analyzing titles and abstracts to identify potentially eligible studies, the researchers read the pre-selected articles in full, to confirm their relevance and consistency regarding the object of study. Inconsistencies and disagreements were resolved by both researchers.

After reading the articles, the researchers extracted the following data: authors, year of publication, database, level of evidence, type of study, main objectives, results, and final conclusions/recommendations, to identify the focus of each work. To categorize and present the results, the study used thematic content analysis¹⁸ , considering the meanings of professional safety and the ethical and bioethical problems experienced by PHC nurses. As this research uses public domain data, no ethical assessment was required.

Results

The initial database search returned 630 studies based on the established criteria. After examining titles and abstracts, we excluded 426 works, leaving 204 for full reading. Of these, we eliminated 178 articles. Thus, the scoping review’s final sample consisted of 26 articles and included Ordinances 2,436/2017 and 529/2013. Table 1 presents the selected articles.

The 26 selected articles were found in the SciELO (16 articles, 62%) and Medline (10, 38%) databases. Seven articles were published in English (27%), 16 in Portuguese (62%), and three in Spanish (11%). They were published in Brazil (16 studies; 61.5%), the United States (3; 11.5%), Spain (5; 19.2%), Chile (1; 3.8%) and Iran (1; 3.8%). Most publications date from 2014 (8 articles; 31%), followed by 2013 (5; 19%), 2016 (5; 19%), 2015 (4; 15%), 2017 (3; 12%) and 2018 (1; 4%). Out of the 26 articles selected, 13 (50%) are evidence level 5, and 13 (50%) are level 1.

During content analysis, we identified four thematic categories: 1) occupational safety constructs and safety contexts; 2) ethical and bioethical problems in primary health care; 3) ethics and bioethics education: contributions to decision making; and 4) perspectives and decisions in experiences of ethical and bioethical problems. Table 2 presents the articles classified according to the thematic categories.

Table 2
Thematic categories of the selected articles

Thematic category	Article title, type of study, level of evidence	Context, concepts, and strategies
Occupational safety constructs and safety contexts	“Cultura da segurança do paciente na atenção primária à saúde”2, cross-sectional study, level 5	Introduction of safety culture and its interface with occupational safety.
	Ordinance 2,436/20174
	“Auditorías en seguridad clínica para centros de atención primaria: estudio piloto”10, cross-sectional study, level 5
	Ordinance 529/201317
	“Dimensions of safety climate among Iranian Nurses”19, literature review, level 1
	“Weaving a culture of safety into the fabric of nursing”20, literature review, level 1
	“Social justice as a lens for understanding workplace mistreatment”21, exploratory study, level 5
Ethical and bioethical issues in primary health care	“Problemas bioéticos na Estratégia Saúde da Família: reflexões necessárias”9, literature review, level 1	Identification of the main ethical and bioethical problems and their consequences for PHC. In Brazil: a) problems involving the team, family, and user; b) problems involving team members; c) problems involving staff/management; d) ethical and bioethical problems involving the family social vulnerability and the ESF itself; e) lack of experience of ethical and bioethical issues. Internationally: a) ethical and bioethical problems involving sharing information in electronic medical records; and b) ethical and bioethical problems involving the life cycle.
	“Ethical problems experienced by nurses in primary health care: integrative literature review”12, integrative literature review, level 1
	“(Bio)ética e Estratégia Saúde da Família: mapeando problemas”13, qualitative study, level 1
	“(Bio)ética e Atenção Primária à Saúde: estudo preliminar nas Clínicas da Família no município do Rio de Janeiro, Brasil”22, exploratory study, level 5
	“Conduta do enfermeiro frente aos conflitos éticos e bioéticos em área vulnerável na ESF”23, qualitative study, level 1
	“Aspectos éticos e bioéticos encontrados na atenção primária à saúde”24, integrative literature review, level 1
	“Problemas bioéticos no cotidiano do trabalho de profissionais de equipes de saúde da família”25, descriptive study, level 5
	“A bioética e o trabalho na Estratégia Saúde da Família: uma proposta de educação”26, qualitative study, level 5
	“How bioethics principles can aid design of electronic health records to accommodate granular patient control”27, literature review, level 1
	“Problemas éticos clínicos en la Atención Primaria del Centro de Salud Familiar de Paine”28, descriptive study, level 5
Ethics and bioethics education: contributions to decision making	“Una bioética clínica para la atención primaria de salud”6, literature review, level 1	Ethics and bioethics education as an important tool for decision making and care promotion.
	“Problemas bioéticos na Estratégia Saúde da Família: reflexões necessárias”9, literature review, level 1
	“Ethical problems experienced by nurses in primary health care: integrative literature review”12, integrative literature review, level 1
	“Elements and strategies for ethical decision-making in nursing”29, integrative literature review, level 1
	“Relação profissional-usuário de saúde da família: perspectiva da bioética contratualista”30, literature review, level 1
	“Ethical behaviour in clinical practice: a multidimensional Rasch analysis from a survey of primary health care professionals of Barcelona (Catalonia, Spain)”31, cross-sectional study, level 5
	“The impact of ethics and work-related factors on nurse practitioners’ and physician assistants’ views on quality of primary healthcare in the United States”32, cross-sectional study, level 5
	“A new questionnaire to endorse normative ethics in primary health care: development, reliability and validity study”33, methodological study, level 5
Perspectives and decisions in experiences of ethical and bioethical problems	“A bioética e o trabalho na Estratégia Saúde da Família: uma proposta de educação”26, qualitative study, level 5	Tools that can help identify and resolve ethical and bioethical conflicts: a) deliberation and casuistry; b) dialogue and communication; c) presence of a supervisor, co-worker or professional expert in advising and consulting with ethics committee; d) artificial neural networks or machine learning methods; e) application of the Inventory of Ethical Problems in Primary Health Care instrument; f) creation of discussion spaces; g) incentive and development of training workshops; h) permanent education.
	“Una bioética clínica para la atención primaria de salud”6, literature review, level 1
	“(Bio)ética e Estratégia Saúde da Família: mapeando problemas”13, qualitative study, level 1
	“Ethical problems experienced by nurses in primary health care: integrative literature review”12, integrative literature review, level 1
	“(Bio)ética e Atenção Primária à Saúde: estudo preliminar nas Clínicas da Família no município do Rio de Janeiro, Brasil”22, exploratory study, level 5
	“Conduta do enfermeiro frente aos conflitos éticos e bioéticos em área vulnerável na ESF”23, qualitative study, level 1
	“Aspectos éticos e bioéticos encontrados na atenção primária à saúde”24, integrative literature review, level 1
	“Elements and strategies for ethical decision-making in nursing”29, integrative literature review, level 1
	“Relação profissional-usuário de saúde da família: perspectiva da bioética contratualista”30, literature review, level 1
	“Deliberação ética em saúde: revisão integrativa da literatura”34, integrative literature review, level 1
	“Tomada de decisão em bioética clínica: casuística e deliberação moral”35, descriptive study, level 5
	“Estratégia Saúde da Família e bioética: grupos focais sobre trabalho e formação”36, qualitative study, level 5
	“Modelos de tomada de decisão em bioética clínica: apontamentos para a abordagem computacional”37, literature review, level 1
	“Construção e validação do instrumento ‘Inventário de problemas éticos na atenção primária em saúde’”38, cross-sectional study, level 5

Discussion

Occupational safety constructs and safety contexts

Occupational safety reflects measures to understand and increase the general safety status of employees in different sectors: textile, food, automobile, metallurgy, and health care¹⁹ . The safety climate reflects values, beliefs, norms, and skills regarding what is important in the work environment¹⁷ . Such climate can suffer external influences, linked to the environment, communication, and the co-responsibility of workers¹⁹ .

In Brazil, health worker safety stems from patient safety culture, an approach in which all workers, including caregivers and managers, take responsibility for their own safety and the safety of their colleagues, patients, and families ¹⁷ . For a safe care practice, the factors that can minimize incidents are: human, related to the professional; systemic, related to the work environment; external, related to factors outside the manager’s governability; related to the patient, for example, non-adherence to treatment ³ . Measures that protect healthcare workers help protect the patient, and vice versa.

Discussions on health safety climate started after the first accidents involving sharps. Since then, each health care level has established its own safety climate based on the peculiarities and priorities deriving from its employees’ experiences²⁰ .

A study on the PHC in Spain identified acceptable levels of safety (≥50%) among nurses in the resolution of clinical issues, care of chronic patients, trust in other professionals, communication between a multidisciplinary team and, specifically, communication between physicians and nurses. But it identified levels of insecurity (≤50%) in the following indicators: administration of injectables and insufficient training/insecurity on facing difficulties when interacting with aggressive patients¹⁰ .

The safety of nurses and PHC teams, including managers, depends on the co-responsibility of their own safety, and that of their colleagues, patients, and families, encouraging the identification, notification, and resolution of safety-related problems⁴ . In hospital care, safety is impacted by factors linked to the institution and service dynamics, such as disease stressors that affect patients and their families; experiences, perceptions, and expectations; late or inadequate health care; and long lines or waiting time for hospitalization and diagnosis. Such factors can disrupt occupational safety²¹ .

In European PHC units, accreditation processes have increased occupational safety. Most audited health centers implemented measures such as providing quality clinical materials and in greater quantity; systematic and safe practice protocols; training to improve communication between physicians and nurses; and standardization of actions in urgent and emergency cases. Additionally, an instrument was developed to identify common situations and contexts in PHC nurses’ daily routine. Applied monthly, this instrument detects factors that favor or hinder occupational safety¹⁰ .

Establishing a culture of occupational safety is no easy task. It requires management strategies and commitment, as well as the workers’ involvement and participation via listening, dialogue, and co-responsibility. Such a culture, when implemented, creates a safe care atmosphere that encourages the identification and solution of different types of problems: attitudinal, cultural, financial, and organizational² .

Ethical and bioethical issues in primary health care

The studies by Siqueira-Batista and collaborators¹³ , Simas and collaborators²² , Caetano and collaborators²³ , and Santos, Couto, and Yarid²⁴ derive from original research that sought to identify the main ethical and bioethical problems experienced by basic ESF teams from southeastern (Rio de Janeiro and Minas Gerais), southern (Santa Catarina), and northeastern (Bahia) Brazil. The studies by Vidal and collaborators⁹ , and Nora, Zoboli, and Vieira¹² are literature reviews on the main ethical and bioethical problems experienced by basic ESF teams. Only Nora, Zoboli, and Vieira’s¹² literature review focused on the main ethical and bioethical problems experienced specifically by ESF nurses in Brazil.

Studies on Brazilian care¹² , ¹³ , ²² - ²⁶ converge on three main types of ethical and bioethical problems: 1) problems involving the team, family, and user; 2) problems involving team members; and 3) problems involving staff/management.

Regarding ethical and bioethical problems involving the team, family, and users, studies identified a set of daily situations that involve: treating user embracement only as screening; lack of humanized treatment, by some professionals, during user embracement; contempt for the professional by users unhappy with the service or resolution of demands; privacy/confidentiality and secrecy of user information; disrespect of user autonomy; communication difficulties between professionals and users and misinterpretations; difficulty of user adherence to prescribed treatment; and judgment and impositions of professional beliefs and values on the user’s life¹² , ¹³ , ²² - ²⁶ .

Issues involving ESF/PHC team members are expressed by: prevalence of a biomedical culture; lack of companionship, respect and collaboration among team members; difficulty in defining the roles and functions of each member; unpreparedness of professionals to face PHC demands; professional demotivation; lack of professionalism; interference of professionals in the conduct of colleagues; lack of communication among the team; and difficulty of community health agents in maintaining confidentiality and preserving professional secrecy¹² , ¹³ , ²² - ²⁶ .

The studies also present issues involving PHC management: difficult access; abusive and authoritarian management; disruption of intersectoral communication; human, physical, financial and material resource issues; political influences; high staff turnover; and lack of occupational safety in the work environment¹² , ²⁶ - ³⁰ .

As to other situations, only the study by Caetano and collaborators²³ showed ethical and bioethical problems involving family social vulnerability and the insecurity of ESF teams in dealing with situations such as drug trafficking, violence, and teenage pregnancy. On the other hand, the studies by Siqueira-Batista and collaborators¹³ , Simas and collaborators²² , and Santos, Couto, and Yarid²⁴ pointed out the absence of reports on the experience of (bio)ethical issues, showing the professionals difficulty in associating daily challenges and concerns with ethical and bioethical principles.

Internationally, Meslin and Schwartz²⁷ highlighted ethical and bioethical problems experienced by North American healthcare professionals and users regarding sharing information in electronic medical records. On the one hand, users have the right to choose which information can be recorded in the medical record; on the other, any omission of information can delay, influence, and compromise treatment. Consequently, this creates a more complex picture: one principle supports the user’s empowerment, autonomy, and well-being, but at the expense of free professional practice²⁷ .

Aravema’s²⁸ study, which sought to identify ethical and bioethical PHC issues in Paine, Chile, found a context similar to that of Brazil: access inequality, lack of material and personal resources, confidentiality issues, and disrespect for user autonomy. The study also listed the main ethical and bioethical problems by life cycle. In childhood, the main issue is vaccination adherence; in adolescence, the lack of spaces for sexual education and discussions on drug use; in adulthood, difficulties in providing care and support terminal patients; and during pregnancy, the lack of responsibility with sexually transmitted infections, such as HIV. As for the main ethical and bioethical issues linked to the nursing practice, the lack of professionalism and humanization, the precariousness of the system, and the difficulty in providing care to terminal patients due to limited support and therapy in PHC stand out²⁸ .

Ethical and bioethical problems identified in PHC may have a series of consequences¹² , ¹³ , ²² , ²⁵ , ³⁷ . Regarding issues involving the team, families, and users, studies¹³ , ²² highlight bond breaking due to breach of trust, disrespect for the user, and lack of professionalism and professional loyalty, hindering adherence to the prescribed treatment¹³ , ²¹ .

As for problems involving team members, studies cite the fragmentation of multidisciplinary work as the main consequence of ethical and bioethical issues²² , ²⁵ . Juxtaposing and isolating actions and knowledge, this fragmentation generated weaknesses and hinders the professional’s relationship with the team, deterring the development of multidisciplinary skills.

One of the consequences of ethical and bioethical issues is the moral suffering of PHC professionals. Their co-responsibility concerning the health of the individual, the family, and the community, as well as the various obstacles that are often outside their purview, hinders the exercise of good health practices and causes suffering¹² .

In conclusion, the ethical and bioethical problems identified in PHC are part of the multidisciplinary team’s daily routine. These problems require proper tools to raise people’s awareness on the need to seek solutions¹² - ¹³ , ²² - ²⁸ .

Ethics and bioethics education: contributions to decision making

Studies in this thematic category point to (bio)ethics education as a key strategy for decision-making and health care⁶ , ⁹ , ¹² , ²⁴ , ²⁹ - ³³ . Analyzing the articles, we observed that health professionals whose training included courses on ethics and bioethics are better able to identify and resolve ethical conflicts. Such courses, based on reflections about thinking and acting in different contexts, develop an internal moral conscience that helps health professionals make prudent decisions that consider the uniqueness of the subjects and the circumstances that modify individual and collective behaviors⁶ , ⁹ , ¹² , ²⁹ , ³⁰ .

Corroborating these findings, studies point to a positive association between quality of care and ethics and bioethics education³¹ - ³³ . Data show that healthcare professionals who know the professional code of ethics feel more apt to make difficult decisions autonomously. Such knowledge is associated with ethical attitude, qualified listening, patient protection, compassion, and empathy towards the individual’s health needs and care. The studies showed, however, that paternalism persists in some professionals, who still find it difficult to respect users’ decisions and wishes³¹ - ³³ .

Other studies have shown that some health professionals have difficulty identifying problems in their practice and relating them to ethics and bioethics principles²⁴ , ²⁵ . A possible solution to this issue, according to these studies, is permanent education. The multidisciplinary team could, for example, articulate ethical and bioethical discussions to already faced cases, discussing how to act in similar situations and seeking ethical-legal support in legislation²⁴ , ²⁵ .

(Bio)ethics education enables an organizational climate of excellence, capable of promoting decision-making based on the professional’s autonomy, responsibilities, values and moral conscience, and is therefore necessary for promoting quality of care¹² , ²⁵ , ²⁸ .

Perspectives and decisions in experiences of ethical and bioethical problems

Studies in this category⁶ , ¹² , ¹³ , ²² - ²⁴ , ²⁶ , ²⁹ , ³⁰ , ³⁴ - ³⁸ point to perspectives for resolving ethical and bioethical conflicts that require professionals’ knowledge, skills, experiences, moral conscience, and ethical sensitivity in decision-making, to not compromise quality of care²⁹ , ¹² , ²² .

Before making any decision, studies suggest that health professionals should use deliberation and casuistry tools⁶ , ²⁹ , ³⁴ , ³⁵ . Such tools help to delimit, analyze, and discuss ethical and bioethical issues considering the holistic-etiological nature of conflicts, the circumstances surrounding them, and the interaction between different subjects (user, family, professional, institution, health system), thus optimizing the search for realistic and prudent solutions.

To overcome ethical and bioethical conflicts, the articles point to some tools used by health professionals, including dialogue and communication⁹ , ¹² , ¹³ , ²² - ²⁴ , ³⁶ . They may seem trivial, but communication and dialogue strengthen the bond between user, family, and professional, thus facilitating teamwork and ensuring continuity of care¹² , ¹³ , ²² - ²⁵ , ³⁶ .

Nora, Zoboli, and Vieira point to the presence of a supervisor, co-worker, or professional expert in counseling and consulting with an ethics committee as tools that help resolve ethical and bioethical conflicts¹² . Siqueira-Batista and collaborators³⁷ discuss artificial neural networks, or machine learning methods, computer systems developed to facilitate difficult decisions to be made by professionals. Junges and collaborators³⁸ , in turn, present an instrument called Inventory of Ethical Problems in Primary Health Care, which, when applied, is capable of outlining a profile of ethical and bioethical issues, inciting responses among professionals.

Resolution of ethical and bioethical conflicts can be systematized by creating spaces to discuss cases faced in everyday life¹² , ²³ , ²⁴ , ³⁶ . This type of discussion can occur during working hours, so as to bring together and involve all professionals²² . Studies also suggest the use of the focus group technique, since, based on the professionals’ perception, it is possible to list the main ethical and bioethical conflicts, elaborating possible ways of approaching, conducting, and solving them³¹ .

Studies also suggest the creation of training workshops and spaces for permanent education⁹ , ¹² , ¹³ , ²² , ²³ , ²⁹ , ³⁶ . For Vidal and collaborators²⁶ and Nora and collaborators²⁹ , educational workshops involving active methodologies, art, education, and dramatization, as a way to articulate exposure, problematization, and debate of the main health care ethical and bioethical issues, are opportunities for the multidisciplinary team to rethink perceptions and attitudes.

Solving ethical and bioethical problems involves scientific, cultural, legislative, deontological, and personal aspects. The more subsidies available to professionals, the safer the decision made will be²⁹ .

Final considerations

Occupational safety stems from multiple and dynamic factors – personal, professional, environmental, material, physical –, but which converge to the idea that all professionals involved in care are responsible for their own safety, and that of their team, the user and their family, and the community. Professionals must use the available resources to act in a safe, ethical, and respectful manner, aware of each person’s needs.

The studies analyzed in this scoping review show that PHC nurses face a number of ethical and bioethical problems that, if left unresolved, can result in bond breaking with the user and family, lack of professionalism, lack of loyalty and reliability towards the user, fragmentation of multidisciplinary work, moral suffering, and professional insecurity. Professional practice thus requires new perspectives, such as (bio)ethics education, deliberation and casuistry, training workshops and spaces for permanent education, providing nurses and their teams with subsidies to identify and solve ethical and bioethical problems.

Studies that correlate nurse safety with ethical and bioethical issues experienced in PHC are still scarce in the literature. This study sought to raise reflections on this topic, to contribute to knowledge production on the safety of health care professionals.

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• Funding: this research received a grant from the Stricto Sensu Graduate Incentive Program (PIPG) of Universidade Federal de São João del-Rei (UFSJ). It was also funded by an undergraduate research grant through Public Notice 009/2017 Pibic/Fapemig ( Minas Gerais Research Foundation ).

Publication Dates

• Publication in this collection
  18 Mar 2022
• Date of issue
  Oct-Dec 2021

History

• Received
  26 Mar 2020
• Reviewed
  19 Oct 2021
• Accepted
  28 Oct 2021