Intensity and frequency of moral distress in Brazilian nurses

Cross-sectional study performed with nurses from 27 Brazilian states through application of the Brazilian Moral Distress Scale in Nurses (Portuguese acronym: EDME-Br) and descriptive statistical analysis.

Results:

Participation of 1,226 Brazilian nurses in the study. The intensity and frequency of overall moral distress were rated as moderate level, with averages of 3.08 (± 1.45) and 2.94 (± 1.37), respectively. Specifically, the highest intensity and frequency was related to the factors Acknowledgement, power and professional identity and Work teams, while the lowest was related to the factor Defense of values and rights.

Conclusion:

Moral distress occurs in precarious work environments, with little expressiveness of the nurses’ role. One highlights the importance of the problem in terms of its amplitude and multicausality, reaching professionals acting in different work contexts.

Descriptors:
Ethics, Nursing; Working Conditions; Patient Care Team; Morale; Burnout, Professional

Country regions	North	Northeast	Midwest	South	Southeast	No answer	Total
Distribution of sample participants (n=1,226)	6.6%	14.1%	8.4%	22.2%	41.9%	6.8	100
Distribution of registered nurses (n=451,666)	6.6%	24.4%	7.9%	13.0%	48.1%	_	100

Variables	Intensity		Frequency
Variables	N	Md (IIq)	n	Md(IIq)
Factor 1 - Acknowledgement, power and professional identity
14 Feeling discriminated by/in relation to other professionals	1163	3.00 (1.00-5.00)	1202	3.00 (1.00-4.00)
15 Feeling unappreciated in relation to other professionals	1161	3.00 (2.00-6.00)	1203	3.00 (2.00-6.00)
16 Executing actions that are not inherent in one's function	1158	3.00 (2.00-6.00)	1199	3.00 (2.00-5.00)
34 Having one's autonomy limited in the decision about the nursing team's specific conducts	1148	3.00 (2.00-5.00)	1191	3.00 (2.00-5.00)
35 Experiencing conflicting relations concerning the health team members' attributions	1160	3.00 (2.00-5.00)	1194	3.00 (2.00-5.00)
36 Working under pressure due to the insufficient time to reach goals or accomplish tasks	1161	3.00 (2.00-6.00)	1196	3.00 (2.00-6.00)
37 Recognizing situations insulting to the professional	1159	3.00 (2.00-6.00)	1193	3.00 (2.00-5.00)
38 Recognizing situations of disrespect for the professional's privacy	1148	3.00 (2.00-5.00)	1196	3.00 (2.00-5.00)
40 Feeling disrespected by hierarchical superiors	1154	3.00 (2.00-6.00)	1196	3.00 (1.00-5.00)
41 Recognizing ethically incorrect attitudes of managers or hierarchical superiors	1153	3.00 (2.00-6.00)	1193	3.00 (2.00-5.00)
43 Feeling pressured by the user due to situation one cannot intervene in	1153	3.00 (2.00-6.00)	1194	3.00 (2.00-5.00)
Factor 2 - Safe and qualified care
23 Recognizing the insufficient service access for the user	1152	3.00 (2.00-6.00)	1204	3.00 (2.00-5.00)
24 Recognizing that the users' welcoming is inadequate	1162	3.00 (2.00-5.00)	1205	3.00 (2.00-5.00)
25 Recognizing that the patient/user's demand for continuing care are not attended	1153	3.00 (2.00-6.00)	1199	3.00 (2.00-5.00)
26 Recognizing the lack of problem-solving ability of health actions due to social problems	1155	3.00 (2.00-6.00)	1194	3.00 (2.00-5.00)
27 Recognizing the lack of problem-solving ability due to the low quality of attendance	1153	3.00 (2.00-5.00)	1196	3.00 (1.00-4.75)
28 Recognizing that educative actions involving the user are insufficient	1155	3.00 (2.00-5.00)	1189	3.00 (2.00-5.00)
29 Experiencing disrespect for the humanized care practices recommended in public policies	1157	3.00 (2.00-5.00)	1196	3.00 (2.00-5.00)
30 Recognizing routines and practices that are inappropriate to professional safety	1160	3.00 (2.00-5.00)	1195	3.00 (2.00-5.00)
31 Recognizing routines and practices that are inappropriate to patient safety	1152	3.00 (2.00-5.00)	1195	3.00 (1.00-5.00)
32 Recognizing routines and practices that are inappropriate to the relatives/companions' safety	1150	2.00 (1.00-4.00)	1197	2.00 (1.00-4.00)
33 Recognizing care impairments due to inappropriate integration among the services/sectors	1152	3.00(2.00-5.00)	1194	3.00 (2.00-5.00)
Factor 3 - Defense of values and rights
39 Experiencing care conducts that ignore the patients' beliefs and culture	1148	1.00 (0-3.00)	1201	1.00 (0-3.00)
42 Feeling pressured to consent or silence in response to frauds for the benefit of the institution	1152	2.00 (0-5.00)	1198	2.00 (0-4.00)
44 Feeling impotent to defend the patient's autonomy	1148	3.00 (1.00-5.00)	1198	3.00 (1.00-4.00)
45 Recognizing situations of disrespect/mistreatment by professionals toward the user	1148	2.00 (1.00-4.00)	1199	2.00 (1.00-3.00)
46 Recognizing situations of disrespect for users' right to privacy/intimacy	1141	2.00 (1.00-4.00)	1194	2.00 (1.00-3.25)
47 Recognizing situations of disrespect for the user's right to confidentiality/secrecy	1147	2.00 (1.00-3.00)	1200	2.00 (1.00-3.00)
48 Recognizing situations of disrespect for patients and relatives' right to information	1147	2.00 (1.00-4.00)	1198	2.00 (1.00-3.00)
49 Feeling unable to defend the user in situations of social vulnerability	1145	2.00 (1.00-4.00)	1199	2.00 (1.00-4.00)
Factor 4 - Work conditions
08 Recognizing that the consumption material is insufficient	1156	3.00 (2.00-6.00)	1202	3.00 (2.00-5.00)
09 Recognizing that the consumption material is unsuitable	1162	3.00 (2.00-5.00)	1206	3.00 (1.00-5.00)
10 Recognizing that the fixed equipment/material available is insufficient	1158	3.00 (2.00-5.00)	1203	3.00 (2.00-5.00)
11 Recognizing that the fixed equipment/material available is unsuitable	1152	3.00 (2.00-5.00)	1206	3.00 (2.00-5.00)
12 Recognizing that the service facilities are insufficient	1152	3.00 (2.00-6.00)	1198	3.00 (2.00-5.00)
13 Recognizing that the service facilities are unsuitable	1153	3.00 (2.00-6.00)	1201	3.00 (2.00-5.00)
Factor 5 - Ethical infractions
17 Experiencing omission by the physician	1160	3.00 (2.00-5.75)	1204	3.00 (2.00-5.00)
18 Experiencing imprudence by the physician	1156	3.00 (1.00-5.00)	1202	3.00 (1.00-4.00)
19 Experiencing omission by the nurse	1153	2.00 (1.00-4.00)	1200	2.00 (1.00-3.00)
20 Experiencing imprudence by the nurse	1155	2.00 (1.00-4.00)	1205	2.00 (1.00-3.00)
21 Experiencing omission by professionals in other categories	1154	2.00 (1.00-4.00)	1202	2.00 (1.00-4.00)
22 Experiencing recklessness by professionals from other categories	1149	2.00 (1.00-4.00)	1206	2.00 (1.00-4.00)
Factor 6 - Work teams
1Working with an insufficient number of professionals to attend to the demand	1155	4.00 (2.00-6.00)	1209	3.00 (2.00-6.00)
2 Working with an incomplete multiprofessional health team	1150	3.00 (2.00-5.00)	1208	3.00 (2.00-5.00)
3 Experiencing conditions of work overload	1159	4.00 (3.00-6.00)	1202	4.00 (2.00-6.00)
4 Working with unprepared physicians	1153	3.00 (2.00-5.00)	1206	3.00 (2.00-5.00)
5 Working with unprepared nurses	1149	3.00 (1.00-5.00)	1207	3.00 (1.00-4.00)
6 Working with unprepared auxiliary nurses and nursing technicians	1157	3.00 (1.00-5.00)	1206	3.00 (1.00-4.00)
7 Working with unprepared professionals from other categories	1161	3.00 (2.00-5.00)	1203	3.00 (2.00-4.00)

Factor	Intensity		Frequency
Factor	µ(±S)	Md(IIq)	µ(±S)	Md(IIq)
Acknowledgement, power and professional identity	3.36(±1.59)*	3.18(2.00-4.74)	3.23(±1.56)*	3.00(1.93-4.55)
Safe and qualified care	3.31(±1.66)	3.18(2.00-4.81)	3.18(±1.61)	3.00(1.91-4.55)
Defense of values and rights	2.47(±1.67)	2.13(1.13-3.50)	2.25(±1.52)	2.00(1.13-3.25)
Work conditions	3.33(±1.78)	3.00(2.00-5.00)	3.22(±1.75)	3.00(1.83-4.83)
Ethical infractions	2.80(±1.74)	2.50(1.33-4.17)	2.54(±1.55)	2.33(1.33-3.67)
Work teams	3.35(±1.55)*	3.29(2.00-4.71)	3.20(±1.50)*	3.14(2.00-4.46)
Overall MD	3.08(±1.45)*	3.00(1.87-4.27)	2.94(±1.37)*	2.89(1.82-4.05)

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author:
Flavia Regina Souza Ramos Travessa Ângela Chaves, 81, Lagoa da Conceição CEP 88065-302 - Florianópolis, SC, Brazil flavia.ramos@ufsc.br