NURSE MANAGERS’ ETHICAL PROBLEMS IN HOSPITAL SETTINGS: AN ANALYSIS FROM THE MACINTYRIAN PERSPECTIVEABSTRACT
Objective: to understand hospital nurse managers’ ethical problems from the perspective of Macintyre’s virtue ethics.
Method: qualitative research of the single case study type, encompassed by Alasdair Macintyre’s theoretical framework of virtue ethics. Sixteen nurses in management positions participated in the study for a minimum period of six months. The setting was a university hospital in Belo Horizonte, Brazil. Data were collected between August and October 2021, through individual interviews with a semi-structured script and document analysis, analyzed using Bardin’s content analysis. Two categories of ethical problems emerged from the thematic analysis linked to violations of care values: internal goods; and linked to breaking norms, patterns of behavior and interpersonal relationships: external goods.
Results: the ethical problem is present in care, in relationships and in the institution. When referring to the profession’s internal assets, ethical problems are characterized as a violation of care values: denial of assistance, negligent and reckless actions or violation of the rights of professionals, patients, staff and institutions. When referring to external goods, such problems are linked to interruption of norms, inappropriate actions and behaviors or ethical conduct questioned and disrespected by professionals.
Conclusion: nurse managers understand ethical problems as circumstances that generate opposition to actions considered correct and that go against what is proper to nurses and against their duty, negatively affecting professionals, patient care, the institution and the public service.
DESCRIPTORS:
Nursing; Ethics Nursing; Hospitals University; Administrators; Ethics Institutional
RESUMO
Objetivo: compreender os problemas éticos de enfermeiras gestoras hospitalares na perspectiva da ética das virtudes de Macintyre.
Método: pesquisa qualitativa, do tipo estudo de caso único, abarcado pelo referencial téorico da ética da virtude de Alasdair Macintyre. Participaram do estudo 16 enfermeiras em exercício de cargo de gestão por um tempo mínimo de seis meses. O cenário foi um hospital universitário em Belo Horizonte, Brasil. Os dados foram coletados entre agosto a outubro de 2021, por meio de entrevistas individuais com roteiro semiestruturado e análise documental, analisadas mediante Análise de Conteúdo segundo Bardin. Da análise temática emergiram duas categorias de problemas éticos - ligados a violação dos valores do cuidado: bens internos; e ligados à ruptura com normas, padrões de comportamento e relações interpessoais: bens externos.
Resultados: o problema ético está presente no cuidado, nas relações e na instituição. Quando referem-se aos bens internos da profissão, os problemas éticos são caracterizados como violação dos valores do cuidado: negação da assistência, ações negligentes e imprudentes ou violação dos direitos do profissional, paciente, equipe e instituição. Quando remetem-se aos bens externos, tais problemas estão ligados à interrupção de normas, às ações e comportamentos indevidos ou condutas éticas questionadas e desrespeitadas pelo profissional.
Conclusão: as enfermeiras gestoras compreendem problemas éticos como circunstâncias que geram uma oposição a ações consideradas corretas e que vão contra ao que é próprio ao enfermeiro e contra o seu dever, atingindo negativamente os profissionais, o cuidado ao paciente, a instituição e o serviço público.
DESCRITORES:
Enfermagem; Ética em enfermagem; Hospitais universitários; Enfermeiras administradoras; Ética institucional
RESUMEN
Objetivo: comprender los problemas éticos de las enfermeras gestoras hospitalarias desde la perspectiva de la ética de las virtudes de Macintyre.
Método: investigación cualitativa, del tipo estudio de caso único, englobada en el marco teórico de la ética de las virtudes de Alasdair Macintyre. Participaron del estudio 16 enfermeros que desempeñaban puestos directivos por un período mínimo de seis meses. El esetting era un hospital universitario en Belo Horizonte, Brasil. Los datos fueron recolectados entre agosto y octubre de 2021 a través de entrevistas individuales con guión semiestructurado y análisis de documentos, analizados mediante análisis de contenido según Bardin. Del análisis temático surgieron dos categorías de problemas éticos vinculados a la violación de los valores del cuidado: bienes internos; y vinculado a la ruptura con normas, patrones de comportamiento y relaciones interpersonales: bienes externos.
Resultados: el problema ético está presente en el cuidado, en las relaciones y en la institución. Al referirse a los bienes internos de la profesión, los problemas éticos se caracterizan como violación de los valores del cuidado: negación de asistencia; acciones negligentes e imprudentes; o violación de los derechos del profesional, paciente, equipo e institución. Cuando se refiere a bienes externos, tales problemas están vinculados a la interrupción de normas, acciones y comportamientos inapropiados o conductas éticas cuestionadas e irrespetadas por el profesional.
Conclusión: las enfermeras directivas entienden los problemas éticos como circunstancias que generan oposición a acciones consideradas correctas y que van en contra de lo propio del enfermero y de su deber, afectando negativamente a los profesionales, la atención al paciente, la institución y el servicio público.
DESCRIPTORES:
Enfermería; Ética en Enfermería; Hospitales Universitarios; Enfermeras Administradoras; Ética Institucional
INTRODUCTION
In Brazil, nurses often act as managers and take over management and leadership positions, a fact highlighted by Article 8 of Decree 94.406/8, which provides for nursing practice and entrusts nurses with planning, organization, coordination and assessment of nursing services. Additionally, the Brazilian National Curricular Guidelines (Diretrizes Curriculares Nacionais) for undergraduate nursing courses (Opinion CNE/CES 1,122/2001) establish administration and management as a nurse’s competence, requiring specific knowledge and skills. When occupying management positions, nurses take over leadership and responsibility in the organization and development of administrative processes, including management of physical and material resources, with leading role and the ability to discern the needs of the people they supervise and motivation of employees1-2.
The role of a nurse manager requires the defense and dissemination of ethical values as well as the guarantee of patients’ rights, seeking to offer holistic care and respecting individuals’ dignity and integrity. To this end, they base their practices on ethics, safety and quality3. Ethics plays an important role in regulating nurse managers’ moral behavior, directing the relationship between nurses, patients and the multidisciplinary staff4.
However, nurse managers face ethical problems in their daily work in hospitals caused by pressure to meet deadlines, duplicity and lack of information, a deficit in the number of nursing professionals and facing the Covid-19 pandemic (one of the greatest challenges of recent years), which has become a risk factor for professionals’ lives. While these and other working conditions produce ethical problems, these, when not properly addressed, aggravate and deteriorate working conditions and relationships. It is understood that ethical problems extend to the unit/staff and organization/system levels. Experiencing these problems constitutes a challenge for nursing practice in management, since strain and ethical clashes can affect the care provided and trigger moral distress3,5-6.
The ethical problem is understood as a conflict of personal values (different values considered by a person) or between different individuals, normally when rules and routines are not sufficient to guide choices7-8. Moral situations, on the other hand, are everyday and trigger judgment and ethical positioning on the part of subjects - a moment in which the ethical-moral content of their context and actions is recognized. Only when individuals recognize the ethically correct action to follow, but are prevented from acting in accordance with such judgment, does moral distress begin, with possible residual and lasting damage to professionals’ integrity9.
The terms “moral” and “ethics” are adopted interchangeably here, maintaining the use present in the literature (e.g., “ethical” referring to problems/dilemmas and “moral” relating to distress). The greater the perception of ethical problems, the greater the risk of moral distress, justifying the importance of knowing the relationships between ethical problems and moral distress6, especially when managers are fundamental for intervening on such problems.
The inability to deal with ethical problems causes nurse managers to experience moral distress, abandon the profession or want to change positions or jobs. Instead, nurses must be able to identify problems, think critically, find possible solutions and make decisions10, whereas managers must expand these capabilities and opportunities.
In this context, nurses who occupy management positions in hospitals can help promote an ethical environment for nurses’ work, encouraging an ethical climate, emphasizing professional commitment and reducing physical and mental harm to professionals, in order to encourage professionalism, cooperation, empathy and trust11.
Given the above, the question that guided the study was: how do nurse managers understand the ethical problems experienced in the hospital? This study is justified by understanding that, for nurses to develop an ethical practice, they must have the ability to understand and define ethical problems, aiming to achieve a theoretical definition, correct sensory and intellectual perception of the situation, which will provide more assertive moral decision-making. It is important to highlight that this study fills the gap in the literature regarding the definition of what constitutes an ethical problem for nurse managers5,10.
In order to understand the ethical problem from nurse managers’ perspective, Alasdair Macintyre’s theoretical framework of virtue ethics was used. This philosopher is one of the main contributors to current ethics. For him, it is impossible to understand ethical parameters and concepts without delimiting the historical context that originated them, the practices and the narrative12.
Macintyre’s ethics is teleological because it is concerned with the good life and the good, but it is also a rationalist ethics that considers emotions, affections, circumstances and cultural and social contexts. It is understood that all places are marked by ethical issues and that virtue ethics is the only way to structure morals and protect individuals. Virtue ethics includes qualities that allow achieving the goods of a given practice, and it is the responsibility of individuals to develop these goods to achieve excellence12-13.
Macintyre’s theory brings the concepts of external and internal goods. Internal goods concern what legitimizes and gives meaning to practice9,14. For instance, for a nurse manager in the care process, internal assets can be considered to be empathetic towards patients, contributing to the humanization process, mobilizing habits, skills and attitudes that favor care as well as being able to plan, organize and assess care. It is understood that the positive results of practicing internal goods are good for patients. Thus, this result is seen as an internal good because its achievement is good for the entire community and because it is necessarily achieved when there is dedication by individuals to the practice in question.
External goods can be achieved in two ways. The first, through internal assets, because, if individuals make every effort to care for patients, they will probably offer quality care, taking into account patients’ needs. The second way would be, for instance, through manipulation, influence and judgment. External goods are not necessarily linked to the exercise of some virtue; therefore, they can be achieved through amoral practices9-10. The first way would be a consequence of internal goods, as there is individual commitment to achievement; and the second follows an alternative path. Returning to the example of nurse managers in the care process, the manifestation of appreciation, respect and gratitude by patients and healthcare staff can be considered external assets to this nurse.
Thus, Macintyre argues that internal goods would be those that combine technical excellence with excellence in virtues, whereas external goods should be pursued as an effective means of achieving internal goods9,14.
Taking into consideration the questions presented, the study aimed to understand hospital nurse managers’ ethical problems from the perspective of Macintyre’s virtue ethics.
METHOD
This is a single, holistic and explanatory case study with a qualitative approach, from the perspective of the virtue ethics theoretical framework. The option for the case study type is justified because it is the method capable of providing an understanding of the situations experienced and the way in which a phenomenon happens, its dimensions and characteristics, through the combination of different types of evidence15.
The research was carried out at a university hospital, in Belo Horizonte, state of Minas Gerais, Brazil. The hospital is made up of a complex of buildings with seven annexes, with a capacity for 504 beds and carries out an average of 4,500 emergency services per month, 36,000 outpatient consultations, 160,000 laboratory tests, 750 surgeries and 160 deliveries. It is a reference in medium and high complexity care and one of the largest healthcare service providers in the state of Minas Gerais.
Sixteen nurse managers participated in the study. Nursing in Brazil is regulated by the Professional Practice Law (LEP - Lei do Exercício Profissional) 7,498, which considers management as a nurse’s exclusive action. However, there is no regulation that specifies the regulation of nurse managers’ work1.
Generally, these professionals carry out multiple activities, including sizing nursing staff, training and encouraging professional development, conflict management and support in decision-making1. In the hospital setting of this study, the nurses who hold the position of technical, coordination and vice-coordination managers, in addition to carrying out the previously mentioned functions, are responsible for creating and maintaining information and relationship networks; contribute to maintaining the good image of the organization; analyze activities and their impact on the environment; plan and disseminate actions; distribute functions; and participate in discussions. Therefore, in this study, “nurse managers” were defined as those who held the position of technical manager, coordinator and vice-coordinator in the aforementioned hospital.
At the time of data collection, there were 41 nurse managers eligible and available for the study in the hospital, including 32 coordinators, seven deputy coordinators and two technical managers. Sixteen nurse managers participated in the study (one technical manager, two vice-coordinators and 13 nursing coordinators), considering the following inclusion criteria: being a nurse manager with an employment relationship for at least six months. A period of six months is considered essential for understanding ethical problems in the management role, enabling the researcher to collect differentiated information. The exclusion criteria were being on vacation or medical leave at the time of data collection. There was no withdrawal or refusal to participate in the study by nurse managers.
To select participants, non-probabilistic snowball or “snowball” sampling was used. This technique is recommended when dealing with private issues that are experienced and defined by a specific population16. An invitation to participate in the research was made randomly to a coordinating nurse, who gave the first interview and, at the end, appointed another coordinating nurse. Nurse managers were invited to participate in the research via telephone, email or in person. Therefore, the interviews were previously scheduled and carried out ensuring privacy for participants. Everyone was asked to nominate more people until the data obtained reached theoretical saturation and, consequently, data collection was interrupted.
To determine the suspension of data collection through theoretical saturation, the following procedures were followed: data recording (interview transcriptions), individual analysis of each interview as they were carried out, thematic grouping, identification of regularity of findings and verification of the absence of new elements in each grouping. The final sample size was 16 participants, as the addition of others would not add new information or topics necessary for the study objective.
Before data collection, the pilot interview strategy was used, which helped with the final structuring of the interview guide. The researcher was able to experience what data collection and dialogue with nurses would be like. Three nurses who had previously held or were holding nursing coordination positions in other similar institutions were interviewed. After finishing, some biases were removed, making the questions in the script more assertive and detailed. Adjustments were made to the script, and the pilot interviews were discarded, not forming the final data of the study.
The researcher was trained to ensure that there were no mistakes or biases in data collection. It is known that researcheres need to focus their attention on participants, carry out the interaction through questions and seek the answer to their research object. Therefore, the researcher’s training was necessary to manage tense and stressful situations and understand the explicit and implicit messages provided by participants.
Data were collected between August and October 2021 through individual interviews with a semi-structured script and document analysis. The use of different data sources made it possible to understand reality from different angles and compare findings. This strategy of employing two or more data sources to understand different perspectives is called “triangulation”. It is believed that the use of just one data collection method would not be enough to make the event understandable15,17.
The interview’s initial questions aimed to outline the profile of nurse managers (sex, age, time since graduation, level of qualification, working hours, among other items), followed by specific questions, such as “What is an ethical problem for you?”, “What defines an ethical problem in your work?”, “What makes you consider this problem an ethical problem?”.
The interviews were audio recorded, transcribed in full (respecting all participants’ speeches, expressions and thoughts) and lasted an average of 27 minutes. Of the total, 87.5% (n=14) were in person and 12.5% (n=2) online through Google Meet.
In addition to the interviews, a documentary analysis of administrative nursing notebooks was carried out. This analysis was carried out by a researcher (the same one who conducted the semi-structured interviews), and cases of doubt were sent to two other researchers. Notebooks are an important means of communication between nursing and, in different legal spheres, a legal document that confirms the execution of nursing work. In the hospital setting of this study, the notebook is filled out by the head nurse and administrative technical coordinators, who record the memory of an occurrence, making explicit what, how, when and where the events occurred as well as what were the consequences and decisions taken. Facts that interfere with the quality of care are recorded, such as absences, delays, problems related to professional activity, conflicts with multidisciplinary staff, conflicts with co-workers or users, pending shifts and other occurrences that can lead to losses in care. These are unique issues that require greater attention from staff and explain the dynamics and complexity of everyday nursing.
Three administrative notebooks were analyzed that had records relating to the interval from January 2, 2020 to October 25, 2021. We chose this period due to the possibility of analyzing them since the beginning of the pandemic (since in January 2020 the World Health Organization declared Covid-19 as a public health emergency of international concern) until the final moment of data collection. It was believed that the notebooks would bring different contexts of experiences of ethical problems in a pandemic context, and it is noteworthy that they contained general information about the hospital complex. To systematize, a Microsoft Excel spreadsheet was used, in which information was inserted that addressed ethical problems (date of occurrence, case narrative, repercussions, actors involved and decisions made).
As a strategy to ensure qualitative rigor, data triangulation, peer review, extended fieldwork (prolonged involvement in the research setting and prolonged analysis of administrative notebooks, increasing the researcher’s sensitivity to the meanings attributed by participants to the phenomenon investigated) and transferability (e.g., through extensive and careful descriptions of the time, place and context of the study) were used. Furthermore, to manage subjectivity, a critical discussion of the data, results and interpretations was carried out in a group of researchers.
Seeking to understand the characteristics, meanings and structures behind the interview fragments, Bardin’s content analysis was used. The three chronological poles for content analysis were followed: pre-analysis; material exploration and treatment of results; and inference and interpretation18. After transcribing the interviews, the text underwent initial skimming and subsequent exhaustive readings. The common characteristics of the text fragments were aggregated and arranged in a spreadsheet, originating the record units. Later, in this same spreadsheet, the fragments were arranged in chunks, giving rise to two thematic categories: “Ethical problems linked to violation of care values: internal goods” and “Ethical problems linked to breaking norms, standards of behavior and interpersonal relationships: external goods”. Each category was added with subcategories, as shown in Figure 1.
The research respected ethical standards and was approved by the Research Ethics Committee (REC). When invited, participants were informed about the nature of the research, ethical and legal aspects and rights assured. They also completed and signed the Informed Consent Form (ICF). The online interviews followed the guidelines of circular letter 2/2021/CONEP/SECNS/MS of the Brazilian National Research Ethics Council (CONEP - Conselho Nacional de Ética em Pesquisa). The interviews were recorded and transcribed in full, and participants were previously informed about this action, which was only carried out with authorization.
To guarantee confidentiality, statements were coded with the letters NM (nurse manager), followed by an Arabic numeral, according to the order in which they were interviewed.
Participation was voluntary, and they were free to withdraw from participating in the research at any time, without embarrassment or harm, however, no participant withdrew. For document analysis, the hospital signed the Data Use Commitment Term (DUCT). Therefore, at no time was the personal data present in the documents exposed or revealed. As the interviews were carried out during the Covid-19 pandemic, the necessary distance and use of a mask and alcohol gel were respected.
The collected data were kept at the Universidade Federal de Minas Gerais School of Nursing, under the responsibility of the researcher in charge. A database was created for future analyses, and, after five years, the data will be destroyed.
The project and article were prepared considering the COnsolidated criteria for REporting Qualitative research (COREQ).
RESULTS
Of the 16 study participants, all were female, aged between 33 and 57 years. Regarding the highest educational level achieved, 11 nurses specialized (accomplished in graduate programs) in occupational nursing, neonatology, infection control, surgical center, public health, obstetric nursing, elderly health, oncology and intensive therapy. The specializations undertaken by participants focus on individual professional career and are not necessarily linked to nurses’ area of activity in the hospital. Among the others, there were four holding a masters’ degree and one holding a doctoral degree. Concerning managerial training, only four professionals said they had training to work in a managerial position, and there were no reports of specific training in the area of ethics.
As for working time at the hospital, nurses ranged from 5 to 23 years. When it comes to the number of jobs at that time, only one nurse reported working in another institution.
Through data analysis, two thematic categories emerged, presented below.
Ethical problems linked to violation of care values: internal goods
The managers reported that the ethical problem is when there is denial of assistance and negligent and reckless actions in patient care; when a professional performs a procedure and does not inform patients that they would perform it, without requesting patients’ consent; when he is negligent and fails to evaluate a patient; or when they do not assess them properly.
[...] he (doctor) is performing a procedure and did not tell the patient that he was going to do this procedure, and the patient is simply there thinking about what is happening (NM10).
[...] so I think that an ethical issue is for you to contact the (medical) staff, for them to be aware of what is happening and not present themselves at the unit, I think that for me this is a serious ethical problem! (NM13).
[...] this is when a professional is aware of the harm they can cause to a patient and, even so, they fail to take certain actions for the benefit of the patient with the risk of causing harm (NM16).
The ethical problem is also a situation that affects the rights of professionals, patients, staff and institutions.
[...] it is a problem that is not right, that is not correct [...] and that, sometimes, affects some people, affects the person and affects dignity (NM3).
[...] it is something that will violate the other person’s rights. It’s something that happens that creates this, both for the patients and for the professionals who are involved [...] it’s when it involves the rights of more than one person, not just mine (NM8).
[...] an ethical problem is invading another’s space, it’s breaking a law, it’s wanting to take away the autonomy of the other, it’s not prioritizing the user, it’s prioritizing yourself as a professional, it’s when I act for my own benefit and end up hurting the other (NM15).
In documentary analysis, an ethical problem was recorded related to filming the nursing staff by a companion without the staff’s consent.
Ethical problems linked to breaking norms, behavior patterns and interpersonal relationships: external goods
An action or behavior that is incompatible with what is expected in a nurse’s conduct is defined as an ethical problem as well as something that goes against what nurses believe is the right thing to do.
[...] an ethical problem is when an action is disconnected from what is expected within a standard/normal work process (NM14).
[...] it is everything that is not compatible with conduct and that can in some way tarnish or deconstruct the image of a nursing professional [...] it is something that, in some way, violates what is our duty and our role and which is not compatible with what our profession deserves (NM1).
As an example of incorrect behavior, nurse managers reported that some professionals on the nursing staff exposed the personal problems and individualities of other colleagues and fueled a patient’s complaint about a professional, generating interpersonal conflicts and discomfort in the staff.
[...] you expose a colleague to a situation. It’s one thing to arrive and see a situation and talk to your manager and the person involved, and another thing is to disclose something you saw (NM14).
[...] you expose a patient, you expose the life of a professional, I think that’s it (NM2).
[...] I have already experienced, for instance, arriving in the locker room and finding an employee speaking badly about another colleague in the middle of everyone and explaining that he does this and does that (NM9).
When there is exposure, aggression and disrespect towards a professional and/or distrust of loyalty and conduct, nurse managers define this as an ethical problem.
[...] it is an ethical problem for a professional to show disrespect towards me, towards my activities and duties that I carry out here [...] I have already experienced disrespect in the middle of the corridor in front of the staff and patients by a medical professional. The doctor grabbed me by the collar of my coat, pulled it and let go. He called me out in a horrible way as if whatever problem was happening was my fault. I was shaking! (NM4).
In documentary analysis, a case of aggression by a hospital employee towards the nursing staff was recorded, as she claimed that her mother was not being properly assisted.
There is disrespect in the relationships between doctors and nursing staff. For instance, when a nurse needs a signature from a medical professional, they are mistreated, ignored, and feel subjugated to their will.
[...] so, many times I had to seek signatures and was mistreated. It looks like I’m begging for something (doctor’s signature) and that thing (doctor’s signature) has been pre-established that he has to do! (NM4).
An ethical problem for nurse managers is when there is doubt and disagreement regarding nurses’ clinical practice or the conduct adopted in managing activities.
[...] some professional here in the sector complaining about another colleague, for instance, complaining that the other colleague doesn’t work in all shifts, because supervision does the shift that way, not assigning the person to certain jobs (NM6).
[...] oh, recently, we had a problem with a medical professional who was demanding that nurses administer chemotherapy to a patient, and they (nurses) assessed that it was not safe for the patient to undergo chemotherapy. Then he (the doctor) didn’t like it, and they argued at the nurses’ station with other people listening and it created an ethical problem there (NM8).
[...] it is an ethical problem when I am unable to provide better assistance to these people, because I do not have autonomy as a professional in this institution, even though legislation allows me, even though I have a legal basis, because I have a legal basis through legislation, even though I have a scientific basis [...] so, it is an ethical problem that I am unable to provide care to the patient because my assistance is restricted by other professionals; this is an ethical problem (NM15).
Nurse managers report that the ethical problem is when there is a violation of the profession’s code of ethics and institutional standards; when there is disrespect or non-compliance with public servant rules; or even when professionals do not follow the nursing oath.
[...] it is that [ethical problem] that we can do that is outside the conduct, the principles of our profession, the issues of our oath that the profession itself determines as correct (NM12).
[...] violating our code of ethics, because today we are supported by legislation and I think that everything that goes against this legislation, against institutional norms, I think would be a problem of an ethical infraction (NM13).
[...] I think that an ethical problem is anything that violates the rules imposed by the institution, by the coexistence of one person with another. It affects the rules imposed by the institution and, in a certain way, is harming the institution, colleagues and the public service (NM7).
DISCUSSION
When assuming that care is an internal asset of nurse managers, failure to exercise virtues in favor of assistance means assuming that their practice would be corrupted9. It has been reported that some professionals ignore ethics when they speak abusive phrases to patients, commit disrespect for autonomy, violate patients’ will, hide the clinical condition or diagnosis and when they apply the knowledge they have learned without any moral emotion, being unable to appreciate patients’ feelings9. Acceleration of the procedure can be added without thinking about aseptic technique or measures to assess pain, not prioritizing patients’ comfort4.
A virtuous action must meet the fair mean, as the path of virtue lies between two extremes: lack and excess. Thus, a prudent individual will assess the situation and circumstances to deliberate in a way that allows the best choices, approaching the good and moving away from the bad19.
Insecurity caused by personal interests incompatible with the organization, ambiguous obligations and feelings of impotence and marginalization cause nurse managers to behave badly, i.e., contrary to their good values, consequently failing to promote ethical assumptions in patient care. However, they must opt for a care plan that is least harmful to patients, weighing the pros and cons, communicating effectively with patients and being empathetic20.
Furthermore, nurse managers understand that minimizing ethical problems involves equity in care. To achieve this, it is necessary to perceive patients as the main reason for healthcare services. This aligns with a study in which it is reported that valuing patients in services promotes more fair, equitable and appropriate care. Therefore, there is differentiated treatment between people according to individual needs, thus highlighting the principle of equity as a guide to care. For Macintyre, equity is the means of materializing justice in the practical world, as acting justly enables social equity13,21.
Therefore, an ethical problem is generated when there is no equity to enforce the right to quality health for all. Equity has applicability in all dimensions of the nursing work process, and to make it viable in healthcare services, it is necessary to think about the transversality of actions, train professionals and promote participatory management. In short, defending an equitable healthcare system is the first step towards achieving a fairer system22.
It is important to say that nurse managers enter the work with virtues and wish to implement ethical principles. This can be exemplified when they act as advocates for patients, trying to prioritize their needs and interests before professionals from the multidisciplinary staff or even the organization. However, the work environment discourages them and makes unethical practices normal and even justifiable23.
Macintyre’s theory understands that the subject can engage in contradictory practices. Therefore, in a given situation, nurse managers may act contrary to their own ethics. To identify the goods of each action carried out by individuals, it is necessary to understand what subjects’ particular history involves so that they can identify the good and direct their actions towards the community, as all actions need to be thought of within the social sphere12.
The lack of collegiality and professionalism among some professionals on the nursing team, doctors and patients’ companions was also identified as an ethical problem for nurse managers. There are serious situations that involve these actors, such as swearing, verbal and image exposure of professionals and patients, aggression and speeches disqualifying nursing knowledge and practice. These are attitudes that cannot be neutralized in the work environment. It is important to highlight the prevalence of the biomedical model in the university hospital setting of this study.
The heterogeneity of professionals who work in organizations creates problems in interprofessional and intraprofessional relationships, resulting in divergences in values regarding care. It is essential that nurse managers are in a balanced, harmonious and respectful environment to carry out their activities safely. Furthermore, ethical behavior must be improved by strengthening these nurses’ professional identity and social status, nursing sizing and ethical climate4,24.
Nurse managers state that it is an ethical problem when there is an action that goes against the norm and standard. In this regard, Macintyre reports that individuals are acting according to the emotivist theory, thereby judging according to what is best for themselves, valuing external products arising from the activities they perform, such as money, power and fame. Thus, the philosopher criticizes the emotivist theory and believes that contemporary society is in moral disorder: individuals do not have an ultimate good for their actions and assume neutrality. As a result, they act according to what suits them, prioritizing the “I”, emphasizing their emotions and desires instead of rational rules14.
In this way, when assuming patient care (a practice), subjects accept pre-established norms and subject their own attitudes and tastes to the standards, excluding all subjectivity from judgment. It is important that actions have a balance between reason and desires, as they bring results for professionals and the community12,14.
In hospitals, there are laws, standards, regulations and ordinances that integrate various services and direct healthcare servessionals’ work process towards harmonious, efficient and economically viable functioning, aiming to meet society’s needs. This legal framework must be known and exercised by nurse managers, in order to commit to the institution, be guided towards ethical behavior and be clear about the reward and punishment systems25-26. Legal provisions should not be static, but dynamic, being reviewed to simplify and improve work efficiency.
It is worth highlighting the public servant legislation and the code of ethics for nursing professionals, as they are ethical-legal devices that guide nursing professionals’ practice and provide for rights, duties and prohibitions. Furthermore, they contain in their content the sanctions and penalties that will be attributed to professionals in case of disagreement with what is defined. Nurse managers’ work must be guided by ethical guidelines, avoiding non-compliance, which can generate civil, administrative, ethical-professional and criminal liability, in addition to providing professionals with better insight into their conduct27-28.
However, when nurse managers raise concerns about doing what is correct and good based on laws, norms and policies, it must be added the fact that Macintyre’s theory understands that only these factors are not capable of making subjects exercise their virtues, as subjects are permeated by their traditions, practices and narratives. Therefore, it is essential for professional practice to consider ethical conduct in mutual relationships (with patient, family, community and healthcare servessionals), in moral construction of individuals, in human activity and in interconnected stories8,14. Therefore, the practice of virtues must be understood beyond the exercise of a rule, but considering the group relationships, environment and practices.
The discussion requires clarification of what would be administrative problems, since the nurse managers in this study reported having difficulties in discerning what is an ethical problem and what is an administrative problem. Thus, conceptually, socio-sanitary and environmental problems, use of available technology, population heterogeneity, health system’s mercantilist logic, pressure groups (which define decision-making), corruption, restricted financial resources, limited coverage and breadth of service are administrative problems29. It is understood that these problems are not only administrative, but also political, contextualizing and causing ethical problems in turn.
As for the ethical problem, it was evident that, for these nurses, an ethical problem is when there is an action or behavior that both violates a person’s rights and does not comply with the code of ethics, norms and institutional rules. Furthermore, the ethical problem arises when care is denied, neglected and reckless, or even when professionals are exposed, attacked, disrespected and have their conduct questioned.
To guide professionals towards ethical professional practice at work, it is suggested to strengthen educational, consultative and surveillance actions for the professional practice of nursing as well as the development of ethical skills in professional training. It is necessary to promote knowledge of professional laws, reflections to promote moral autonomy and virtuous habits. Furthermore, it is understood that it is up to individuals to develop moral training according to the virtues valued individually and in tune with what is valued in the work environment.
This study contributed to understanding the ethical problem in nurse managers’ practice and allowed us to understand the aspects that can generate ethical problems in nurses’ work process.
A limitation of this study was data collection during the COVID-19 pandemic, as it is understood that, when talking about ethics, there is an impact on the values and problems experienced at the time; thus, in different circumstances, other issues could be more important in participants’ statements. Although this type of study does not imply, a priori, generalizations, the setting was a single institution and the object was focused only from nurse managers’ perspective also represented limitations, as institutional differences and hierarchical positions must be taken into account. Therefore, multiple perspectives and settings can broaden the understanding of ethical problems, which is recommended for future studies.
CONCLUSION
As research evolved, various understandings of ethical problems emerged from the perspective of virtue ethics, which contributed to the analysis of concepts and identification of attributes. In summary, nurse managers understand ethical problems as what is not right to do; circumstance that generates opposition to what nurses understand as the right thing to do; action or behavior not compatible with standard conduct, going against the rules, principles, norms, legislation, code of ethics and oaths that the profession, institution and public service determine; situation that violates people’s rights; denial, negligence and recklessness in patient care; exposure, testimony and distrust of a professional’s ethical conduct and knowledge; unnecessary exposure of a patient; disrespect for people and aggression; situation that negatively affects professionals, patient care, the institution and the public service; and situation that goes against what is proper to nurses and against their duty.
Clarifying the definition of ethical problems for nurse managers is essential to ensure greater visibility, identification and recognition of these problems in practice. Understanding that ethical problems are present in different healthcare settings is essential, as they affect patients, professionals and institutions.
ACKNOWLEDGMENT
We would like to thank the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), Minas Gerais State Research Support Foundation (Fundação de Amparo à Pesquisa do Estado de Minas Gerais), Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico), Nursing Administration Research Center, Universidade Católica Portuguesa Center for Interdisciplinary Research in Health and also ETHICS4CARE Research Center.
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NOTES
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ORIGIN OF THE ARTICLE
Article extracted from the thesis “Problemas éticos na pandemia da Covid-19: visão de enfermeiros gestores em um hospital universitário”, presented to the Graduate Program in Nursing at the Universidade Federal de Minas Gerais, in 2023.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Minas Gerais, Opinion 4.807.325, Certificate of Presentation for Ethical Consideration 46988021.4.0000.5149.
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TRANSLATED BY
Letícia Belasco.
