ABSTRACT

Objective:

To assess the intensity and frequency of moral distress in mental health nurses in Brazil.

Method:

Cross-sectional study with 173 nurses from the Psychosocial Care Network in Brazil. The Brazilian Scale of Moral Distress in Nurses, adapted for the context of mental health, was used. For data processing, descriptive and inferential statistical analysis was used.

Results:

Mostly moderate levels of intensity and frequency of moral distress (medians between 2.25 – 3.73 and 2.00 – 3.22, respectively) were observed, with emphasis on the factors working conditions and social conflicts.

Conclusion:

The level of moral distress evidenced in mental health nurses in Brazil reflects the dimension and amplitude of the phenomenon in different points of the Psychosocial Care Network. The relevance of discussions on coping strategies for moral distress is highlighted, articulating elements such as sensitivity, resilience, and moral courage, so that ethical deliberation is applied in care and management settings.

DESCRIPTORS
Psychological Distress; Mental Health; Ethics, Nursing; Working Conditions

RESUMEN

Objetivo:

Evaluar la intensidad y frecuencia del sufrimiento moral en enfermeros de salud mental en Brasil.

Método:

Estudio transversal con 173 enfermeros de la Red de Atención Psicosocial del territorio brasileño. Se utilizó la Escala Brasileña de Sufrimiento Moral en Enfermeros adaptada para el contexto de la salud mental. Se utilizó análisis estadístico descriptivo e inferencial para el procesamiento de datos.

Resultados:

Se observó, en su mayoría, niveles moderados de intensidad y frecuencia de sufrimiento moral (medianas entre 2,25 – 3,73 y 2,00 – 3,22, respectivamente), con énfasis en los factores condiciones de trabajo y conflictos sociales.

Conclusión:

El nivel de sufrimiento moral evidenciado en enfermeros de salud mental en Brasil refleja la dimensión y amplitud del fenómeno en los diferentes puntos de la Red de Atención Psicosocial. Se destaca la relevancia de las discusiones sobre estrategias de enfrentamiento del sufrimiento moral, articulando elementos como la sensibilidad, la resiliencia y el coraje moral, para que la deliberación ética sea aplicada en contextos de cuidado y gestión.

DESCRIPTORES
Distrés Psicológico; Salud Mental; Ética en Enfermería; Condiciones de Trabajo

RESUMO

Objective:

To assess the intensity and frequency of moral distress in mental health nurses in Brazil.

Method:

Cross-sectional study with 173 nurses from the Psychosocial Care Network in Brazil. The Brazilian Scale of Moral Distress in Nurses, adapted for the context of mental health, was used. For data processing, descriptive and inferential statistical analysis was used.

Results:

Mostly moderate levels of intensity and frequency of moral distress (medians between 2.25 – 3.73 and 2.00 – 3.22, respectively) were observed, with emphasis on the factors working conditions and social conflicts.

Conclusion:

The level of moral distress evidenced in mental health nurses in Brazil reflects the dimension and amplitude of the phenomenon in different points of the Psychosocial Care Network. The relevance of discussions on coping strategies for moral distress is highlighted, articulating elements such as sensitivity, resilience, and moral courage, so that ethical deliberation is applied in care and management settings.

DESCRITORES
Psychological Distress; Mental Health; Ethics, Nursing; Working Conditions

INTRODUCTION

Moral distress is defined as an emotional imbalance manifested when nurses are exposed to a conflicting situation and identify the morally correct action to be taken, but structural and/or relational barriers prevent them from acting according to their values(¹1. Jameton A. A reflection on moral distress in nursing together with a current application of the concept. J Bioeth Inq. 2013;10(3):297–308. doi: http://dx.doi.org/10.1007/s11673-013-9466-3. PubMed PMID: 24048753.
https://doi.org/10.1007/s11673-013-9466-... ). Its occurrence is associated with the subjective conditions and experiences of the nurses’ work process, which require ethical positions, clinical decisions, care and conflict management, expressed through manifestations of frustration, anger, physical and emotional exhaustion, and professional impotence(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ,³3. Drago LC, Ramos FRS, Brehmer LCF, Silveira LR, Brito MJM. Nurse managers’ moral suffering in a university hospital. Revista de Pesquisa Cuidado É Fundamental Online, 2020;12(1):1074–80.).

From a procedural perspective, moral distress is considered an ethical/moral experience manifested in the face of a moral problem (starting point), requiring some degree of sensitivity, concern, and moral discomfort by the nurse, so that their moral judgment occurs in a more prudent way(⁴4. Ramos FRS, Barlem ELD, Brito MJM, Vargas MA, Schneider DG, Brehmer LCF. Conceptual framework for the study of moral distress in nurses. Texto Contexto Enferm. 2016;25(2):1–10. doi: http://dx.doi.org/10.1590/0104-07072016004460015
https://doi.org/10.1590/0104-07072016004... ). In care practice, failures in this process lead to changes and personal and professional resonances in nurses, and bring out negative impacts to the people they assist(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ).

In the field of mental health, materialized in the Brazilian scenario by the different points of the Psychosocial Care Network (RAPS), the nurse acts directly in the management of services and assistance for people with mental disorders and for those with needs arising from the use of alcohol and other drugs, supported by Resolution No. 678/2021, which regulates the performance of the nursing team in this field of work(⁵5. Conselho Federal de Enfermagem (COFEN). Resolução n. 678, de agosto de 2021. Aprova a atuação da Equipe de Enfermagem em Saúde Mental e em Enfermagem Psiquiátrica. Diário Oficial da União; Brasília; 2021 [citado em 2023 mar 15]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-678-2021_90358.html
http://www.cofen.gov.br/resolucao-cofen-... ).

For this context, it is recommended that nurses develop ethical and technical skills for a humanized, comprehensive, and community-based work, based on the users’ needs(⁶6. Peres MAA, Martins GCS, Manfrini GC, Cardoso L, Fonseca PIMN, Shattell M. Vinte anos da Lei da Reforma Psiquiátrica brasileira: significados para a enfermagem psiquiátrica e em saúde mental. Texto Contexto Enferm. 2022;31:e20220045. doi: http://dx.doi.org/10.1590/1980-265x-tce-2022-0045en
https://doi.org/10.1590/1980-265x-tce-20... ). However, contrary to this perspective, problems are found related to professional training, lack of understanding of the policies and care model in force in mental health care and, above all, to the very disarticulation of RAPS, which contributes to the discontinuity of care(⁷7. Sabeh ACB, Cecilio HPM, Campos CJG, Reis HFT, Wysocki AD, Santos EM. Social representations of nurses of the Emergency Care Unit towards people with mental disorder. Rev Esc Enferm USP. 2023;57:e20220298. doi: http://dx.doi.org/10.1590/1980-220X-REEUSP-2022-0298en
https://doi.org/10.1590/1980-220X-REEUSP... ).

These particularities, added to the different ethical/moral problems and disrespect for users’ rights, work overload, staff deficit, inflexible organizational cultures, insufficient professional recognition, and low remuneration, are predictors of moral distress in mental health nurses(⁸8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... ,⁹9. Oliveira CA, Oliveira DCP, Cardoso EM, Aragão ES, Bittencourt MN. Moral distress of nursing professionals of a psychosocial care center. Cien Saude Colet. 2020;25(1):191–8. doi: http://dx.doi.org/10.1590/1413-81232020251.29132019
https://doi.org/10.1590/1413-81232020251... ).

In view of this panorama, for professionals to develop effective skills for coping with ethical/moral and institutional problems in response to moral distress, their generating situations shall be clearly defined. There is a certain limitation of Brazilian studies covering the theme in mental health nurses, and only an integrative literature review(⁸8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... ) and a qualitative study(⁹9. Oliveira CA, Oliveira DCP, Cardoso EM, Aragão ES, Bittencourt MN. Moral distress of nursing professionals of a psychosocial care center. Cien Saude Colet. 2020;25(1):191–8. doi: http://dx.doi.org/10.1590/1413-81232020251.29132019
https://doi.org/10.1590/1413-81232020251... ) were identified. Studies on moral distress in this specific population predominate in the international scenario, where countries such as Japan(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ), South Korea(¹¹11. Noh D, Kim S, Kim S. Moral distress, moral sensitivity and ethical climate of nurses working in psychiatric wards. J Korean Acad Psychiatr Ment Health Nurs. 2013;22(4):307. doi: http://dx.doi.org/10.12934/jkpmhn.2013.22.4.307
https://doi.org/10.12934/jkpmhn.2013.22.... ), Jordan(¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ), U.S.A(¹³13. Lambour S. The experience of moral distress in psychiatric nurses [dissertação]. Virginia: University of Virginia; 2016. doi: http://dx.doi.org/10.18130/V3MS2K
https://doi.org/10.18130/V3MS2K... ), Italy(¹⁴14. Delfrate F, Ferrara P, Spotti D, Terzoni S, Lamiani G, Canciani E, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav. 2018;109(2):97–109. PubMed PMID: 29701626.), Norway(¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ), Thailand(¹⁶16. Upasen R, Saengpanya W, Sambutthanon J. Strategies to cope with moral distress among mental health nurses in Thailand. Journal of Health Science and Medical Research. 2020;1(39):47–55. doi: http://dx.doi.org/10.31584/jhsmr.2020762
https://doi.org/10.31584/jhsmr.2020762... ), and Iran(¹⁷17. Ghafouri R, Lotfi-Bajestani S, Nasiri M, Ohnishi K, Atashzadeh-Shoorideh F. Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nurs. 2021;20(1):166. doi: http://dx.doi.org/10.1186/s12912-021-00674-4
https://doi.org/10.1186/s12912-021-00674... ) devoted more attention to this issue.

Based on the issue raised and considering the particularity of Brazil, a continental, multicultural country with significantly different sociodemographic aspects, as well as the absence of observational studies on the dimension of moral distress in nurses working in RAPS, the relevance of investigating the object is warranted. Therefore, the present study aimed to evaluate the intensity and frequency of moral distress in mental health nurses in Brazil.

METHOD

Design of Study

Cross-sectional study with non-probability, ­convenience sampling(¹⁸18. Cheng A, Kessler D, Mackinnon R, Chang TP, Nadkarni VM, Hunt EA, et al. Reporting guidelines for health care simulation research: extensions to the CONSORT and STROBE statements. Simul Healthc J Soc Simul Healthc. 2016;11(4):238–48. doi: http://dx.doi.org/10.1097/SIH.0000000000000150
https://doi.org/10.1097/SIH.000000000000... ).

Local and Population

The study was carried out in the Brazilian RAPS, distributed in the 27 units of the federation (26 states and the Federal District). Nurses working in Psychosocial Care Centers (CAPS) (type I, II and III, CAPSi - childhood and adolescence, CAPSad and CAPSad III - alcohol and drug users), specialized psychiatric (public) hospitals, specialized reference units in general hospitals, mental health clinics, and street clinics were included, regardless of the time since the end of the undergraduate course, time of practice, or type of employment. To calculate the estimated N of the population (12,294), the number of registered services mentioned above and their geographic distribution, Resolution No. 543/2017 of the Federal Nursing Council (which provides for the dimensioning of nursing staff) and the Technical Note No. 11/2019 (establishes the minimum composition of nurses in mental health services) were considered.

Sample Definition

The sample size was calculated using the finite population formula for epidemiological studies, with a confidence level of 95% and sampling error of 10% of the population average. With this calculation, the resulting minimum sample was 85 participants. However, 173 nurses participated in the study, with regional representativeness (quotas), in a similar distribution to the general population calculated for the study. It should be noted that the increase in the sample decreased the sampling error to 7%, considering the same confidence standards.

Data Collection

Data were collected online, via google.docs, from March to June 2021, through the Brazilian Scale of Moral Distress in Nurses adapted for the context of mental health (EDME-Br-SM). This measurement instrument was adapted and validated through a methodological study(¹⁹19. Bruggmann MS, Schneider DG, Ramos FRS, Vargas MAO, Brehmer LCF, Bhering A. Adaptation and validation of a moral distress instrument in mental health nurses. J Nurs Meas. 2024. Ahead of print.), based on the Brazilian Scale of Moral Distress in Nurses(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ).

The process considered the criteria, content and construct validation steps, in eight moments: 1) determination of what to be measured (moral distress in mental health nurses(⁸8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... )); 2) generation of a set of items – criterion validation (analysis and comparison of items from the original instrument, considering adjustments, inclusions, and exclusions); 3) determination of the measurement format (two Likert scales to measure moral distress for intensity, ranging from 0 (none) to 6 (for very intense suffering) and frequency, ranging from 0 (never) to 6 (very frequent); 4) review by experts - content validity (items evaluated by 14 experts in moral distress and 20 in mental health, according to their experiential and cultural context, in terms of relevance, clarity, and consistency. Pre-test with 30 mental health nurses and application of the Content Validity Index (CVI) 5) inclusion of items (predictors were reviewed); 6) application of the instrument in a sample of interest (173 mental health nurses from different Brazilian regions); 7) item evaluation – criterion validity (statistical analysis); 8) scale optimization (instrument validated with 37 items and seven factors).

The EDME-Br-SM includes the following sociodemographic variables: age, sex, region of the country, time since end of undergraduate course, complementary and post-graduate training, number of employment relationships, nature and type of employment, level of care in which they work, time of practice in the main job, weekly workload, and type of service/unit in which they work. Its predictors were organized into the following factors: Factor 1 (F1) – Working conditions, with nine items; Factor 2 (F2) – Defense of values and rights, with five items; Factor 3 (F3) – Safety and professional autonomy, with seven items; Factor 4 (F4) – Ethical violations, with four items; Factor 5 (F5) – Social conflicts, with five items; Factor 6 (F6) – Professional ethical competence, with three items; and, Factor 7 (F7) – Conflicts with Management, with four items.

To access the participants, social media, telephone contact with the RAPS devices, and messages through application were used. The snowball sampling technique was used, which is a non-probabilistic sampling technique, where the selected sample indicates new participants in their network of acquaintances, through linear sampling. To access the instrument, the respondent received a redirection link to the google.forms platform to access the Free Informed Consent Form signed by the authors, informing the nature and objectives of the study. After agreeing to the term, the participant should click on “I agree to participate in the study” to access the instrument itself.

Data Analysis and Treatment

Data were stored and organized in spreadsheets in Microsoft Excel 2010 and exported for analysis through the software SPSS (Statistical Package for Social Sciences), version 25.0. For the purposes of statistical analysis of the scores of intensity and frequency of moral distress in the EDME-Br-SM, the following intervals were considered as parameters: low (0–1.99), moderate (2.00–3.99), and high (4.00–6.00)(²⁰20. Dyo M, Kalowes P, Devries J. Moral distress and intention to leave: a comparison of adult and paediatric nurses by hospital setting. Intensive Crit Care Nurs. 2016;36:42–8. doi: http://dx.doi.org/10.1016/j.iccn.2016.04.003
https://doi.org/10.1016/j.iccn.2016.04.0... ).

Descriptive statistical analysis was used with relative and absolute frequency distribution for sociodemographic and work variables. The analysis of intensity and frequency of moral distress for each EDME-Br-SM factor was presented by medians and interquartile ranges (Q1-Q3). The Shapiro-Wilk test was performed to test data normality. Sequentially, non-parametric tests of Mann-Whitney were performed to compare the distributions of moral distress between men and women, and the Kruskal-Wallis test to compare the distributions of moral distress between the categories of other variables, with the null hypothesis being rejected when p < 0.05.

Ethical Aspects

The study was approved by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina, under Opinion 4.193.686, 2020, in compliance with Resolution Nº 466/2012 of the National Health Council and other complementary provisions that deal with guidelines and standards that regulate research involving human beings.

RESULTS

In the sample of 173 nurses working in mental health services in Brazil, there was a prevalence of female participants (n = 137; 79.2%), aged between 30 and 39 years (n = 91; 52.6%), from the Southeast region (n = 61; 35.3%), with graduate certificate (n = 98; 56.7%), an employment relationship (n = 106; 61.3%), in the public sector (n = 142; 82.1%), permanent work bond (n = 83; 48%), in secondary level of health care (n = 92; 53.2%), working time in the main job for up to 5 years (n = 76; 43.9%), with a weekly workload of 31 to 40 hours (n = 82; 47, 4%), working in different CAPS modalities (n = 93; 69.5%). There was variability in the participants’ time after undergraduate course, and the results were similar in the periods of 0–5 years (n = 44; 25.4%), 6–10 years (n = 46; 26.6%), and 11–15 years (n = 43; 24.9%). The analysis of the medians and interquartile ranges (Q1-Q3) of intensity and frequency of the EDME-Br-SM factors is shown in Table 1, while the analysis of the instrument’s items is shown in Table 2.

According to the statistical tests used, no association was found between the variables sex, region, time since end of undergraduate course, education, nature of the employment relationship, level of health care, and moral distress (p > 0.05). In the variable age, a higher median value for moral distress was observed in people between 40 and 49 in factor 7 “Conflicts with management” (p < 0.05). For the other factors, there were no statistically significant differences between the distributions of moral distress by age group.

There was a statistical difference in the frequency distributions of moral distress in the variable number of employment contracts in the factor “Professional ethical competence”, indicating greater moral distress in nurses who work in three or more jobs, compared to those who work less. The predictive situations of moral distress in this factor also had a greater association with nurses working in a CLT regime (Brazilian regime which gives no guarantee of permanence), compared to other work regimes. Conversely, nurses who work up to 30 hours a week had the highest values of moral distress in the predictors of the factor “Safety and professional autonomy” in relation to those who work more hours (p < 0.05).

The variable time of practice in the main job was associated with the factors “Safety and professional autonomy”, “Social conflicts” and “Conflicts with management”. The two groups with the greatest moral distress for these factors were nurses whose work practice time ranges from a period between 6 and 10 years and 11 and 15 years. There is also an association between the service in which the nurse works and moral distress. Nurses from CAPS III showed greater intensity of moral distress in the factor “Safety and professional autonomy”; those from CAPSi, in the factor “Ethical violations”; and those from the mental health outpatient clinics, in the factor “Defense of values and rights” (p < 0.05).

In Table 1, it is noted that only the factor “Defense of values and rights” presented a value considered low and such discrepancy indicates a possible heterogeneity of the phenomenon among nurses in this factor, pointing to a probable influence of sociodemographic and labor variables on moral distress. In the opposite direction, it is observed that the other factors presented moderate values for intensity and frequency of moral distress, with emphasis on “Work conditions” and “Social conflicts”.

In Table 2, the predictors “Recognize that the lack of permanent education support impairs the work process”, “Recognize that disarticulations in the Psychosocial Care Network impair access and care for the user and/or family member” and “Recognize that situations of family abandonment negatively interfere with adherence and resolution of the user’s treatment” showed the highest values for median and third quartile (75%). These predictors had the maximum score in the third quartile of moral distress, that is, at least 25% of the nurses who participated in the study assigned the maximum score for both the intensity and the frequency of these items.

DISCUSSION

From the results of intensity and frequency of moral distress according to the scale factors, moderate to high levels of the phenomenon were mostly observed, with “Working Conditions” and “Defense of values and rights”, with the highest and lowest medians, respectively, being highlighted.

For the predictors related to the factor “Working conditions”, with moderate to high levels for the intensity and frequency of moral distress, it is considered that the effective articulation of the RAPS services promotes comprehensive assistance to users in the different network devices(⁸8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... ). Thus, complete communication between professionals and services will creatively encourage other processes relevant to nurses’ work to take place, such as the collective construction of knowledge and the implementation of care technologies, based on permanent health education. However, for this scenario to be configured and to strengthen nurses in situations of moral distress in this factor, it is assumed that the correct dimensioning of nursing is a determining factor, thus reducing work overload and providing safe means for qualified professional care(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ).

The items of the factor “Defense of values and rights” refer to the user’s right to humanized, integral, private, and safe assistance, where their autonomy and values are respected. However, when these aspects are violated by a member of the multidisciplinary team, nurses can experience moral distress. In this sense, it is worth noting that disrespect for users’ autonomy is directly correlated to the phenomenon and affects mental health care nurses(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ,¹³13. Lambour S. The experience of moral distress in psychiatric nurses [dissertação]. Virginia: University of Virginia; 2016. doi: http://dx.doi.org/10.18130/V3MS2K
https://doi.org/10.18130/V3MS2K... ,¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ,¹⁶16. Upasen R, Saengpanya W, Sambutthanon J. Strategies to cope with moral distress among mental health nurses in Thailand. Journal of Health Science and Medical Research. 2020;1(39):47–55. doi: http://dx.doi.org/10.31584/jhsmr.2020762
https://doi.org/10.31584/jhsmr.2020762... ). In the present study, the factor aforementioned had the lower median values for intensity and frequency of moral distress, the same result presented by a Brazilian study on moral distress in nurses from other work settings(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ). It is believed that these values are related to the expansion of discussions on ethical and technical competences in mental health, with emphasis on communication skills, respect for people with mental disorders and their families, guarantee of rights, autonomy of users in their treatment, and effectiveness of community-based services in this process(⁷7. Sabeh ACB, Cecilio HPM, Campos CJG, Reis HFT, Wysocki AD, Santos EM. Social representations of nurses of the Emergency Care Unit towards people with mental disorder. Rev Esc Enferm USP. 2023;57:e20220298. doi: http://dx.doi.org/10.1590/1980-220X-REEUSP-2022-0298en
https://doi.org/10.1590/1980-220X-REEUSP...

8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... -⁹9. Oliveira CA, Oliveira DCP, Cardoso EM, Aragão ES, Bittencourt MN. Moral distress of nursing professionals of a psychosocial care center. Cien Saude Colet. 2020;25(1):191–8. doi: http://dx.doi.org/10.1590/1413-81232020251.29132019
https://doi.org/10.1590/1413-81232020251... ).

Nevertheless, even in the face of findings with lower values, the predictors of this factor still generate moral distress in mental health nurses and so, have to be discussed. Therefore, it is worth noting that the defense of users’ sociocultural rights and values is an advocacy practice carried out by nurses, which seeks to strengthen and qualify their autonomy(²¹21. Vargas CP, Vargas MADO, Tomaschewski-barlem JG, Ramos FRS, Schneider DG, Camponogara S. Patient advocacy actions by intensivist nurses. Rev Esc Enferm USP. 2019;53:e03490. doi: http://dx.doi.org/10.1590/S1980-220X2018011703490. PubMed PMID: 31389487.
https://doi.org/10.1590/S1980-220X201801... ), providing guidance on ethical, technical assistance that is free from damage arising from malpractice, negligence, or imprudence.

From the perspective of the users’ rights defense, it is worth mentioning that opposing forces pointing to the professional non-compliance with their professional code of ethics are related to the factor “Ethical violations” and generate moral distress(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ). In this factor, the items related to recognizing acts of imprudence and negligence on the part of other professionals in the team had the highest values for moral distress among the block items. Besides rescuing differences related to training and professional skills in dissimilar scenarios, these predictors of moral distress also refer to the historical and social context of mental health care, closely associated with the curtailment of rights, neglect, abuse, disrespect, and abandonment of the person with mental disorder, either by the State, society, or professionals(⁶6. Peres MAA, Martins GCS, Manfrini GC, Cardoso L, Fonseca PIMN, Shattell M. Vinte anos da Lei da Reforma Psiquiátrica brasileira: significados para a enfermagem psiquiátrica e em saúde mental. Texto Contexto Enferm. 2022;31:e20220045. doi: http://dx.doi.org/10.1590/1980-265x-tce-2022-0045en
https://doi.org/10.1590/1980-265x-tce-20... ,²²22. Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cien Saude Colet. 2018;23(6):2067–74. doi: http://dx.doi.org/10.1590/1413-81232018236.07082018
https://doi.org/10.1590/1413-81232018236... ).

The multifaceted ethical problems emerging from the practice of mental health care nurses are strongly associated with moral distress, causing these professionals to distance themselves from the profession(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ,¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ,¹³13. Lambour S. The experience of moral distress in psychiatric nurses [dissertação]. Virginia: University of Virginia; 2016. doi: http://dx.doi.org/10.18130/V3MS2K
https://doi.org/10.18130/V3MS2K... ,¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ,²³23. Ohnishi K, Kitaoka K, Nakahara J, Välimäki M, Kontio R, Anttila M. Impact of moral sensitivity on moral distress among psychiatric nurses. Nurs Ethics. 2018;26(5):1473–83. doi: http://dx.doi.org/10.1177/0969733017751264. PubMed PMID: 29495931.
https://doi.org/10.1177/0969733017751264... ). However, respecting the law of professional practice and ethical principles constitutes the basis of acting ethically that can minimize situations leading to the phenomenon. In this regard, the construction of practice based on ethical, technical, and legal precepts of the profession is an element that contributes to the visibility and empowerment of nurses in different work contexts(¹⁶16. Upasen R, Saengpanya W, Sambutthanon J. Strategies to cope with moral distress among mental health nurses in Thailand. Journal of Health Science and Medical Research. 2020;1(39):47–55. doi: http://dx.doi.org/10.31584/jhsmr.2020762
https://doi.org/10.31584/jhsmr.2020762... ,²⁴24. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Moral Distress in Iranian Psychiatric Nurses: a content analysis. Iran J Psychiatry Behav Sci. 2022;16(3):1–8, 23. doi: http://dx.doi.org/10.5812/ijpbs-121885
https://doi.org/10.5812/ijpbs-121885... ) and is related to the factor “Safety and professional autonomy”.

To exercise their autonomy, nurses have to associate their technical-scientific knowledge with the attentive observance of their rights, duties, and prohibitions, considering the ethical education that marks their professional identity. In this direction, the elements “recognition, power and identity”(²2. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578. doi: http://dx.doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802... ) relate to the factor “Safety and professional autonomy”, considering that autonomy and knowledge are associated and raise the level of nursing in the scientific and social scenario.

The factor “Social conflicts” is particularly linked to the context of mental health services in Brazil and presented the second highest median for the intensity and frequency of moral distress, with the highest predictor of the instrument “Recognizing that situations of family abandonment negatively interfere with the adherence and resolution of the user’s treatment” (approximately 25% of the sample assigned the maximum score for the intensity and frequency of the item). It is believed that the highlight of the predictor and the factor in general in the study is related to a complex Brazilian historical-social paradigm of inequality, which gives way to a significant number of people with low family income and limited access to health, education, and culture services, thus perpetuating a community that insufficiently values the reality of mental disorders(⁶6. Peres MAA, Martins GCS, Manfrini GC, Cardoso L, Fonseca PIMN, Shattell M. Vinte anos da Lei da Reforma Psiquiátrica brasileira: significados para a enfermagem psiquiátrica e em saúde mental. Texto Contexto Enferm. 2022;31:e20220045. doi: http://dx.doi.org/10.1590/1980-265x-tce-2022-0045en
https://doi.org/10.1590/1980-265x-tce-20... –⁸8. Bruggmann MS, Schneider DG, Ramos FRS. Situations that generate moral distress in mental health nurses. SMAD Rev Eletrônica Saúde Mental Álcool Drog. 2022;18(2):127–37. doi: http://dx.doi.org/10.11606/issn.1806-6976.smad.2022.181518
https://doi.org/10.11606/issn.1806-6976.... ).

Also associated with the factor, aspects such as inadequate treatment, omissive professional behavior(²²22. Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cien Saude Colet. 2018;23(6):2067–74. doi: http://dx.doi.org/10.1590/1413-81232018236.07082018
https://doi.org/10.1590/1413-81232018236... ) and other situations of social vulnerability of users represent generators of moral distress in nurses working in RAPS(⁹9. Oliveira CA, Oliveira DCP, Cardoso EM, Aragão ES, Bittencourt MN. Moral distress of nursing professionals of a psychosocial care center. Cien Saude Colet. 2020;25(1):191–8. doi: http://dx.doi.org/10.1590/1413-81232020251.29132019
https://doi.org/10.1590/1413-81232020251... ,²²22. Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cien Saude Colet. 2018;23(6):2067–74. doi: http://dx.doi.org/10.1590/1413-81232018236.07082018
https://doi.org/10.1590/1413-81232018236... ). These situations contribute to the low adherence of users to the services, leading to therapeutic failures that gradually progress to more serious mental disorders and require complex interventions such as hospital admissions, thus generating a cycle of new conflicts(²⁴24. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Moral Distress in Iranian Psychiatric Nurses: a content analysis. Iran J Psychiatry Behav Sci. 2022;16(3):1–8, 23. doi: http://dx.doi.org/10.5812/ijpbs-121885
https://doi.org/10.5812/ijpbs-121885... ,²⁵25. Van Wijk LB, Mângia EF. Atenção psicossocial e o cuidado em saúde à população em situação de rua: uma revisão integrativa. Cien Saude Colet. 2019;24(9):3357–68. doi: http://dx.doi.org/10.1590/1413-81232018249.29872017
https://doi.org/10.1590/1413-81232018249... ).

In this context, it is worth noting that the potential risk of aggression to which nurses are exposed while providing assistance to users with violent behavior represents stressful experiences for their health, particularly when they lack management abilities to handle such a situation(¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ,²⁶26. Hylén U, Engström I, Engström K, Pelto-Piri V, Anderzen-Carlsson A. Providing good care in the shadow of violence – an interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues Ment Health Nurs. 2019;40(2):148–57. doi: http://dx.doi.org/10.1080/01612840.2018.1496207
https://doi.org/10.1080/01612840.2018.14... ). This fact is corroborated by the predictor “Experience situations of physical and/or verbal aggression by the user/family member in relation to professionals”, which presented a moderate median for moral distress in this study.

In mental health, the user’s and team’s safety is weakened when technical training is inadequate to address psychiatric conditions(¹⁷17. Ghafouri R, Lotfi-Bajestani S, Nasiri M, Ohnishi K, Atashzadeh-Shoorideh F. Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nurs. 2021;20(1):166. doi: http://dx.doi.org/10.1186/s12912-021-00674-4
https://doi.org/10.1186/s12912-021-00674... ,²⁶26. Hylén U, Engström I, Engström K, Pelto-Piri V, Anderzen-Carlsson A. Providing good care in the shadow of violence – an interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues Ment Health Nurs. 2019;40(2):148–57. doi: http://dx.doi.org/10.1080/01612840.2018.1496207
https://doi.org/10.1080/01612840.2018.14... ). Therefore, “Professional ethical competence” is related to the global context of safety, considering that the team’s knowledge is significant to minimize events arising from practice. In this context, studies show that mental health nurses who are insecure in their work are more likely to develop moral distress(¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ,¹⁷17. Ghafouri R, Lotfi-Bajestani S, Nasiri M, Ohnishi K, Atashzadeh-Shoorideh F. Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nurs. 2021;20(1):166. doi: http://dx.doi.org/10.1186/s12912-021-00674-4
https://doi.org/10.1186/s12912-021-00674... ,²⁶26. Hylén U, Engström I, Engström K, Pelto-Piri V, Anderzen-Carlsson A. Providing good care in the shadow of violence – an interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues Ment Health Nurs. 2019;40(2):148–57. doi: http://dx.doi.org/10.1080/01612840.2018.1496207
https://doi.org/10.1080/01612840.2018.14... ). In the present study, the predictors of this factor showed moderate values of moral distress, associating the block with the negative experience of nurses when working with professionals with no profile or unprepared to meet the demands.

The impact of these situations on nurses is closely linked to what each situation represents in their personal and professional condition and how each professional handles and uses their resources. Thus, for a less stressful work environment to be structured, permanent health education strategies that address ethical education, the problematizing teaching, and spaces for reflection on practice are required. Consequently, the knowledge emerging from this process will contribute to refining ethical and professional skills, encouraging nurses to explore morally correct actions(²⁴24. Tavakol N, Molazem Z, Rakhshan M, Asemani O. Moral Distress in Iranian Psychiatric Nurses: a content analysis. Iran J Psychiatry Behav Sci. 2022;16(3):1–8, 23. doi: http://dx.doi.org/10.5812/ijpbs-121885
https://doi.org/10.5812/ijpbs-121885... ,²⁶26. Hylén U, Engström I, Engström K, Pelto-Piri V, Anderzen-Carlsson A. Providing good care in the shadow of violence – an interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues Ment Health Nurs. 2019;40(2):148–57. doi: http://dx.doi.org/10.1080/01612840.2018.1496207
https://doi.org/10.1080/01612840.2018.14... ).

The factor “Conflicts with management” had the second lowest median for moral distress among the factors, with a significant association between the variables age and time working in the main job. In RAPS services, organizational and relational aspects have a direct impact on the quality of care provided by operational centers to users and their families. In this conception, conflicting relationships that go beyond the limits of ethical relationships, the fragility of interpersonal relationships, disrespect, lack of professional autonomy, and institutional practices that make qualified care unfeasible contribute to an environment that generates suffering. At this point, the significant role managers play in providing resources and building an institutional ethical climate is highlighted(¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ), which promotes professional autonomy through ongoing health education processes and the implementation of assistive technologies(¹⁶16. Upasen R, Saengpanya W, Sambutthanon J. Strategies to cope with moral distress among mental health nurses in Thailand. Journal of Health Science and Medical Research. 2020;1(39):47–55. doi: http://dx.doi.org/10.31584/jhsmr.2020762
https://doi.org/10.31584/jhsmr.2020762... ). Therefore, it should be noted that if management is dynamic and efficient, the nurses’ work process in RAPS tends to be more organized, promoting greater autonomy and safety for decision-making processes, thus minimizing situations that generate moral distress(¹⁷17. Ghafouri R, Lotfi-Bajestani S, Nasiri M, Ohnishi K, Atashzadeh-Shoorideh F. Psychometrics of the moral distress scale in Iranian mental health nurses. BMC Nurs. 2021;20(1):166. doi: http://dx.doi.org/10.1186/s12912-021-00674-4
https://doi.org/10.1186/s12912-021-00674... ).

Regarding the sample, it is worth mentioning that the participants in this study were mostly female (79.2%), aged between 30 and 39 years (52.6%), with nursing experience between 6 and 10 years (26.6%), similar to studies of moral distress in mental health nurses carried out in countries such as Japan(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ), South Korea(¹¹11. Noh D, Kim S, Kim S. Moral distress, moral sensitivity and ethical climate of nurses working in psychiatric wards. J Korean Acad Psychiatr Ment Health Nurs. 2013;22(4):307. doi: http://dx.doi.org/10.12934/jkpmhn.2013.22.4.307
https://doi.org/10.12934/jkpmhn.2013.22.... ), Jordan(¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ), U.S.A(¹³13. Lambour S. The experience of moral distress in psychiatric nurses [dissertação]. Virginia: University of Virginia; 2016. doi: http://dx.doi.org/10.18130/V3MS2K
https://doi.org/10.18130/V3MS2K... ), Norway(¹⁵15. Jansen TL, Hem MH, Dambolt LJ, Hanssen I. Moral distress in acute psychiatric nursing: multifaceted dilemmas and demands. Nurs Ethics. 2020;27(5):1315–26. doi: http://dx.doi.org/10.1177/0969733019877526
https://doi.org/10.1177/0969733019877526... ), and Thailand(¹⁶16. Upasen R, Saengpanya W, Sambutthanon J. Strategies to cope with moral distress among mental health nurses in Thailand. Journal of Health Science and Medical Research. 2020;1(39):47–55. doi: http://dx.doi.org/10.31584/jhsmr.2020762
https://doi.org/10.31584/jhsmr.2020762... ). An Italian study of moral distress in mental health nurses was different from the majority, with a higher proportion of male participants (53.2%), aged between 41 and 50 years (51.4%)(¹⁴14. Delfrate F, Ferrara P, Spotti D, Terzoni S, Lamiani G, Canciani E, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav. 2018;109(2):97–109. PubMed PMID: 29701626.).

This study also added a comparison analysis by groups, in which an association was identified between moral distress and age, number of employment relationships, type of employment relationship, length of service, weekly workload, and type of service. In general, studies on the subject did not identify an association between the variables sex, age, professional experience, and predictors of moral distress in nurses(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ,¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... –¹⁴14. Delfrate F, Ferrara P, Spotti D, Terzoni S, Lamiani G, Canciani E, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav. 2018;109(2):97–109. PubMed PMID: 29701626.). However, a Jordanian study found that the additional training was positively associated with moral distress and that younger nurses have greater moral distress(¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ).

Regarding the level of moral distress in mental health nurses, a South Korean study(¹¹11. Noh D, Kim S, Kim S. Moral distress, moral sensitivity and ethical climate of nurses working in psychiatric wards. J Korean Acad Psychiatr Ment Health Nurs. 2013;22(4):307. doi: http://dx.doi.org/10.12934/jkpmhn.2013.22.4.307
https://doi.org/10.12934/jkpmhn.2013.22.... ) showed average values considered moderate (3.74). In Japan, these professionals showed relatively low levels of moral distress, although with relative frequency, mostly associated with the predictor “Inadequate number of nurses for the demands of the service”(¹⁰10. Ohnishi K, Ohgushi Y, Nakano M, Fujii H, Tanaka H, Kitaoka K, et al. Moral distress experienced by psychiatric nurses in Japan. Nurs Ethics. 2010;17(6):726–40. doi: http://dx.doi.org/10.1177/0969733010379178
https://doi.org/10.1177/0969733010379178... ). In Jordan, the level of moral distress among mental health nurses was moderately high(¹²12. Hamaideh SH. Moral distress and its correlates among mental health nurses in Jordan. Int J Ment Health Nurs. 2014;23(1):33–41. doi: http://dx.doi.org/10.1111/inm.12000
https://doi.org/10.1111/inm.12000... ). In contrast, in the United States(¹³13. Lambour S. The experience of moral distress in psychiatric nurses [dissertação]. Virginia: University of Virginia; 2016. doi: http://dx.doi.org/10.18130/V3MS2K
https://doi.org/10.18130/V3MS2K... ) and Italy(¹⁴14. Delfrate F, Ferrara P, Spotti D, Terzoni S, Lamiani G, Canciani E, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav. 2018;109(2):97–109. PubMed PMID: 29701626.), these professionals had low and moderate levels of moral distress.

In view of the results presented by this and other studies on moral distress in mental health nurses, it is significant to raise the level of discussions about coping strategies for moral distress, seeking to create a protection network for these professionals. This way, moral sensitivity represents the first protective factor for nurses, equipping them to refine the perception and recognition of the ethical/moral problem, considering the most prudent choice for each case(²⁷27. Yasin JCM, Barlem ELD, Barlem JGT, Andrade GB, Silveira RS, Dalmolin GL. Elements of moral sensitivity in the practice of clinical hospital nurses. Texto Contexto Enferm. 2020;29:1–14. doi: http://dx.doi.org/10.1590/1980-265x-tce-2019-0002
https://doi.org/10.1590/1980-265x-tce-20... ). Even in the face of evidence that more sensitive nurses suffer more, moral sensitivity remains an advantage for professionals, as it activates cognitive structures, preparing professionals for decisions that minimize the negative effects of moral distress(²³23. Ohnishi K, Kitaoka K, Nakahara J, Välimäki M, Kontio R, Anttila M. Impact of moral sensitivity on moral distress among psychiatric nurses. Nurs Ethics. 2018;26(5):1473–83. doi: http://dx.doi.org/10.1177/0969733017751264. PubMed PMID: 29495931.
https://doi.org/10.1177/0969733017751264... ,²⁸28. Zhang N, Li J, Xu Z, Gong Z. A latent profile analysis of nurses’ moral sensitivity. Nurs Ethics. 2020;27(3):855–67. doi: http://dx.doi.org/10.1177/0969733019876298
https://doi.org/10.1177/0969733019876298... ).

In the context of coping with moral distress, moral resilience is presented as the ability to manage stressors arising from practice, so that moral courage is developed. Conceptually, moral resilience seeks to respond to ethical/moral problems to preserve the professional’s integrity and avoid suffering(²⁹29. Rushton CH, Schoonover-Shoffner K, Kennedy SM. Executive summary: transforming moral distress into moral resilience in nursing. AJN. Am J Nurs. 2017;117(2):52–6. doi: http://dx.doi.org/10.1097/01.NAJ.0000512298.18641.31
https://doi.org/10.1097/01.NAJ.000051229... ).

Moral courage, in its turn, involves the nurse’s ability to face ethical/moral problems, overcome fear, endure suffering, stand up for their values, and be morally prudent in situations that would lead them to act otherwise. The effect of moral courage includes the moral commitment, assertive decision-making, the patient’s, user’s, and professional’s comfort and safety(³⁰30. Sadooghiasl A, Parvizy S, Ebadi A. Concept analysis of moral courage in nursing: a hybrid model. Nurs Ethics. 2018;25(1):6–19, 20. doi: http://dx.doi.org/10.1177/0969733016638146
https://doi.org/10.1177/0969733016638146... ).

In view of the above, it is worth noting that more sensitive, resilient, and morally courageous nurses are able to equip themselves for ethical decision-making in health and deliberate on facts, with greater discretion and confidence, thus reducing moral distress.

As a limitation of the study, its originality in the field of mental health in Brazil is believed to have made comparative analyses in the national scenario impossible. Therefore, further investigations on moral distress in nurses in this work context are suggested, considering the dissimilar distribution of RAPS in Brazilian regions with different socioeconomic and cultural characteristics, and needs. Thus, it is believed that the object’s coping strategies shall undergo in-depth discussion. The implication of the study in practice gives way to reflection on the performance of mental health nurses in Brazil, in addition to encouraging the construction of policies aimed at qualifying all dimensions of care, thus reducing the undesirable effects of moral distress.

CONCLUSION

The present study allowed the analysis of the frequency and intensity of moral distress in nurses who work in different mental health services in Brazil, focusing on the most severe predictors of the phenomenon. It was found that these professionals have mostly moderate levels of general moral distress in their daily practice.

The factors “Working Conditions” and “Social Conflicts” are associated with the predictors with the highest median of moral distress among the studied sample. In this sense, it is worth pointing out that the complex and specific work spaces of RAPS need an ethical, technical, and humanized environment, where institutional impediments are rethought to transform the work process and nurses can act according to their moral values. In this wise, ethical problems emerging from care practice, when perceived by more prepared and confident nurses, tend to be prudently deliberated.

In the opposite direction, the predictors with lower levels of moral distress among the studied sample were associated with the factor “Defense of values and rights”, indicating that the nursing practice in these spaces, historically directed to its improvement, has sought to guarantee and respect the global rights of users, even though there are situations that cause moral discomfort.

The evidence that moral distress reaches and affects, in different proportions, Brazilian nurses working in mental health services demonstrate the dimension and plurality of the problem. Therefore, the relevance of discussions and reflections on coping strategies for moral distress is highlighted, articulating elements such as sensitivity, resilience, and moral courage, so that the ethical health decision-making process becomes more effective in care and management settings.

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