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SOFRIMENTO MORAL VIVENCIADO POR TRABALHADORES DA SAÚDE EM CENTROS DE TRIAGEM DA COVID-19, BLUMENAU-SC, 2021

MORAL DISTRESS EXPERIENCED BY HEALTHCARE WORKERS IN COVID-19 TRIAGE CENTERS, BLUMENAU-SC, 2021

Jaqueline Marcos dos Santos
Universidade Federal de Santa Catarina
E-mail: msjaque@hotmail.com
ORCID: 0000-0002-6599-8102

Marta Verdi
Universidade Federal de Santa Catarina
E-mail: verdiufsc@gmail.com
ORCID: 0000-0001-7090-9541

Resumo: A pandemia da Covid-19 evidenciou novos problemas éticos desencadeadores de sofrimento moral no cotidiano de trabalho em saúde que merecem ser tratados para além de um grave problema de saúde pública. Objetivo: Compreender a vivência do sofrimento moral dos trabalhadores da saúde no exercício de seu trabalho de enfrentamento da pandemia da Covid-19 em Centros de Triagem da Microrregião de Blumenau, Santa Catarina, Brasil. Metodologia: Trata-se de um estudo qualitativo realizado com 31 trabalhadores da saúde por meio de entrevistas virtuais durante a pandemia. Foi realizada a análise de conteúdo com o auxílio do software Atlas-ti. Resultados: Com base no referencial de Wilkinson, a análise revelou que o sofrimento moral destes trabalhadores se constituiu pelas dimensões da experiência e do efeito. Na experiência, as principais ameaças à integridade moral foram o assédio moral e o impedimento moral, além de outros motivos geradores de sofrimento moral. Como efeito deste processo ocorreu a vivência de sentimentos que trouxeram consequências físicas e psicológicas da angústia moral e estratégias de enfrentamento pouco efetivas. Conclusão: O estudo possibilitou compreender o processo de vivência do sofrimento moral, apontando a deliberação moral como estratégia de enfrentamento.

Abstract: The Covid-19 pandemic has highlighted new ethical problems that trigger moral distress in daily healthcare work that deserve to be addressed in addition to being a serious public health problem. Objective: To understand the experience of moral distress by healthcare workers when carrying out their work to combat the Covid-19 pandemic in Triage Centers in the Microregion of Blumenau, Santa Catarina, Brazil. Methodology: This is a qualitative study carried out with 31 healthcare workers through virtual interviews during the pandemic. Content analysis was carried out with the help of Atlas-ti software. Results: Based on Wilkinson\'s framework, the analysis revealed that the moral distress of these workers was constituted by the dimensions of experience and effect. In experience, the main threats to moral integrity were moral harassment and moral impediment, in addition to other reasons that lead to moral distress. As an effect of this process, feelings were experienced that brought physical and psychological consequences of moral anguish and ineffective coping strategies. Conclusion: This study made it possible to understand the process of experiencing moral distress, indicating moral deliberation as a coping strategy.

Palavras-chave: ética; problemas éticos; sofrimento moral; trabalhador da saúde; Covid-19.

Keywords: ethics; ethical problems; moral distress; healthcare worker; Covid-19.

INTRODUCTION

Moral distress (MD) stems from negative emotions arising from morally undesirable situations experienced by healthcare workers (HCW) (1). These situations involve value conflicts that require ethical positions in an attempt to overcome the problem. When impediments occur that compromise moral deliberation, feelings of powerlessness and anguish turn this phenomenon into a particular type of suffering (2). What differentiates MD from other forms of suffering is the ethical-moral component that mobilizes coping with the perception of moral uncertainty (3,4). This perception can be accompanied by moral discomfort followed by physical, psychological and behavioral manifestations in case the most prudent course of action is prevented from happening (3).
Covid-19 has revealed new problems that have affected the mental health of HCW, such as high risk of infection, isolation, anxiety and fear (5). These issues have resulted in significant elements that have aggravated the factors that trigger MD (6). The daily routine of working with a high number of patients, longer working hours and no rest, caused physical and mental exhaustion, impairing attention to individual protection actions (7). HCW also had to make difficult decisions in the face of inadequate conditions and the lack of fair criteria for allocating scarce resources (8). As an aggravating factor, the federal government discontinued the actions of the Ministry of Health, making it difficult to operationalize strategic actions to control the epidemic (9). With regard to the implementation of policies aimed at the health workforce in the fight against Covid-19, a study indicated isolated, superficial, repetitive and insufficient regulations for coordinating actions and protecting HCW (10).
Some studies have investigated the level of moral distress (11-14), the predictors (6,11,14,15) and the impacts of MD on the quality of life (16) and mental health (14,17) of frontline HCW in Covid-19. MD scores were higher than in previous studies (13), with a higher frequency of distress in women (15) and associated with high levels of psychological distress and burnout (17). Predictive factors include the lack of preparation of HCW (13,17,18), the lack of efficient communication (13,16,17) and infrastructure and logistical problems related to the shortage of personnel, personal protective equipment (PPE), medicines, instruments and diagnostic tests (6,13-15,17,18). Failures in organizational support at work (13-16) led HCW to moral uncertainties that generated distress. The lower the perception of an ethical organizational climate in health services, the higher the number of MD reports (11).
There are limited studies that delve into the experience of MD in the diversity of settings of Brazilian health services during the pandemic, as most were carried out in high-income countries, focusing on the hospital area and the beginning of the outbreak (11,12,15-18). A Brazilian study (6) analyzed the predictors of MD in national and international news published online, but to date there have been no studies addressing the issue in Primary Health Care (PHC).
The role played by PHC, through the Centers for Coping with Covid-19, known as Triage Centers (TC), justifies the need to investigate MD in this context (19). In PHC, MD is triggered by factors related to the day-to-day work (20) called "everyday" issues, experienced by thousands of people and systematically made invisible or neglected (21).

OBJECTIVE

To understand the experience of MD by HCW in the exercise of their work to face the Covid-19 pandemic in TC of the Microregion of Blumenau, Santa Catarina, Brazil.

METHODOLOGICAL PROCEDURES

This is an exploratory field study with a qualitative approach, carried out with the HCW of the Covid-19 TC in the municipality of Blumenau, Santa Catarina, Brazil, one of which is located in a park and five of which are fast-tracks attached to the General Outpatient Clinics.
Thirty-four participants were recruited out of a total of 100 HCW from the chosen TC. During the interview process, three participants discontinued: two because they did not meet the eligibility criteria, and one asked to withdraw consent. The convenience sample consisted of 31 HCW, including one administrative assistant, one dentist, 12 nurses, one pharmacist, nine doctors, one psychologist and six nursing technicians.
The inclusion criteria for the study were: working at the TC for at least four months; providing direct care to users; and willingness to take part in the study. There were no exclusion criteria.
Individual interviews were conducted via video calls, using a semi-structured script based on the Brazilian Scale of Moral Distress in Nurses (22). Questions about daily working life, value conflicts, moral impediment and the perception of anguish, discomfort or suffering related to these situations were addressed, as well as a final open-ended question. The interviews took place between March and May 2021, lasting an average of 45 minutes, involving only the researcher and the participant and recorded on digital media.
The analytical process was based on Bardin\'s (23) content analysis procedures with the help of the software ATLAS.ti 9. The analysis phases were organized according to three chronological stages: pre-analysis, material exploration, and treatment of the results and interpretation.
Pre-analysis involved organizing and transcribing the interviews, reading the material and entering it into ATLAS.ti 9. To preserve the identity of the participants, we used codes consisting of the first letter of the profession, followed by an ordinal number referring to the order of the interview, the acronym CT followed by an ordinal number corresponding to the place of work and the letter M or F depending on the informed gender, followed by an ordinal number relating to the order of the interview (example E7CT3F14).
In the material exploration phase, the coding process began, resulting in five subcategories, which were grouped into two analytical categories. Wilkinson\'s reference (4) was the basis for the analytical emergence of the two categories: the phases of experience and the effect of MD.
Ethical care in the research was incorporated in the research in order to prevent any harm to the participants. The study project was approved by Technical Health School of Blumenau (Escola Técnica de Saúde de Blumenau - ETSUS) and by the Human Research Ethics Committee of the Federal University of Santa Catarina (UFSC) with opinion 4.593.704.

RESULTS

Thirty-one HCW participated in the study, 24 women and seven men, aged between 25 and 58. The length of time they worked at the TC ranged from four to 13 months, with an average of 11 months, with working hours varying from 20 to 50 hours a week. With regard to employment, 23 HCW had a temporary employment contract and five indicated that they had more than one employment contract, working in other healthcare establishments. Among the participants, six had a high school degree, 11 had an undergraduate degree and 14 had a postgraduate degree.
In the analytical process, ethical problems triggering MD were identified, and the experience of this phenomenon by the study participants was analyzed. Based on Wilkinson\'s framework (4), the analytical categories of the MD experience and its effects were constituted, as summarized in Table 1.

Experience of Moral Distress

The experience of MD includes the process of triggering MD, which occurred as a result of experiences that threatened moral integrity, and ethical problems that were the reasons for triggering it. Among the threats to moral integrity expressed by 17 participants were moral commitment to care, moral harassment and moral impediment.
Participants reported having a moral commitment to care despite the fear and apprehension involved in caring for Covid-19 cases. This commitment is related to the responsibility of professional duties.

I think this pressure comes mostly from me. A much more moral pressure, of actually having to do something. (E12CT2M6)

There is this apprehension about working there? Yes. But we know the professionals\' responsibility. If I was hired to work as a nurse, in our code of ethics, when I graduated, I took an oath that I would care for people\'s health. (E1CT5F1)

Situations perceived as moral harassment were mentioned in relations between managers and HCW, in relations among HCW, and by users in their relations with HCW. In subordinate relationships, disrespect was mentioned. Among the HCW, there was verbal aggression, cursing, threats, bullying and discrediting of newly qualified doctors. On the other hand, users committed abuse through words, gestures and behavior, and even physical aggression in cases that required doctors to prescribe.

There was a situation where she [immediate superior] accused me in front of the patient [...] right then I could have filed a complaint against her, but it was early on and I was terrified [...] I suffered a lot of bullying. (M5CT4F22)

That situation was really unpleasant because this professional accused me of things I didn\'t do [...]. But that had been happening for a long time, and I wasn\'t one to take problems to the management; I simply ignored them. But there came a point when I couldn\'t take it anymore because she was disrespecting me in front of the users, and it was becoming quite morally aggressive. (E3CT5F9)

[...] there are patients who, because we don\'t do what they want, disrespect us, sometimes even with moral offense, foul language, and even physical aggression [...] there have even been times we had to call the police [because of] users who become violent. (O1CT4F6)

Participants reported MD when faced with the incompleteness of moral deliberation by not carrying out the chosen course of action due to moral impediments.

If we can\'t do our job properly, give the patient at least the minimum they need, we don\'t do well! Because we put ourselves in their shoes, we empathize with that patient. [...] So when our attempt to do our best is frustrated, we end up not feeling well either. (E10CT1F18)

My impediment was fear, fear of being fired. I\'m hired, I\'m on probation, if I complain too much they\'ll throw me out. (M5CT4F22).

The situations of moral impediment had different issues that united them. They occurred in the relationships among HCW and with the institution. In the context of interprofessional relations, there was disrespect and threats among HCW when their professional conduct was questioned.

Doctors often don\'t accept the nurses\' behavior. We can explain the situation to them, but in the end it\'s up to them. So we might be looking at a situation and when we get to the office the doctor doesn\'t have the same view, he changes and ends up releasing the patient. (E6CT2F13)

My colleague and I questioned [the conduct of a doctor] and we were threatened with prosecution, threatened with the end of our careers. (E7CT3F14)

In relations with the institution itself, HCW suffered moral impediment because of flaws in the healthcare flow and between services in the network.

Sometimes we see a patient who needs to be transferred with an advanced SAMU ambulance [emergency ambulance service] and can\'t get it. We waste a lot of time trying to convince a colleague that the patient needs to be transferred [...] I feel like I\'m begging for something that should be obvious. (M3CT2F10)

The prescription of ineffective medication for Covid-19, authorized by the Federal Council of Medicine (Conselho Federal de Medicina, CFM) and carried out by some doctors, has clashed values and triggered ethical problems.

I\'ve even had a complaint because a patient\'s father wanted me to prescribe the pre-treatment kit. I\'ve spent so much time trying to explain what I know, what I\'ve studied, to try to convince him [...]. And then I had to answer with a huge text, including a scientific article, saying why I didn\'t prescribe a medication that has no scientific evidence for Covid. And we\'re powerless. (M7CT2M3)

We have access to the patients\' medical records through the city\'s system and end up seeing prescriptions made by colleagues. Things I don\'t agree with, I don\'t prescribe. [...] when I need to guide the patient, I do it in the way I believe, with what I study, with the evidence [...]. But I always make it clear that the patient has autonomy. And if he needs to find another doctor to do what he wants and needs, he can. I also have my autonomy as a doctor and I will respect my values and my ethical principles. (M1CT5F4)

The narrative of the participant (M1CT5F4) is illustrative when asked how the prescribing of ineffective medication affected her.

It doesn\'t affect me, objectively speaking, but it does. How am I going to explain it? It\'s really a moral issue because we come into conflict, and that bothers me. (M1CT5F4)

There was also an ethical conflict when doctors signed Covid-19 test reports without witnessing them.

There are some things about the flow that bother me, which is also an ethical deviation, which I\'m prevented from doing [...]. The nurse technician does the collection. It\'s me, the doctor, who needs to report this test, but I didn\'t carry it out and I\'m putting myself in charge of a test that I haven\'t even seen. (M9CTM5)

Situations involving the allocation of resources related to the provision of care, although not frequent, caused moral impediment. Professionals had to choose the patient most at risk in order to provide the recommended care, leaving patients who were on the edge without therapeutic assistance and hospital transfers due to overcrowding and insufficient resources.

I\'ve had patients I wanted to send to hospital, but I didn\'t because they wouldn\'t accept it. It wasn\'t a patient who was in a serious condition, but he could become so, which would require tests and a more thorough evaluation. And I\'ve already done this with at least three patients. (M4CT2F16)

The most frequent reasons for MD were situations that constituted threats to moral integrity, including moral harassment and moral impediment. Then, there are the problems encountered in relationships, in the organization of work processes and in the lack of basic conditions for carrying out work activities. In addition, 16 participants indicated stress caused by everyday work problems as a motivating factor for MD.

The SAMU regulating doctor hung up on the doctor. I called again, I threatened and said: look, we know that your call is recorded, from the moment I handed over the patient\'s shift to you, you\'re responsible for the patient\'s life [...]. Just to give you an idea of how difficult this communication is. (E7CT3F14)

There were situations that increased the possibility of contamination. Nebulization, for example, wasn\'t supposed to be done in the Health Unit, but there were doctors who wanted to nebulize. Then there was a fuss because the doctor, who is the highest authority in health, said that he had to nebulize and the nurses said that they couldn\'t nebulize because there was this regulation. (E12CT2M6)

Nursing professionals mentioned devaluation, mainly because of the low pay, which is why some professionals dedicated themselves to other jobs, suffering from overload and a high rate of sick leave.

The overload is related to our salary, which is very low [...] but because I think, oh I have to do it, I have to earn more, I end up coming [to work overtime]. So it\'s more of an individual burden to agree to do it. (T5CT5F23)

Absenteeism is extremely high among technical staff, we have a lot of people on leave. Every week, two or three technicians are away. It\'s related to this condition, because everyone has two jobs. (E12CT2M6)


Effects of Moral Distress

The second category presents the effects of MD and is related to the participants\' perception of the feelings, the consequences and the coping strategies of MD.
Women most often reported experiencing feelings of discomfort, anguish, anxiety, sadness and fear.

It\'s anguish, I certainly think anguish, anxiety, wow! And stress, too, has increased a lot [...]. There were days when you\'d get to work and breathe: [Breath] "Ah! again! Another day with that huge queue!" (E9CT2F17).

The first people to die there and to lose members of their class were health professionals. So we didn\'t even have time to mourn, to grieve for a coworker. There was a moment when we asked for five minutes, we wanted to say a prayer for the loss of a coworker and the people were outraged. (E6CT2F13)

Fear was the feeling that emerged most, reported by 17 participants, due to the lack of information at the beginning of the pandemic about prevention, therapies and contagion.

At the beginning of the pandemic, we were attending to patients and we didn\'t have much guidance on how we should really act in relation to... uh, whether we should attend to emergencies, whether we should attend to patients normally, in relation to PPE, whether we would have legal protection if we became infected, in relation to any family members. (O1CT4F6)

Thus, the fear of contamination affected most of the participants, especially of contaminating their family members.

I still have this fear that I\'m bringing something into the house or the family. At first I isolated myself, I distanced myself from everyone. When I got home, I didn\'t go near my son or my husband, only after I\'d had a shower, and I was still very careful. (E6CT2F13)

At the beginning, right when I started working with Covid, I lived with my parents in this same building. I was so desperate, so scared, that I ended up renting; I\'m living in a one-bedroom apartment in the same building because of them. (M5CT4F22)

The risk of illness and death from Covid-19 has triggered anguish and fear of a worsening health situation for users seeking services.

I\'ve even thought about taking medication or something to reduce it, because the anxiety is so great. Anxiety because of the fear we experience, the risk of contamination, the fear of losing someone there, not being able to help someone. (E6CT2F13)

The high demand from users and the seriousness of the cases shook HCW in the face of the lack of working conditions for the recommended care, thus generating feelings of impotence and anguish.

It\'s despairing! It\'s very sad! It\'s a situation we can\'t imagine we\'re going through and never imagined. I spent six years studying, and I graduated in the eye of the storm. And now when you stop and say: the stamp is mine and I\'m the one who has to do it, and I can\'t do it because I can\'t keep up, there are too many people to attend to, and my colleagues can\'t keep up either, we\'re exhausted. And me, in a situation like this, without oxygen. (M1CT5F4)

Fear was also evident in the face of aggression and threats from users.

If a patient wants that hydroxychloroquine, he doesn\'t have to go through me, hydroxychloroquine is available at the SUS [Brazilian Unified Health System] pharmacy. [...] If he brings a prescription from his private doctor, he doesn\'t need to go to the SUS doctor. [...], but they don\'t understand that. Your doctor said you could get it here at the pharmacy, but you can get the prescription from him. You have every right to a second opinion, just as I have every right not to prescribe. [...] So, in these cases, I was afraid that the patient would physically assault me! (M3CT2F10)

The consequences of MD were expressed most frequently by doctors and nurses. Men had a higher incidence of physical and emotional manifestations, but milder ones, such as anxiety attacks, tension, irritability and gastrointestinal crises.

I think it\'s an annoyance, not with other people, I think it\'s an annoyance of the mind itself. The head is annoyed. I\'m tired, tired all the time. (M7CT2M3)

Obviously I had a clinical manifestation of this, I had anxiety and I had to treat it. I had epigastralgia and had to treat it. (E12CT2M6)

In women, recurring manifestations were psychological syndromes, such as burnout, depression and panic. These syndromes encompassed sensations and emotions, mainly anxiety attacks with episodes of crying, chest tightness, tachycardia, shortness of breath, insomnia and irritability.

About two months ago I was diagnosed with depression. I had to see a psychiatrist because I was under a lot of stress. I was in triage, but if a patient arrived I couldn\'t even hear him anymore. (T5CT5F23)

Many, many tears shed, a lot of tightness in my chest, I had two episodes of panic during care that I had to leave, finish attending to the patient and leave because I had a panic attack [...]. (M3CT2F10)

Female workers reported a higher number of cases of sick leave and thoughts of leaving their jobs due to physical and mental illness.

I\'ve always been a very centered person, but I got destabilized in August [...] and so I took 15 or 20 days off. But I\'m still taking medication because of the fears [...]. (E8CT4F15)

Several times I\'ve thought about (leaving my job), and even today I\'m still thinking about maturing this idea. (E3CT5F9)

In order to deal with the burden of emotions and suffering, participants came up with strategies such as abstracting from the problems and looking for support in religious practices, physical activities and leisure.

I don\'t watch TV anymore, if there\'s anything on I turn it off. At work, when I\'m exhausted, I go out, drink coffee, get a drink of water and go to the bathroom. (M1CT5F4)

Being a Christian also means that I have this spiritual support, so I\'m always involved in our activities here at the church. (E12CT2M6)

I try to read when I\'m at home, listen to music. My father lives in the countryside, so I try to go there to relax. (E8CT4F15)

Women were the only ones to use anxiolytic and antidepressant medication, and medical professionals were the ones who sought out psychological therapy the most.

I take medication, and now I\'m off it, but I was taking medication all the time so that I could sleep because I was losing sleep, and antidepressants. (E3CT5F9)

Personally, I go to therapy, I go to the gym, I dance, and I try to meditate. These are personal things that we try to do in order not to go crazy. (M1CT5F4)

DISCUSSION

In the process of experiencing MD, moral commitment to care, also experienced by HCW in other studies (14,15,18), acted as a self-imposed moral pressure, responsible for activating moral sensitivity and perceiving situations in which ethical conflicts permeate. However, in contact with the various moral impediments, moral commitment accentuated the feeling of powerlessness, compromising the moral integrity of HCW.
Considering that an individual\'s moral integrity is built through values integrated into their moral personality throughout their life, events that threaten the exercise of a critical eye capable of analyzing, accepting or rejecting situations based on their morals can trigger MD (24).
Moral harassment was a type of threat that generated MD that participants reported. When persistent, it subjects HCW to humiliating, vexatious and embarrassing circumstances and is intended to cause emotional and psychological damage, affecting personal values in relation to work and professional image (25). Although not all reports presented continuous situations caused by the same motivating agent, a study conducted with nurses (26) showed that regardless of the characteristics of the work environment and the frequency of moral harassment, exposure to this type of violence negatively impacts their mental health and well-being. In summary, MD does not always result from moral harassment; however, both can trigger psychological and moral suffering, which manifest through pain or anguish.
Moral impediment, in situations where the nurse\'s conduct was disregarded by the doctor, results from fragmented, uniprofessional work anchored in the hegemony of medical knowledge. These situations distance HCW from carrying out their legal duties, generating a perception of devaluation in their professional role by taking positions they consider morally inappropriate (27).
In addition, moral impediment caused by scientific denialism and the propagation of fake news by Former President Bolsonaro (28) has damaged the health education process and led to conflicts between users and doctors. Such situations generated ethical conflicts, mainly because the CFM supported the prescription of medicines without scientific proof. This was one of the institutional strategies for spreading Covid-19, with the aim of prioritizing the protection of capital through economic policy, and which resulted in thousands of avoidable deaths (29). The Ministry of Health\'s lack of coordination has hampered financial transfers to states and municipalities, jeopardizing the acquisition of equipment and supplies and the SUS\'s response to the pandemic (9).
Therefore, the allocation of resources has become an ethical problem, mainly experienced in the Intensive Care Units (ICU) of many hospitals, which has raised ethical questions related to regulatory standards on decision-making when faced with the need to allocate resources (30). This judgment should be linked to the institution and thus protect the moral integrity of these HCW (31).
The temporary contracts of most of the participants revealed the precariousness of their work, resulting from insecurities such as low salaries, overload, psychological distress, greater risk of contamination and sick leave. The fragile employment relationship silenced some HCW, who feared losing their jobs or facing retaliation. This silencing, treated as censorship, is established through power relations (32), which in this case was exercised by the neoliberal system as a political maneuver of fear, aimed at controlling the psychological impulses of self-defense and leading individuals to adapt and cooperate (33). The defense mechanisms created to mask the source of distress can have health consequences as long as the pain remains unknown. According to this principle, mental distress arises as a reaction to the domination to which the body is subjected, the loss of individual history and psychological imbalances (34).
Threats to moral integrity are related to situations that affected values, such as in cases of moral harassment and moral impediment, especially in the face of moral commitment to care and making difficult decisions.
In addition to these threats, the experience of MD showed generating motives, revealing ethical problems inherent in the organization of work processes, thus corroborating previous studies (15,18). However, organizational support for solving problems and for dealing with stressful situations was associated with less MD (13). It is noticeable that the management of TC, when planning their actions, did not take into account the psychological distress of HCW in the face of exposure and work overload. The ethical implications are obvious, since these factors contradict moral limits, thus compromising health and life. It is essential to emphasize the importance of resources that preserve the mental health of HCW, with psychoeducation activities regarding the issues (35).
Among the effects of MD, fear has hindered the completion of moral deliberation, which can nullify the development of moral competences and reflexivity for deliberation (3). This working environment triggered feelings of discomfort, anxiety and sadness, requiring HCW to be resilient.
The moral domain of resilience is associated with the biological, psychological, cognitive, spiritual and relational dimensions of the human being. Moral resilience is defined as the ability to maintain or restore integrity in the face of moral problems, protecting oneself from suffering (36). When the level of resilience is low in the face of stressful situations, the impact of this experience can have important consequences for mental health.
Microviolence, characterized by subtle acts of repetitive and public violence in everyday work, has a negative impact on the organization and division of labour, resulting in a deterioration of the work climate (37). It includes acts of incivility such as verbal aggression, swearing, abuse of power, among others (38), which indicates the possibility that HCW have suffered microviolence. Trivialization of social injustice is considered a form of violence imposed on people in work relationships. The banal treatment of illnesses suffered as a result of work-related problems threatens workers\' health (39). Thus, HCW who suffered morally experienced double oppression: on the one hand, the threat to their moral integrity, and on the other hand, the trivialization of MD, since there were no initiatives on the part of management to minimize the problems.
Female workers had a higher number of diagnoses of psychological syndromes compared to men, which is consistent with findings in the literature (15). The male tendency not to express feelings in order not to show weakness or ask for help can result in physical symptoms and aggression, protecting or masking depression and anxiety. The high prevalence of mental health problems, with frequent diagnoses of depression and anxiety, indicates the medicalization of women\'s mental health and a reflection of underdiagnosis and underprescription among men (40).
The lack of coping strategies can aggravate feelings of anguish, powerlessness, oppression and victimization, while coping behaviors can preserve moral integrity (4). Coping strategies were identified that led to comfort, distancing from the problem and momentary escape. However, none of the reports indicated an attempt to rediscuss work processes in search of solutions.
It is essential that the management of health work processes takes into account the specificities and subjectivities of this work, considering the ways of producing care that are legitimized in everyday practices in order to resolve ethical conflicts present in a precarious work environment (41). As possibilities for recognizing and addressing MD, it is recommended to develop organizational policies that invest in individual values and in processes of deliberation and moral reflection in the workplace and in health education (24).

Limitations of the study

Considering that the study was carried out during the Covid-19 pandemic, there may be limitations related to social distancing, which was necessary for data collection. The dialogue between the participants and the researcher may have been limited in terms of emotional, affective and empathetic character due to physical distancing, given the sensitivity of the topic.

FINAL CONSIDERATIONS

The results indicate that HCW experience MD in the daily work of Covid-19 TC, understanding the experiences from the dimensions of the experience and effect of MD. In the context of experiencing MD, threats to moral integrity were related to moral commitment to care, moral harassment and situations of moral impediment. The causes of MD revealed ethical conflicts that threatened the moral integrity of these workers. As an effect of this process, experiencing these feelings generated physical and psychological consequences and ineffective coping strategies. In this regard, this study has made progress in understanding the elements that make up the experience of MD, indicating proposals for coping through deliberation and moral reflection.
As an institutional action in defense of the SUS and the health of HCW, it is essential to rediscuss work processes and the causes of conflictive relationships that generate ethical problems. For this to happen, the ethical dimension of health work needs to be centralized right from professional training and capillarized by training processes within the services. It is suggested that further studies be carried out to investigate the necessary ethical competencies to deal with MD of workers in everyday health practices.

Collaborators

The authors participated in the planning and design of the research, in data analysis and interpretation, in the writing and critical revision of the article, and approved the final version.

Funding

This research was carried out with the support of the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) – Funding Code 001.

REFERENCES

1. Ulrich CM, Grady C. Moral Distress in the Health Professions [Internet]. Ulrich CM, Grady C, editors. Cham: Springer International Publishing; 2018.
2. Barlem ELD, Ramos FRS. Constructing a theoretical model of moral distress. Nurs Ethics. 2015, 22(5):608–15.
3. Ramos FRS, Barlem ELD, Brito MJM, Vargas MA, Schneider DG, Brehmer LCDF. Conceptual framework for the study of moral distress in nurses. Texto e Contexto Enfermagem. 2016, 25(2).
4. Wilkinson JM. Moral distress in nursing practice: experience and effect. Oxford, UK; 1987.
5. Lijun K, Yi L, Shaohua H, Min C, Can Y, Bing XY, et al. The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatr. Lancet Publishing Group; 2020.
6. Caram CS, Ramos FRS, Almeida NG, Brito MJM. Moral suffering in health professionals: portrait of the work environment in times of COVID-19. Rev Bras Enferm. 2021;74.
7. Amnesty International. Exposed, silenced, attacked: Failures to protect health and essential workers during the covid‐19 pandemic. 2020.
8. Silva KR, Souza FG, Roquete FF, Faria SMC, Peixoto BCF, Vieira A. Allocation of resources for health care in COVID-19 pandemic times: integrative review. Vol. 73, Rev Bras de Enferm. 2020.
9. Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trabalho, Educação e Saúde. 2020,18(3).
10. Leite SN, Finkler M, Martini JG, Heidemann I, Verdi M, Hellmann F, et al. Management of the health workforce in facing covid-19: Disinformation and absences in brazil’s public policies. Ciencia e Saude Coletiva. 2021,26(5):1873–84.
11. Donkers MA, Gilissen VJHS, Candel MJJM, van Dijk NM, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021,22(1).
12. Miljeteig I, Forthun I, Hufthammer KO, Engelund IE, Schanche E, Schaufel M, et al. Priority-setting dilemmas, moral distress and support experienced by nurses and physicians in the early phase of the COVID-19 pandemic in Norway. Nurs Ethics. 2021,28(1):66–81.
13. Plouffe RA, Nazarov A, Forchuk CA, Gargala D, Deda E, Le T, et al. Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic. Eur J Psychotraumatol. 2021,12(1).
14. Smallwood N, Pascoe A, Karimi L, Willis K. Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic. Int J Environ Res Public Health. 2021,18(16).
15. Meese KA, Colón-López A, Singh JA, Burkholder GA, Rogers DA. Healthcare is a Team Sport: Stress, Resilience, and Correlates of Well-Being among Health System Employees in a Crisis. Journal of Healthcare Management. 2021,66(4):304–22.
16. Ness MM, Saylor J, DiFusco LA, Evans K. Leadership, professional quality of life and moral distress during COVID-19: A mixed-methods approach. J Nurs Manag. 2021,29(8):2412–22.
17. Petrella AR, Hughes L, Fern LA, Monaghan L, Hannon B, Waters A, et al. Healthcare staff well-being and use of support services during COVID-19: A UK perspective. Vol. 34, General Psychiatry. BMJ Publishing Group; 2021.
18. Kreh A, Brancaleoni R, Magalini SC, Chieffo DPR, Flad B, Ellebrecht N, et al. Ethical and psychosocial considerations for hospital personnel in the Covid-19 crisis: Moral injury and resilience. PLoS One. 2021, 16.
19. Brasil. Ministério da Saúde. Portaria no. 1.445, de 29 de maio de 2020. Institui os Centros de Atendimento para Enfrentamento à Covid-19 [Internet]. Brasília-DF; 2020
20. Barth PO. Distresse moral em enfermeiras da atenção básica brasileira [Tese]. [Florianópolis]: UFSC; 2016.
21. Berlinguer G. Bioética Cotidiana. UnB, editor. Brasília; 2004.
22. Ramos FRS, Barlem ELD, Brito MJM, Vargas MAO, Schneider DG, Brehmer LCF. Construction of the Brazilian scale of moral distress in nurses - a methodological study. Texto e Contexto Enfermagem. 2017,26(4):1–12.
23. Bardin L. Análise de Conteúdo. 1st ed. 70 E, editor. São Paulo; 2016.
24. Lunardi VL, Barlem ELD, Bulhosa MS, Santos SSC, Lunardi Filho WD, Silveira RSD, et al. Sofrimento moral e a dimensão ética no trabalho da enfermagem. Rev Bras Enferm. 2009, 62:599–603.
25. Peli P, Teixeira P. Assédio Moral: uma responsabilidade corporativa. Ícone, editor. São Paulo; 2006.
26. Harb A, Rayan A, Osama OZ. The Relationship Between Workplace Bullying and Positive Mental Health Among Registered Nurses. J Am Psychiatr Nurses Assoc. 2021,27(6):450–7.
27. Caçador BS, Ramos FRS, Brito MJM. Processo de angústia/sofrimento moral em enfermeiros da Estratégia Saúde da Família. Vol. 7. 2016.
28. Marques R, Raimundo JA. O Negacionismo científico refletido na pandemia da covid-19. Boletim de Conjuntura BOCA [Internet]. 2021;
29. Conectas Direitos Humanos, CEPEDISA. Boletim n. 10 Direitos na Pandemia. Mapeamento e análise das normas jurídicas de resposta à Covid-19 no Brasil. 2021.
30. Torres A, Félix A, Oliveira PIS. Escuelas de Sofia y la pandemia de COVID-19 en Brasil: reflexiones bioéticas. Rev Bioet Derecho. 2020, 50:333–52.
31. Satomi E, Souza PMR, Thomé BC, Reingenheim C, Werebe E, Troster EJ, et al. Fair allocation of scarce medical resources during COVID-19 pandemic: ethical considerations. Einstein (Sao Paulo). 2020, 18: eAE5775.
32. Orlandi EP. Silêncios: presença e ausência. 2008.
33. Oliveira CS. Neoliberalismo, sofrimento e indiferença. Revista Katálysis. 2022,25(2):365–73.
34. Dejours C. A loucura do trabalho. Cortez, editor. São Paulo; 1992.
35. Miyazaki MCOS, Soares MRZ. Estresse em profissionais da saúde que atendem pacientes com COVID-19. Sociedade Brasileira de Psicologia. 2020;
36. Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. AACN Adv Crit Care. 2016,27:111–9.
37. Muñoz OHR. Microviolencia en el trabajo, una práctica cotidiana del ejercicio del poder del management en las organizaciones –una reflexión urgente en tiempos de reconciliación. Sociedad y Economía. 2017,33:237–62.
38. Abramovay M, Valverde DO. Cotidiano das escolas: entre violências. UNESCO-Organização das Nações Unidas para a Educação, a Ciência e a Cultura; 2006. 404 p.
39. Bila NIGFA. A banalização da injustiça social no cotidiano de trabalho: a propósito da violência no trabalho e ameaça à saúde do trabalhador [Tese]. [Natal]: UFRN; 2008.
40. Bacigalupe A, Cabezas A, Bueno MB, Martín U. El género como determinante de la salud mental y su medicalización. Vol. 34, Gaceta Sanitaria. Ediciones Doyma, S.L.; 2020.
41. Hennington ÉA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia [Internet]. Vol. 42, Rev Saúde Pública. 2008.