Abstract

This single-case qualitative study aims to identify the elements associated with moral deliberation in the Family Health Strategy (ESF) by interviewing thirty-five professionals from family health teams. Data were collected via interviews guided by a semi- structured script and observation and analyzed using thematic content analysis. The results showed that moral deliberation in the concrete context of the practice of ESF professionals proved to be a subjective and incipient construction, influenced by factors internal and external to individuals. We concluded that identifying the elements that influence moral deliberation in the context of the ESF can favor the ethical improvement of health practices.

Keywords:
Ethic; Moral; Professional Practice; Family Health Strategy; Decision-making

Introduction

In the Brazilian National Health System (SUS), the Family Health Strategy (ESF) is an instrument to reorient the care model in Primary Health Care (APS) and to reorganize the work process of professionals with a multidisciplinary team who provides comprehensive and longitudinal health care to people and families (Brazil, 2017BRASIL. Ministério da Saúde. Portaria n. 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, DF, 22 set. 2017, Seção 1, p. 68. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html >. Acesso em: 20 jan. 2020
https://bvsms.saude.gov.br/bvs/saudelegi... ).

The production of care requires family health professionals to commit to the health care of the population while guided by an empathic and qualified listening, attentive to the subjective and objective needs of users in their social context (Santos; Michima; Merhy, 2018SANTOS, D. S.; MISHIMA, S. M.; MERHY, E. E. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 3, p. 861-870, 2018. DOI: 10.1590/1413-81232018233.03102016
https://doi.org/10.1590/1413-81232018233... ). The ESF proposes a model with new and constant challenges for workers. In their experience, teams often encounter complex and significant situations that cover structural, organizational, and relational aspects between professionals, professionals-users, and professionals-management, with high demand and responsibility during practice (Cardoso et al., 2016CARDOSO, C. M. L. et al. Moral Distress in Family Health Strategy: experiences expressed by daily life. Revista da escola de enfermagem da USP, São Paulo, v. 50, n. esp., p. 86-92, 2016. DOI: 10.1590/S0080-623420160000300013
https://doi.org/10.1590/S0080-6234201600... ; Gomes; Aparisi, 2017GOMES, D.; APARISI, J. C. S. Deliberação Coletiva: uma construção contemporânea da bioética brasileira para as práticas do SUS. Trabalho, Educação e Saúde, Rio de Janeiro, v. 15, n. 2, p. 347-371, 2017. DOI: 10.1590/1981-7746-sol00052
https://doi.org/10.1590/1981-7746-sol000... ).

These situations involve ethical problems considered challenging for professional practice since they are usually difficult to conduct, becoming sources of insecurity and doubts. They can also compromise the interest and well-being of the person or their family as well as affect the professional’s conduct. This enables several courses of action for a solution, which requires deliberate moral positioning to achieve the most reasonable decision (Nora; Zoboli; Vieira, 2015NORA, C. R. D.; ZOBOLI, E. L. C. P.; VIEIRA, M. Ethical problems experienced by nurses in primary health care: integrative literature review. Revista Gaúcha de Enfermagem, Porto Alegre, v. 36, n. 1, p. 112-121, 2015. DOI: 10.1590/1983-1447.2015.01.48809
https://doi.org/10.1590/1983-1447.2015.0... ).

The ethical problems in APS do not refer to the classic cases of bioethics, whose conduct revolves around extreme situations. In fact, they are more subtle and appear as common circumstances of daily work, related to the management of health services, to the relationships of professionals - with each other and with users -, and to the work process itself in APS (Ferraz et al., 2021FERRAZ, C. M. L. C. et al. Moral sensitivity in the practice of Family Health Strategy professionals. Rev Rene, Fortaleza, v. 22, 2021. DOI: 10.15253/2175-6783.20212260281
https://doi.org/10.15253/2175-6783.20212... ), which can enhance the complexity of these ethical conflicts regarding the identification, coping, and determination of their consequences on practice, professionals, and care (Nora; Zoboli; Vieira, 2015NORA, C. R. D.; ZOBOLI, E. L. C. P.; VIEIRA, M. Ethical problems experienced by nurses in primary health care: integrative literature review. Revista Gaúcha de Enfermagem, Porto Alegre, v. 36, n. 1, p. 112-121, 2015. DOI: 10.1590/1983-1447.2015.01.48809
https://doi.org/10.1590/1983-1447.2015.0... ; Siqueira-Batista et al., 2015SIQUEIRA-BATISTA, R. et al. (Bio)ethics and Family Health Strategy: mapping problems. Saúde e Sociedade, São Paulo, v. 24, n. 1, p. 113-128, 2015. DOI: 10.1590/S0104-12902015000100009
https://doi.org/10.1590/S0104-1290201500... ).

In this sense, this study focuses on moral deliberation - understood as analyzing and weighting ethical problems in a contextualized way - while seeking concrete solutions by problematizing possibilities to identify a prudent, responsible, and feasible course of action, which considers individual and social values and conducts (Zoboli, 2016ZOBOLI, E. L. C. P. A aplicação da deliberação moral na pesquisa empírica em bioética. Revista Iberoamericana de Bioética, Madrid, n. 2, p. 1-19, 2016. DOI: 10.14422/rib.i02.y2016.006
https://doi.org/10.14422/rib.i02.y2016.0... ; Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ). The process of moral deliberation values the context and singularities of each situation without marginalizing the issues related to ethical obligations and links all the elements necessary for a more comprehensive view of the experiences or problems evaluated (Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ).

The study does not aim to analyze the systematized itinerary of the process of moral deliberation proposed by Gracia (2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ) but to understand moral deliberation in the ESF from what the reference and the deliberative method instruct, seeking to critically reflect on ethical problems and the conduct of daily decisions (Schneider; Ramos, 2019SCHNEIDER, D. G.; RAMOS, F. R. S. Ensino Simulado e deliberação moral: contribuições para formação profissional em saúde. Porto Alegre: Moriá, 2019.) in APS.

In the literature (Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ; Ramos et al., 2020RAMOS, F. R. S. et al. Association between moral distress and supporting elements of moral deliberation in nurses. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3332, 2020. DOI: 10.1590/1518-8345.3990.3332
https://doi.org/10.1590/1518-8345.3990.3... ), moral deliberation has a multidimensional influence related to knowledge and professional experience, institutional protocols, organizational characteristics, codes of ethics and laws of professional practice, communication, inter-professional collaboration, and intuition. Moreover, the experience of morality can burden professionals when they cannot deliberate, helping construct subjects and identities (Ramos et al., 2016RAMOS, F. R. S. et al. Conceptual Framework dor the study of Moral Distress in nurses. Texto & contexto - Enfermagem, Florianópolis, v. 25, n. 2, e4460015, 2016. DOI: 10.1590/0104-07072016004460015
https://doi.org/10.1590/0104-07072016004... ; Vilela et al., 2020VILELA, G. S. et al. Nurse’s identity construction in the face of the moral distress process in an intensive care unit. REME - Revista Mineira de Enfermagem, Belo Horizonte, v. 24, e-1334, 2020. DOI: 10.5935/1415.2762.20200071
https://doi.org/10.5935/1415.2762.202000... ), which can greatly affect professional practice.

We investigated the factors involved in moral deliberation to identify the elements and ethical skills that help bring reflections, dialogues, and prudent and responsible resolutions of ethical problems to the ESF, which are essential for excellence in professional practice.

In this approach, this study aimed to identify the main elements associated with moral deliberation in the Family Health Strategy. By identifying these elements, our analysis can contribute to the reflection on ethical problems experienced in practice and promote the discussion about the ethical conduct of ESF teams, seeking excellence in professional practice.

Methods

An integrated single-case study was developed with the qualitative method, which seeks to deepen the significant characteristics of a given phenomenon and involves a real-life context (Yin, 2015YIN, R. K. Case Study. Panning and Methods. 5. ed. Porto Alegre: Bookman, 2015.). This approach aims to understand the singularities and meanings that subjects give to their actions in various contexts, bringing awareness to human experiences in the interface with the sociocultural dimension (Minayo, 2017MINAYO, M. C. S. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Revista Pesquisa Qualitativa, São Paulo, v. 5, n. 7, p. 1-12, 2017. Disponível em: <Disponível em: https://editora.sepq.org.br/index.php/rpq/article/view/82/59 >. Acesso em: 20 jan. 2020
https://editora.sepq.org.br/index.php/rp... ).

The study was conducted in family health units in a municipality in the state of Minas Gerais, Brazil, from January to July 2019. At the time of data collection, 43 ESF teams were registered in the municipality’s primary care information system. The inclusion criterion for teams was having a minimum team complete. That is, to participate in the research, family health teams should have a physician, nurse, nursing technician, and Community Health Agent (CHA). Of the 43 teams registered, 32 met this criterion. These health professionals should also have at least six months of work in their ESF unit, a period considered necessary for participants to experience and act on ethical problems in the work environment. Those who were on vacation or on sick leave during data collection were excluded from the sample. Based on these two criteria, 19 family health teams met the requirements for data collection.

Thirty-five professionals from ESF teams participated in the study, including nine nurses, nine nursing technicians, seven physicians, and 10 CHA, in line with data saturation for each professional category. Information was recurrent, valuing the multiple dimensions of the phenomenon studied and the search for the quality of actions and interactions throughout the process (Minayo, 2017MINAYO, M. C. S. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Revista Pesquisa Qualitativa, São Paulo, v. 5, n. 7, p. 1-12, 2017. Disponível em: <Disponível em: https://editora.sepq.org.br/index.php/rpq/article/view/82/59 >. Acesso em: 20 jan. 2020
https://editora.sepq.org.br/index.php/rp... ). No professionals refused to participate in the research.

Two sources of evidence were used in the study in accordance with data triangulation, which confers scientific rigor, reliability, and robustness to descriptions of findings (Yin, 2015YIN, R. K. Case Study. Panning and Methods. 5. ed. Porto Alegre: Bookman, 2015.). The interviews were previously scheduled and conducted individually in a private room in the ESF units with an average duration of 28 minutes and guided by a semi-structured script with questions about the elements related to moral deliberation in the practice of ESF professionals. Professionals were offered the opportunity to listen to and validate the interviews after completing them. The interviews were recorded and transcribed in full.

The non-participant observations occurred with the professionals’ awareness throughout the data collection period in the ESF units’ reception room, meeting room, basic care room, consultations, and team meetings. The observations were recorded and identified as Observation Notes (ON), contributing to the identification of convergent or non-investigative lines (Yin, 2015YIN, R. K. Case Study. Panning and Methods. 5. ed. Porto Alegre: Bookman, 2015.).

The thematic content analysis proposed by Bardin (2016BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2016.) was conducted to verify data from the stages of pre-analysis, exploration of the material, treatment of results, inference and interpretation. The qualitative data analysis software atlas.ti 8 was used as technological support to examine the interviews in the data organization process, enabling an overview of the findings during the analytical process (Brito et al., 2016BRITO, M. J. M. et al. Potentialities of Atlas.ti for data analysis in qualitative research in nursing. In: COSTA, A. P. et al. Computer supported qualitative research. New York: Springer, 2016. p. 75-84. DOI: 10.1007/978-3-319-43271-7
https://doi.org/10.1007/978-3-319-43271-... ).

From data analysis, two analytical categories reported on the moral deliberation in the practice of Family Health Strategy professionals: (1) supporting elements and (2) obstacles. To better understand the findings, these categories were joined in a single, more comprehensive category: elements associated with moral deliberation in the practice of ESF professionals.

The research followed all the formal requirements of resolution 466/2012 of the National Health Council, being approved by the appropriate bodies of the municipality via the Institutional Letter of Agreement and by the Research Ethics Committee of the Universidade Federal de Minas Gerais (Opinion no. 2.285.857/2017). The participants signed the Informed Consent Form after becoming aware of the possible risks, benefits, or discomforts of the research. To ensure anonymity, the statements were identified with the initial letter of professional categories - (N) nurse, (NT) nursing technician, (P) physician, and (CHA) Community Health Agent - followed by the number established for each interview.

Results: elements associated with moral deliberation in the practice of ESF professionals

The elements related to moral deliberation in the practice of FHS professionals are related to the teams’ knowledge of the population, formal and scientific knowledge, communication, dialogue and teamwork, and the values and virtues involved in the production of care.

Participants CHA5 and NT5 believe that knowing the specific reality of the enrolled population up- close allows better identifying this population’s problems as well as reflecting on the limits and potentialities of action for solutions, which may favor the conduct of community cases.

For participant P6, understanding the singularities and socioeconomic context of patients encourages her to seek knowledge to direct the situations.

Also regarding the relevance of knowing contextual aspects for moral deliberation, NT1 explains that she is always attentive to the prescriptions made by doctors to ensure that patients can follow what was prescribed and, if necessary, turn to the nurse or doctor of her team to request a change of medication.

However, elements that concern service organization proved to be challenges for moral deliberation in the practice of ESF teams since the obstacles mentioned by participants hinder understanding the population and its real needs.

N₅ states that institutional pressures for achieving goals and for productivity oppose what she believes is ethical practice, limiting the quality of care centered on the subject.

Participant P1 alludes to the form of institutional organization as an obstacle to the production of care centered on subjects. The family health team in which she works has more people registered than is recommended by the Ministry of Health. This is an obstacle to deliberation precisely because with several people to follow-up, professionals have no time to know the population and act according to its needs, reproducing the curative model of care for acute cases.

Participant N1 states that recognizing the professional experience gained from work in primary care and the time of work in the team is important for the ethical decision-making process since these expand knowledge about work and the population. P₄ recognizes the contribution of experience in learning good professional practice, and for not having any previous experience, the participant seeks the partnership of more experienced professionals of the team to act safely.

Interviewees indicated formal and scientific knowledge as a guiding element of professional deliberations in the ESF context. P2 declares that he has formally acquired this knowledge in medical school and in his specialization in family health and believes that scientific knowledge makes him more confident to analyze problems in a sensitive and judicious way.

For N6, formal knowledge is directly related to professional improvement and a better practice in the ESF context.

The situations related to the communication of professionals with each other, with users, and intersectorally proved to be essential to present and evaluate the best decision to be made, indicating dialogue and communication as deliberation elements in ESF.

During a prenatal consultation, a nurse of one of the family health teams was concerned about talking to the patient in a clear, objective, and simple way, ensuring that she understood her health situation and the magnitude of her problem, related to the altered blood glucose test. The professional presented to the pregnant woman all possible complications of the case and listened to her doubts and anguish. Professional and user thus shared decisions about the conduction of the therapeutic project. (ON)

The participants of this research seek answers to the ethical questions which appear in the values and virtues apprehended in personal and professional experiences in ESF.

N7 and P6 report seeking to understand the needs of the population with an empathic, respectful, and humble listening.

The statements show that the involvement of the multidisciplinary ESF team and the support to the ESF, represented by the Family Health Support Center (NASF), are adopted in practice to establish the best course of action of cases.

Teamwork is presented as a scope of practice of ESF professionals in their commitment to meet the needs of individuals, as expressed by N₄, P2, and CHA₃.

The set of elements involved in moral deliberation found in this study shows the extent and complexity of this process in the daily practice of ESF professionals.

Discussions

This study showed that moral deliberation is influenced by several aspects related to the professionals and work environment of the ESF, which support or hinder this aspect in the family health teams. The elements identified in the study do not occur separately but as interactions that translate into ethical factors and skills that improve the conduct of reflection, dialogue, and prudent and responsible deliberation (Ramos et al., 2020RAMOS, F. R. S. et al. Association between moral distress and supporting elements of moral deliberation in nurses. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3332, 2020. DOI: 10.1590/1518-8345.3990.3332
https://doi.org/10.1590/1518-8345.3990.3... ) in the ESF.

Moral deliberation can be understood as a proposal for the analysis of ethical problems in all its complexity, seeking to find the best course of action in a prudent, responsible, and feasible way (Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ). This implies weighting the situation, understanding the values in conflict and predictable consequences, and envisioning the presentation of possible solutions. The care with values in conflict in ethical problems aims to minimize uncertainty to reach the reasonable decision, that is, the most prudent one (Zoboli, 2016ZOBOLI, E. L. C. P. A aplicação da deliberação moral na pesquisa empírica em bioética. Revista Iberoamericana de Bioética, Madrid, n. 2, p. 1-19, 2016. DOI: 10.14422/rib.i02.y2016.006
https://doi.org/10.14422/rib.i02.y2016.0... ; Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ).

Family health teams develop their practices in defined territories and are committed to providing longitudinal care to people, maintaining a constant relationship with them regardless of the absence or presence of diseases, and ensuring comprehensive care within their life contexts (Santos; Michima; Merhy, 2018SANTOS, D. S.; MISHIMA, S. M.; MERHY, E. E. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Ciência & Saúde Coletiva, Rio de Janeiro, v. 23, n. 3, p. 861-870, 2018. DOI: 10.1590/1413-81232018233.03102016
https://doi.org/10.1590/1413-81232018233... ).

Our results showed that the ESF care model, which promotes the care team’s proximity to the population and knowledge about patients’ objective and subjective needs, supports moral deliberation, but daily work still offers challenges to achieve the full potential of the APS model.

Corroborating these results, an integrative review on the elements and strategies that facilitate nurses’ ethical decision-making before problems showed that understanding people’s social context and values predisposes nurses to construct a comfortable itinerary for ethical decision-making (Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ). Moreover, the ESF proposes a bond which favors the relationship of trust between professional, user, and family members and helps apprehend the characteristics of problematic situations, a prerequisite for moral deliberation (Zoboli; Saints; Schveitzer, 2016ZOBOLI, E. L. C. P.; SANTOS, D. V.; SCHVEITZER, M. C. Pacientes difíceis na atenção primária à saúde: entre o cuidado e o ordenamento Interface - Comunicação, Saúde, Educação, Botucatu, v. 20, n. 59, p. 893-903, 2016. DOI: 10.1590/1807-57622015.0500
https://doi.org/10.1590/1807-57622015.05... ).

Recognizing ethical problems in daily work is essential in the practice of ESF professionals and in the ethical deliberation process. Moral sensitivity is understood as an individual attribute that encompasses contextual and intuitive aspects in the process of ethical deliberation, allowing the individual to recognize moral problems and conflicts that involve him and other related persons - particularly the patients under his care, in this case - and to know the consequences and implications of his decisio ns on others (Arslan; Calpbinici, 2018ARSLAN, F.; CALPBINICI, P. Moral Sensitivity, Ethical Experiences and Related Factors of Pediatric Nurses: A Cross- Sectional, Correlational Study. Acta Bioethica, Santiago, v. 24, n. 1, p. 9-18, 2018. DOI: 10.4067/S1726-569X2018000100009
https://doi.org/10.4067/S1726-569X201800... ). This investigation thus showed that the ESF teams’ in-depth knowledge of the population allows identifying the needs of users in all their complexity, enabling adequate responses to their needs and performing quality care.

The statements indicate that despite the potentiality of the ESF care model, problems related to the work organization of family health teams are obstacles for moral deliberation. The participants of this research reported developing their practices based on the logic of production by procedures and care, stating that this form of care production distances them from what they believe to be quality care - one attentive to the needs of and centered on individuals/families. Furthermore, due to the overload population enrolled in the area of the ESF units, professionals cannot perform longitudinal care, perpetuating the model of care to chronic conditions.

Also corroborating our findings, organizational characteristics indicated tensions between institutional values (establishment of goals and productions) and professionals (care centered on the individual/family, quality of care), which poses contradictory demands (Ramos et al., 2020RAMOS, F. R. S. et al. Association between moral distress and supporting elements of moral deliberation in nurses. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3332, 2020. DOI: 10.1590/1518-8345.3990.3332
https://doi.org/10.1590/1518-8345.3990.3... ; Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ) and moral uncertainty to team members. This concept is understood when the professional feels discomfort and realizes that something contradicts his ethical precepts when following the established course of action, allowing moral stagnation and/or suffering from the impossibility of deliberating in accordance with his judgment (Ramos et al., 2019RAMOS, F. R. S. et al. Aspectos sociodemográficos e laborais associados ao distresse moral em enfermeiros brasileiros. Acta Paulista de Enfermagem, São Paulo, v. 32, n. 4, p. 406-415, 2019. DOI: 10.1590/1982-0194201900056
https://doi.org/10.1590/1982-01942019000... ).

The ethical problems experienced by ESF professionals are mostly complex and the solution to them can often be imprecise (Cardoso et al., 2016CARDOSO, C. M. L. et al. Moral Distress in Family Health Strategy: experiences expressed by daily life. Revista da escola de enfermagem da USP, São Paulo, v. 50, n. esp., p. 86-92, 2016. DOI: 10.1590/S0080-623420160000300013
https://doi.org/10.1590/S0080-6234201600... ; Coast; Moreira; Brito, 2020). The family health professionals investigated here face and respond to ethical problems in several ways, such as by seeking improvement with formal and scientific knowledge. Some studies contradict our findings by indicating that professionals mainly resort to intuition or experiences of colleagues when faced with ethical problems (Voldbjerg et al., 2017VOLDBJERG, S. L. et al. Newly graduated nurses’ use of knowledge sources in clinical decision-making: an ethnographic study. Journal of Clinical Nursing, Hoboken, v. 26, p. 1313-1327, 2017. DOI: 10.1111/jocn.13628.
https://doi.org/10.1111/jocn.13628... ; Ramos et al., 2020RAMOS, F. R. S. et al. Association between moral distress and supporting elements of moral deliberation in nurses. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3332, 2020. DOI: 10.1590/1518-8345.3990.3332
https://doi.org/10.1590/1518-8345.3990.3... ). Intuition focuses especially on feelings and emotional aspects about the problem evaluated rather than on specific evidence, being therefore susceptible to misunderstandings and errors (Ramos et al., 2020RAMOS, F. R. S. et al. Association between moral distress and supporting elements of moral deliberation in nurses. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 28, e3332, 2020. DOI: 10.1590/1518-8345.3990.3332
https://doi.org/10.1590/1518-8345.3990.3... ).

In turn, research corroborates our results on the search for the professional experience of others as a clear source of knowledge (Voldbjerg et al., 2017VOLDBJERG, S. L. et al. Newly graduated nurses’ use of knowledge sources in clinical decision-making: an ethnographic study. Journal of Clinical Nursing, Hoboken, v. 26, p. 1313-1327, 2017. DOI: 10.1111/jocn.13628.
https://doi.org/10.1111/jocn.13628... ; Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ). When faced with problems in daily work, less experienced professionals tend to decide based on considerations of those more experienced, understood as dependable people and holders of practical knowledge (Voldbjerg et al., 2017VOLDBJERG, S. L. et al. Newly graduated nurses’ use of knowledge sources in clinical decision-making: an ethnographic study. Journal of Clinical Nursing, Hoboken, v. 26, p. 1313-1327, 2017. DOI: 10.1111/jocn.13628.
https://doi.org/10.1111/jocn.13628... ). An integrative review research identified that individual factors, including scientific and tacit knowledge and own and colleagues’ experience, influence nurses’ ethical decision-making the most (Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ).

However, deliberating must combine scientific knowledge, experience, moral sensitivity, and skills development, especially by shaping some character traits in the construction of responses (Schneider; Ramos, 2019SCHNEIDER, D. G.; RAMOS, F. R. S. Ensino Simulado e deliberação moral: contribuições para formação profissional em saúde. Porto Alegre: Moriá, 2019.). Professionals should therefore develop their ethical skills and competences regarding the deliberative process. Making prudent decisions presupposes judging and evaluating ethical problems within their context and predicting their consequences, aiming at excellence in health care practice (Nora et al., 2016NORA, C. R. D. et al. Elements and strategies for ethical decision-making in nursing. Texto e Contexto - Enfermagem, Florianópolis, v. 25, n. 2, 2016. DOI: 10.1590/0104-07072016004500014
https://doi.org/10.1590/0104-07072016004... ).

From these premises, one can understand deliberation as a moment of reflecting on issues in an interpersonal way that seeks a shared decision, guided by the practice of communication and dialogue (Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ; Zoboli; Schveitzer, 2013ZOBOLI, E. L. C. P.; SCHVEITZER, M. C. Valores da enfermagem como prática social: uma metassíntese qualitativa. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 21, n. 3, p. 695-703, 2013. DOI: 10.1590/S0104-11692013000300007
https://doi.org/10.1590/S0104-1169201300... ). The communication of ESF professionals with each other and with users emphasized the health teams’ willingness to listen and interact with the people involved, reflecting their respect for the speech and ideas of others, and aroused the feeling of shared responsibility and collaboration among team members for joint deliberation.

The moral solution investigated in the care of older adults proved to be potential for use in palliative care since it reflected better relationships between the members of the multidisciplinary team, promoting a mutual understanding of different perspectives (Janssesns et al., 2015). Moreover, in the collective, the dialogical encounter seeks fullness, and the decisions established by interdisciplinarity can be considered in fact prudent (Doris; Aparisi, 2017DORIS, G.; APARISI, J. C. S. Deliberação coletiva: uma contribuição contemporânea da bioética brasileira para as práticas do SUS. Trabalho, Educação e Saúde, Rio de Janeiro, v. 15, n. 2, p. 347-371, 2017. DOI: 10.1590/1981-7746-sol00052
https://doi.org/10.1590/1981-7746-sol000... ). The deliberative process is therefore essential in the practice of the multidisciplinary ESF team as a potential space to transform professional excellence.

Values and virtues were presumably recognized as supportive of the professionals’ answers to the issues in practice and of ethical action. Moral deliberation encourages reflection and debate on ethical problems, seeking a recommended course of action which considers professionals’ values (Zoboli; Schveitzer 2013ZOBOLI, E. L. C. P.; SCHVEITZER, M. C. Valores da enfermagem como prática social: uma metassíntese qualitativa. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 21, n. 3, p. 695-703, 2013. DOI: 10.1590/S0104-11692013000300007
https://doi.org/10.1590/S0104-1169201300... ; Gracia, 2016GRACIA, D. Tomar decisiones Morales: del casuísmo a la deliberación. Dilemata, La Rioja, v. 8, n. 20, p. 15-31, 2016. Disponível em: <Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5329386 >. Acesso em: 20 jan. 2020
https://dialnet.unirioja.es/servlet/arti... ). These values become supporting elements of reflection, possibilities of action, and possible consequences of the deliberative itinerary (Schneider; Ramos, 2019SCHNEIDER, D. G.; RAMOS, F. R. S. Ensino Simulado e deliberação moral: contribuições para formação profissional em saúde. Porto Alegre: Moriá, 2019.).

In the concrete context of the practice of ESF professionals, moral deliberation proved to be a subjective and incipient construction, influenced by factors internal and external to individuals. This study shows the relevance of moral deliberation for conducting the ethical problems of the ESF considering that its driving elements are interpersonal relationships mediated by dialogue, multi-professional teamwork, values, knowledge, professional experience, and knowledge of the population and its needs.

Identifying the elements that influence moral deliberation in ESF can favor the ethical improvement of health practices. Therefore, creating spaces to reflect on the ethical problems of APS and on resolution strategies is essential. This shows the importance of developing ethical-moral competencies in the training and daily practice of health professionals.

Final considerations

The study allowed identifying and analyzing the elements involved in the moral deliberation of ESF professionals. This concept unfolds in the teams’ connection to and knowledge of the population, essential for contextualizing the problems, needs, and values of the subjects involved. Moreover, it is influenced by the organizational characteristics and work process of APS, which are at times obstacles to deliberation. Finally, the communication process, guided by dialogue and developed in the context of the multidisciplinary team, increased the potentiality of collaboration among professionals to promote moral deliberation.

This study aims to contribute to the elaboration of strategies that improve the moral deliberation of ESF professionals for a more ethical professional practice which provides quality health care.

We considered the lack of studies that clearly focus on the elements of moral deliberation and the excellence of professional practices in the ESF as a research limitation.

Acknowledgments

We would like to thank NUPAE - Research Group on Nursing Administration, a research center of which we are part.

References

Publication Dates

History