Moral distress among nursing professors: The exercise of parrhesia

Introduction

The term parrhesia (from the Greek, παρρησία) goes back to the politics of Ancient Greek and meant the privilege of Greek citizens to have equal rights to speak freely in the midst of the Assembly. ¹ It implied the democratic ideal of Athenians not only to speak freely, but also to speak the truth, even at personal risk. Thus, the notion of parrhesia is originally rooted in politics and democracy, which later was adopted in the sphere of personal ethics and the constitution of the moral subject. ¹

Foucault dedicated his last years of life to rescue this concept through a long dialogue with ancient philosophy, in an attempt to search for the elements intrinsic to the courage of truth. ^1,2 He focused on texts considered symbolic to Western thought, operating a genealogy of practices used to underline the traits of an ethical relationship linked to courage, because only someone who voluntarily puts himself/herself in the face of eminent risk could practice parrhesia. ²

More than a word, parrhesia is a way of speaking, a way of being, and a virtue that accompanies an individual in his or her actions. Hence, it is seen as the courage to speak truth, even at personal risk. The boldness of the speaker drives one away from his or her comfort zone, as parrhesia has an unsettling effect on one’s interlocutor, with potential to break the bond between speaker and interlocutor. ^1,3

College professors are responsible for performing highly complex tasks, including the need to update knowledge constantly, having to deal with persistent pressure accruing from qualification processes, career progression goals, being results-driven, and working with public policies promoting high productivity and, moreover, experiencing an excessive workload without due recognition. ^4,5

Thus, social practices related to the production of knowledge may be mediated by power strategies intending to control and govern one’s actions. From this perspective, individuals subject to such a regime experience their subjectivity and desires being molded in such a way that renders them docile, efficient in terms of production but inefficient in terms of discussing and reacting to the system. ³

Power relationships existing in a university may be considered from Foucault’s perspective as a more or less organized, pyramidal and coordinated beam, composed of a set of possible actions that operate on a field of possibilities in which the individuals’ behavior is inscribed, and therefore, is mobile, reversible and unstable. ³

One’s actions take place through strategic devices that reach all members, given that there is no aspect of one’s social life that is exempt from their mechanisms. ³ In other words, power relationships are not above or beyond teaching practices. On the contrary, they circulate through complex webs of actions, the effects of which are contingent and indeterminate. ⁶

Background

Based on this premise, nursing professors may experience specific situations of power relationships that cause them to confront their values and ethical principles, such as the case of states of domination, in which power relationships are fixed and asymmetric, in which freedom is extremely restricted and may culminate in moral distress. ⁷

In 1984, Jameton defined the term moral distress to describe the psychological reaction of individuals toward situations when one knows what is morally right but is unable to act accordingly. ⁷ In 1987, Wikinson added some considerations to Jameton’s definition, which were related to mental and emotional responses to moral distress, defining it as “a state of psychological imbalance and negative feeling experienced when one makes a moral decision but is unable to follow its course of action.” ⁸

Other contemporary definitions are also noteworthy, especially because they present some main components associated with the phenomenon, such as complicity in wrongdoing, lack of voice, wrongdoing associated with professional (not personal) values, repeated experiences, and three levels of root causes (patient, unit, system). ^9,10

The university context is associated with conflicts between values, standards and beliefs that permeate teaching practices, among which the main sources are as follows: an excessive number of tasks, demands imposed by funding agencies, constant need for updating, excessive number of classes and advisees receiving guidance concerning scientific research, participation in examination boards and commissions, publication of papers, academic dishonesty, conflicts among peers, lack of autonomy, lack of student interest, and inconsistent teaching proposals. ^11,12

From this conception, the study of parrhesia in the nursing field can serve professionals as an important philosophy to support and guide nursing professors to face and manage situations and circumstances that can trigger moral distress. Parrhesia is a verbal action in which an individual identifies his or her personal relationship with truth and, despite potential consequences, acts in accordance with his or her beliefs, discourse and actions. In other words, individuals accept a potentially risky situation when choosing to establish a frank and true dialogue, because they recognize that telling the truth is a moral duty. ¹

Therefore, nursing professors need to reflect upon themselves and their practice in an attempt to construct their identity as something that comes from the relationship with doing, from cultivating themselves, from the way they experience their work, and the meaning they assign to it. From this perspective, a nursing professor concerned with the educational process studies him/herself and possibilities of change, awakening to the need to face complex ethical problems within the workplace.

Aim of this study

This study’s aim was focused on the need to understand moral distress experienced by nursing professors teaching in higher education institutions and the use of parrhesia as a coping strategy.

Methods

Instrument

The questionnaire provided a brief description of the moral distress concept and closed-ended questions intended to characterize the participants (e.g. sex, age, and region where professors worked), followed by open-ended questions, which are presented in Table 1.

The open-ended questions were based on related Brazilian and international literature and later submitted to a panel of experts composed of four PhD nursing professors with extensive experience in the topic. The panel assessed the questionnaire’s semantic equivalence, relevance, redundancy, and conformity with the study’s objective and language.

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Table 1.

Questionnaire questions; Brazil, 2019.

Questions

What are the main activities you perform in your work routine? Can you incorporate what you think and believe in your actions? Please exemplify.

What are the main difficulties encountered in your work as a professor? How do you deal with these difficulties?

Are there any resistances to your actions as a nursing professor? How do you perceive and deal with them?

Do you believe that you experience moral distress in your work? How do you usually respond to these situations?

Which are the main situations potentially causing moral distress that you identify in your work?

How do you perceive your performance in terms of theoretical and practical tasks concerning undergraduate students? Are there any confrontations and conflicts?

What do you think that could aid nursing professors to cope with distressing situations (in professional, personal and institutional terms)?

How do you perceive your performance in terms of graduate activities (in case you teach in a graduate program)? Do you implement activities the way you want to?

Source: Study’s data.

Data analysis

Data were analyzed using discursive textual analysis, which is a method to analyze qualitative data intended to produce new understanding regarding discourses and phenomena. ¹³ According to its hermeneutic roots, discursive textual analysis values the participants’ expression of phenomena, seeking the collective construction of meanings, which are later understood, described and interpreted. ¹³

Therefore, more than expressing existing realities, discursive textual analysis becomes involved in a constant movement of production and reconstruction of the realities it investigates, adding a dialectical nature to the hermeneutic perspective, capable of transforming dispersed excerpts of texts into well-structured and grounded sets of arguments. ¹³

The analysis is developed through three fundamental stages: unitization of texts, establishment of relationships, and apprehension of a new emergent discourse, focusing on a self-organized process. ¹³

Unitization is achieved by deconstructing the text, by performing rigorous and in-depth reading, analyzing the text in detail, fragmenting it and highlighting units of meaning. Categories emerged from the establishment of relationships between units of meaning, naming and grouping close elements of meaning. The last stage of analysis, the apprehension of a new emergent, involved the description and interpretation of meanings based on the text, which permitted the achievement of a new understanding of the phenomena and the discourses investigated. ¹³

Ethical aspects

Ethical aspects and human rights were ensured in accordance with the recommendations of Resolution 466/12, Brazilian Council of Health, which regulates studies involving human subjects. The Institutional Review Board (CEPAS) approved the project (Opinion report 67/2016).

The participants were identified by letters NP (nursing professor), followed by a number that corresponded to the order of interview (e.g. NP1, NP2, etc.).

Results

Most of the 33 nursing professors composing the study sample were women aged approximately 50 years old. The participants were affiliated with institutions located in the following regions: south (15), southeast (9), midwest (1), north (4), and northeast (4).

Based on the literature and the study’s data, three categories emerged: Performance of nursing professors and potentially distressing situations, the experience of moral distress, and parrhesia as coping strategy, which are presented as follows.

The experience of moral distress

The situations of moral distress the nursing professors experienced mainly concern personal, professional and organizational value conflicts, which are complex situations within power relations, which make it increasingly difficult to balance activities:

I suffer when I want to teach—I like this very much—and students are not willing to learn. I want them to be professionally and personally successful but they don’t always seem to want it, I’m under the impression that I can’t achieve what I set out to do. (NP02)

I live in moral distress. The frustration is immense when you study and prepare yourself to teach certain topics in the teaching dimension but are unable to apply them because of the limitations imposed by your peers, the leadership, and by the very structure of the higher education institution. (NP03)

I see myself in moral distress in relation to interpersonal relationships, especially with competitive peers, in terms of the university’s structure, the fact that the teaching-learning process is poorly conducted, and also the fact that public universities are decaying. Recently, I learned I am hypertensive and I totally blame it to suffering at work. (NP17)

I realize that I should be more focused on the students’ learning process. I usually get late every time I have a department meeting, so I don’t have to witness the huge amount of egos arguing during most of the meeting. (NP24)

I experience moral distress in times when the real context of supervised training is not like the theory we discuss in the classroom. It causes me discomfort, because otherwise patients would have better quality care and students would experience better learning if all those workers involved were accountable and committed to their work. (NP29)

Parrhesia as a strategy to deal with moral distress

Some professors realized that telling the truth might threaten the structures of a context marked by the uncomfortable coexistence of rules and ethical conflicts, thus reconfiguring certain practices, in addition to introducing the possibility of criticizing practices. This entails great potential for personal and organizational transformation:

My greatest difficulty, which I try to overcome every day, is to show myself active and present, even when dealing with the criticism of professors with many years of experience, who don’t accept suggestions for improvement. I always say what I think and put my beliefs into action, even if I feel increasingly isolated by my peers. (NP11)

I always seek to implement what I believe, in accordance with my knowledge and moral development, by reflecting and discussing with my co-workers, even if it causes annoyances. I think that my emotional maturity allows me this behavior. (NP33)

[…] there is much resistance to my actions, especially because I speak and act according to my moral duty. I always want to innovate, update references and care practices and seek new teaching methods, but I realize something from the discourse of my colleagues, who question why I do what I do. They say I ask for trouble. I feel like I’m paddling against the tide, but I persist with a feeling that I won’t give up and will keep doing what I believe. (NP20)

Discussion

The results show that nursing professors working in federal public universities in Brazil face numerous situations that result from asymmetrical power relationships, which may culminate in anguish, frustration, and moral distress, especially when workers do not become involved in a process of change, even though they acknowledge it to be necessary.

Power is always present, especially in actions intended to control someone else’s behavior. Therefore, these relationships are mobile, reversible and unstable, permeate the entire social field and occur especially when individuals are free; there needs to exist some freedom on both sides. ³ It means that the possibility of resistance needs to exist in unbalanced power relations; otherwise, there would be no power relations. Foucault considers power to be a more or less coordinated and organized bundle of relations. ³

Therefore, situations of great vulnerability that trigger moral distress are related to an excessive number of tasks, lack of preparedness, lack of encouragement to update didactic-pedagogical elements, interpersonal conflicts, lack of student interest, and the poor physical and management conditions for teaching and in health facilities. These situations hinder and/or impede activities that are relevant for teaching. ¹⁴

Similarly, the factors related to moral distress among Canadian nurses are mainly related to power relationships impregnated with authoritarianism, incoherent organizational policies existing in healthcare settings, time restrictions, lack of resources, and high levels of responsibility delegated to these workers. In addition, external factors rooted in imbalanced power relationships coupled with specific internal factors, such as lack of autonomy, poor knowledge, and fear of leadership personnel, become key elements triggering moral distress. ¹⁴

One study conducted with professors teaching in vocational nursing programs located in the south of Brazil reports some experiences of these professionals triggering moral distress, namely: lack of interest and distance on the part of students from health care practices, weaknesses in teaching, the organizational dynamics of supervising training settings, and poor care provided to patients. ¹⁵

Another source of moral distress found in this study is the discrepancy between the theory taught in the classroom and the clinical practice that is verified in healthcare settings, which makes it difficult to put in practice what is taught. It is part of the routine of these professors to teach in healthcare settings where care is directly delivered to patients and families. There are situations, however, in which these settings are morally compromised and workers display anti-ethical behavior and attitudes. Thus, a situation that could be an opportunity for students to learn becomes a bad example. ¹⁶

Another aspect that emerges in this study is a recognition of the high number of activities faculty members have to perform within the scope of teaching, research, extension and management, activities that do not to seem to contribute to increased production or improved quality of teaching. Instead, this overload of tasks hinders the implementation of planned activities, generating frustration and distress. ^16,17

In agreement with this study, a systematic literature review intended to identify the main factors of psychological illnesses among Brazilian professors found that excessive workload, lack of control over one’s time, students’ behavioral problems, excessive bureaucracy, difficulty implementing new teaching methodologies and difficulty relating with supervisors are among the main sources of stress and distress reported by professors. ^18,19

In regard to professors’ low qualification or lack of pedagogical training, as well as a lack of incentive to implement new teaching methodologies, a Brazilian study intended to investigate the background of nurses in the teaching field and identify barriers imposed to the practice of college professors reports that most higher education institutions with programs directed to the health field, traditionally hire faculty/staff composed of professionals with a bachelor’s degree without any training to teach. Such a practice results in professors feeling insecure and facing difficulties addressing the learning-teaching process. ²⁰

In addition, in terms of didactic-pedagogical aspects, a study conducted in a federal institution located in Rio Grande do Norte, the objective of which was to identify difficulties experienced by nursing professors in the implementation of active methodologies, shows that the main difficulties included curricular problems that did not support such methodologies and resistance on the part of faculty members in changing and updating outdated teaching practices. ²¹

In this context, this study’s results and those reported in the literature enable reflection upon the difficulties that emerge in the process of transitioning between teaching methodologies, especially when outdated, though crystallized, practices need to be replaced; such a process seems to destabilize some professionals, who have a kind of resistance to the new. ^21,22 Hence, replacing old methodologies requires time, knowledge, availability and, most importantly, sensitivity on the part of workers to acknowledge the need to transform their craft.

According to Clinton and Springer, ²³ Foucault’s legacy for the field of nursing lies in the different forms of resistance, which can be used to govern situations and circumstances with which professors disagree.

Among such forms of resistance there is parrhesia, understood as a verbal action in which an individual identifies his or her personal relationship with the truth and, regardless of the consequences, acts in harmony with his or her thoughts, speech and actions. ¹ That is, an individual puts himself/herself at risk when engaging in frank and true dialogue as she/he conceives the attitude of saying the truth as a duty to help others, as well as himself/herself. ^6,24

Resistance practices focused on parrhesia are part of the context of nursing. For instance, a study to identify how nurses engage in patient advocacy in the hospital context reports that nurses work to ensure the rights of patients and to support their decisions concerning health care based on what they believe and through the establishment of a candid dialogue. Through this, they fulfill their moral duties and ensure their autonomy in hospital settings, even at the risk of facing ruptures in their professional relatioships. ²⁴

Still, possibilities to change power relationships are concrete realities for those nurses who seek ways to resist and to have the freedom for moral deliberation, who refuse to accept things as they are presented. In these cases, many professionals believe that reporting incorrect acts arising from the dynamics of the work at hospital settings seems to be the most efficacious form of resistance to use, considering this attitude can result in significant transformations in favor of the quality of healthcare delivery, from an ethical point of view. ²⁵

Some participants in this study, however, report they choose silence rather than confront situations that lead to moral distress, mainly because they do not believe these situations can be changed or are afraid their actions may hold more risk than benefit, such as having to deal with isolation at work.

Identifying factors leading to moral distress among nurses shows that the silence some workers choose when facing ethical concerns and the fear of negative consequences can actually derive from a real external danger, such as fear of being ostracized at work, a situation that arises when co-workers deliberately ignore or isolate others. Therefore, the feeling of not belonging to the work team, of being rejected, becomes a factor leading to inaction and suffering. ¹⁴

One study seeking to identify strategies of resistance adopted by nursing workers when facing situations of moral distress reports strategies involving individualism and acceptance when dealing with power relationships, denying oneself and one’s values based on the understanding that nursing is a profession of donation and self-sacrifice. The main “actions” of these workers included detachment and apparent disregard for problem-solving. ²⁶

Forms of resistance such as resignation, acceptance of everyday situations and mortification of professional interests lead to the understanding that it is not just about the way power relationships are constructed and deconstructed in the nursing and healthcare field, but also the way workers transform themselves into subjects, subjectify and govern themselves, and not always in an ethical manner. ²⁶

From this perspective, nursing professors need to reflect upon themselves and their practice in order to build their identities as originating from their relationship with doing, as a cultivation of themselves. Each needs to reflect on how she/he experiences his or her practice and the meaning she/he attributes to it. In this sense, nursing professors concerned with the educational process study themselves and the possibility of change, awakening to the need to deal with complex problems in the work environment. ¹¹

Therefore, true speech becomes part of the aesthetic of existence, working as an instrument of self-transformation and stylization of conduct. Foucault defends a lifestyle subordinated to true speech able to resist individualization. In this sense, parrhesia can contribute to re-organizing the way an individual talks, acts and lives, balancing sociocultural, economic, and scientific dimensions permeating human subjectivity. ²⁷

Limitations

This study’s limitations include the relatively small number of participants and the fact that there are few studies addressing moral distress and parrhesia among nursing professors, which hinders more in-depth discussions of results.

Conclusion

This study’s results present new evidence of moral distress experienced by nursing professors in the context of higher education and the use of parrhesia as a potential coping strategy. In these cases, nursing professors experience moral distress when they are prevented from acting in accordance with their values and knowledge, especially when they identify that attempting to change morally distressing situations entails risks and that the institution does not provide support, even when problems are reported.

Therefore, coping strategies based on the parrhesia philosophy may enable nursing professors to acquire the confidence they need to acknowledge ethical conflicts existing in the educational context and express their needs based on their beliefs and ethical principles.

Educational activities implemented in accordance to professional proposals can minimize the occurrence and effects of moral distress and strengthen the results of the teaching-learning process.

Hence, there is an urgent need in the current context of transformations, to reinvent the way university professors perform their roles, reflecting upon their own practice, as well as upon teamwork, organization of tasks, and teaching structure to recovery the ethical dimension of the profession.

Still, the ability of nursing professors to reflect upon their own pedagogical practice is essential to undertake any effort toward education renewal. Therefore, it is necessary to establish new cultures in teaching environments that allow for discussions, in which thinking and acting are consistent and support the training of professors committed with educational practice and heath care.

Considering that the focus of research in the nursing field is on the care provided to people in its multiple dimensions, the discursive textual analysis used in this study proved to be an important qualitative method for data analysis, as it permitted investigating and understanding the phenomenon by interpreting the meanings expressed through discursive evidence.

Further studies are needed to better clarify the nature of situations that trigger moral distress in the context of higher education, as well as to identify coping strategies that nursing professors can adopt.