Conflict management in COVID-19 Vaccination: a critical reflection

Introduction: healthcare professionals work in dynamic and complex environments to make ethical decisions, which are guided by fundamental principles such as beneficence, non-maleficence, autonomy and justice, in addition to local laws and professional codes of ethics. The COVID-19 pandemic has brought unprecedented challenges, raising ethical concerns in various areas of care provision, and which in the field of nursing has raised ethical and personal conflicts. Objective: to reflect on specific nursing interventions during the COVID-19 vaccination that generated conflicts, positive and negative contributions and the management strategies used. Method: critical reflection supported by a bibliographic review of relevant scientific literature. Conclusions: during the COVID-19 vaccination, the lack of continuity of care by the same professional, the pressure to meet targets and the lack of resources placed nurses in situations of intrapersonal conflict, jeopardizing the fundamental principles of the profession and the safety of users. Ensuring continuity of care, strengthening the ethical training of professionals and promoting dialogue between the different actors involved in crisis management decision-making, will contribute to better management of future challenges.


INTRODUCTION
Healthcare is a complex and multifaceted field, where ethical, moral and practical issues often overlap.Conflicts arise in various contexts and involve professionals, users, family members and the institutions themselves.Understanding and addressing conflicts is crucial to ensuring the safety of patients, the effectiveness of treatments and the satisfaction of all parties involved.In this context, constructive conflict management becomes essential to promote a healthier and more productive working environment, as well as the quality of care provided. (1)he COVID-19 pandemic has exacerbated some ethical dilemmas, with detrimental impacts on well-being.Professionals have had to be reactive, work in an unpredictable organizational environment, and develop strategies to minimize negative impacts on users, health professionals and on the organizations themselves. (2)he aim of this paper is to analyze and reflect on some specific nursing interventions during the COVID-19 vaccination that generated intra-and interpersonal conflicts, positive and negative contributions, and the management strategies used.
The relevance of this topic lies in the need to guarantee the quality and safety of nursing care in crisis situations, to promote critical reflection on the ethical challenges faced by nurses.

DEVELOPMENT Contextualizing the conflict
The emergence of the COVID-19 pandemic in Portugal marked an unprecedented moment in the country's history, triggering a series of challenges and significant changes in the daily lives of the Portuguese.
Vaccination has emerged as a promising way out of the global health and economic crisis.The rapid development of vaccines and the accelerated implementation of mass vaccination was unprecedented.This led nurses to experience a deep personal ethical conflict, torn between the duty to meet the vaccination targets set by the Health Authorities and the ethical responsibility to do the right thing.This generated feelings of frustration and impotence in the professionals, with an impact on the health and well-being of the users and themselves.
Ethical conflicts occur when, in certain situations, we must decide between our personal principles/values and collective interests or current norms.
Nurses' ethical conflicts during the pandemic were between the right and duty to act, judged from a moral point of view. (3)n the conflict-generating factor we want to analyze, the nurses who prepared the vaccines were not the same ones who administered them, and often it was others who recorded them.There were also situations in which post-vaccination surveillance was not even carried out by nurses, but by police officers and volunteers from local councils.
These ingredients were likely to undermine ethical principles and lead to situations of great suffering for the nurses.The imbalance between the ethics of making things happen and individual ethics led to unsolvable discomfort that the professionals had to overcome. (4)s a result, the nurses experienced internal conflicts caused by the lack of working conditions and the experience of ethical issues, a dichotomy between doing a greater good for public health, to the detriment of the feeling of individual duty. (5)hallenging fundamental principles of the profession, such as user autonomy, beneficence, non-maleficence and justice, as well as the right to care referred to in the profession's code of ethics: ensuring continuity of care, rigorously recording observations and interventions carried out, among others. (6)urses have shown themselves to be resilient, and their own resilience is a mechanism to help reduce the levels of anxiety, depression and burnout they are experiencing as a result of the pandemic.

Analysis of stakeholder diferences
By analyzing the differences between the stakeholders during the vaccination process, we can see that the nurses wanted to guarantee the safety and well-being of the users, providing individualized and quality care, based on the ethical principles of the profession.However, they were often pressured to comply with the guidelines of national and international health authorities, jeopardizing the fundamental principles mentioned Health Leadership and Quality of Life.2024; 3:.74 2 above.
The main objective of the Health Authorities, the Government and the Coordination of the Vaccination Campaign was to vaccinate as many people as possible in the shortest possible time in order to control the pandemic and reduce the impact on Public Health. (7)However, the pressure to meet targets, the lack of knowledge experienced, the emergency nature of the action, combined with the limited material and human resources, may have led to a neglect of the quality of care and patient safety.
The World Health Organization document (8) states that one of the principles to be considered in a mass vaccination campaign, which includes the one experienced in the COVID-19 context, is that these campaigns must be carried out in safe conditions, without undue harm to health professionals and the community; the capacity to implement a vaccination campaign must be assessed, seeking to adjust the adequacy of human resources.
It seems to us that it would have been essential to create an open and transparent dialogue between the stakeholders (Users, Health Professionals, Government/Health Authorities and the Coordination of the Vaccination Campaign), recognizing and valuing the role of nurses as essential health professionals, with the knowledge and experience to guarantee the safety and quality of the care provided; contributing positively to the preparation of the operational strategic plan against COVID-19.In short, understanding stakeholders helps mitigate risks.
The Government and the Coordination should have invested in human and material resources to ensure adequate working conditions, allowing nurses to provide more individualized and quality care, guaranteeing the ethical principles already described and consequently the safety and quality of vaccination in Portugal.
An analysis of the ethical and moral conflicts faced by Portuguese nurses during the COVID-19 vaccination reveals the complexity and challenges of professional practice in crisis situations.The lack of continuity of care by the same professional, the pressure to meet targets and the lack of resources have placed nurses in situations of intrapersonal conflict, compromising fundamental principles of the profession and the safety of users.
This reflection allows us to realize that a multifaceted approach is essential, involving strengthening ethical training, guaranteeing continuity of care, promoting dialogue between the different players and valuing the autonomy of the user.It is essential that nurses be recognized as essential health professionals, with the knowledge and experience to guarantee the safety and quality of the care provided.
The work carried out by nurses involves leadership and management skills. (5)Leineweber and collaborators, cited by Ferreira et al. (5) suggest that a good leader is essential for nurses' mental health, just as the proper implementation of policies and practices are essential for healthy coexistence between work and family.
It is essential to reflect on situations like this so that in the future the recommendations presented can guide nursing practice and the formulation of public health policies, with a view to improving the quality of care and preventing future ethical conflicts.
The effective implementation of deliberation as part of the working process of nurses and health teams would benefit from the support of management, since the deliberative process requires the desire of both parties to understand, cooperate and collaborate in decision-making, with argumentation and openness, in order to modify or broaden views and opinions.The various strategies for deliberation identified have stages in common: presenting the case, identifying the ethical problem, indicating the most appropriate solution for the case and decision making. (9,10)

Implications for practice and research
This reflection has direct implications for nursing practice, highlighting the need to: • Prioritize continuity of care and the nurse-patient therapeutic relationship.
• Reinforce the importance of ethical training for nurses to deal with ethical dilemmas in crisis situations.
• Promote communication and dialog between nurses, managers and health authorities.
• Valuing the autonomy of the user and guaranteeing their access to complete and personalized information.
• Continuously evaluate the safety of vaccination.
• Adjust the number of vaccination centers, considering decentralization in future pandemics.
We suggest future research: • Gain a deeper understanding of nurses' experiences and perspectives on the ethical conflicts experienced during pandemic vaccination.
• Assess the impact of the lack of continuity of care by the same nurse on adherence to vaccination, patient safety and satisfaction with nursing care.
• Analysis of vaccination policies and protocols in different contexts, identifying good practices and https://doi.org/10.56294/hl2024.74 3 Gama A, et al areas for improvement.
• Analysis of the occupational risks and psychological and psychosocial processes of nurses in these contexts.

FINAL CONSIDERATIONS
In short, the COVID-19 pandemic has proved to be a crucial moment of change and scientific advances, but also of reflection on changes that have arisen at a personal, family, professional and organizational level, making it essential to reflect on all the intrapersonal and interpersonal changes and conflicts that have emerged from it.
Managing conflicts between stakeholders requires a proactive and empathetic approach.Companies can navigate conflicts and maintain positive relationships by prioritizing effective communication, understanding different perspectives and seeking mutually beneficial solutions.