Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands

Abstract

Background: In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design: A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations: Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings: Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion: Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care

“…Participants who believed they worked in a toxic culture discussed being powerless to make changes, and focused on protecting themselves in what they viewed as a hostile environment, while maintaining as ethical a practice as possible. This finding mirrors other research on ethical decision‐making and working in a toxic environment (Jansen et al., 2020; Lützén & Schreiber, 1998; Pickering et al., 2017) and is congruent with research on the impact of austerity measures (Kerasidou & Cribb, 2019; Owens et al., 2019).…”

Coercion in psychiatric and mental health nursing: A conceptual analysis

“…2014), risk of suicide and self‐harm (Jansen et al . 2019; Perkins et al . 2012) and risk of escape from the unit or psychiatric facility (Efkemann et al .…”

“…Organizational factors contributing to a more coercive climate include lack of management support and leadership, institutional constraints, organizational policies that emphasize control and safety, work overload, and lack of time for nurses to intervene with patients on a regular basis (Jansen et al . 2019; Looi et al . 2014; Price et al .…”

“…On the other hand, nurses participating in a study conducted by Jansen et al . (2019) reported organizational pressure to reduce the use of coercive measures as much as possible, despite insufficient resources. Thus, there is a contradiction in the literature between (a) the presence of a coercive apparatus that legitimizes and promotes coercion in psychiatry and (b) organizational pressures on nurses and care providers to reduce or eliminate the use of coercion.…”

Nurses’ ethical challenges caring for people with COVID-19: A qualitative study

“… 6 Studies have shown that nurses are likely to face ethical challenges on multiple fronts in clinical practice. 7 …”