Moral Distress in Psychiatric and Mental Health Nursing

Moral Distress in Psychiatric and Mental Health Nursing

Moral Distress in Psychiatric and Mental Health Nursing

Read the attached Article entitled “Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing”

Write a 2-page paper in which you do the following:

Summarize the moral/ethical issue in the article (no more than 1 paragraph).

Describe the moral and ethical dilemmas surrounding the issue.

Analyze the ethical issue and compare them to the state of Texas health laws and regulations.

Outline the process of ethical decision making you would use to address this ethical dilemma.

Review Article 227

http://www.jhealthres.org J Health Res ? vol.29 no.3 June 2015

ETHICAL ISSUES AND MORAL DISTRESS

IN PSYCHIATRIC AND MENTAL HEALTH NURSING:

A LITERATURE REVIEW

Ratchaneekorn Kertchok*

Faculty of Nursing, Chulalongkorn University, Bangkok 10330, Thailand

ABSTRACT:

This review focuses on ethical issues in psychiatric and mental health nursing and moral distress that occurs with psychiatric nurses. Literature published between 2000 and 2014 was identified using the

PubMed, CINAHL, ScienceDirect, and by hand search in the library before being analyzed under themes

related to ethical issues and moral distress in psychiatric and mental health nursing. A summary of the

existing literature related to challenges in psychiatric mental health nursing practiced; ethical issues in

psychiatric and mental health nursing; moral distress, its definition, associated situations and

consequences, and moral distress literature; and the findings need to be shared to increase awareness

of the moral distress experienced in psychiatric and mental health nursing. However, the related

literature does not address support strategies to help reduce moral stress. There is a growing need to

better understand moral distress in psychiatric mental health nursing in order to identify ways to

support encountered situations.

Keywords: Moral distress, Mental health, Nursing, Ethical issue

DOI: 10.14456/jhr.2015.10 Received: August 2014; Accepted: December 2014

INTRODUCTION

Mental illness is a significant problem across countries and worldwide. People with mental illness need to be treated and rehabbed by mental health professionals. It can be a challenge for these practitioners when providing care for people with mental illness. Mental illness is defined as “A diagnosable mental disorder that affects thinking, mood, behaviors, relationships with others, and ability to function”, (p 503)

[1] .

Psychiatric nurses are a group of mental health professionals who take actively important roles in providing care for people with mental illness [2]. Psychiatric nurses uphold nursing regulations/codes, ethics, and institutional rules that guide them in providing care for clients. They also need to work with multidisciplinary teams when caring for clients to achieve optimal health and well-being [3].

* Correspondence to: Ratchaneekorn Kertchok

E-mail: [email protected]

In the real world of psychiatric nursing practice, however, psychiatric nurses have to confront complex situations when caring for patients with severe mental illness at all stages (acute, sub-acute, and rehabilitation phase). They also have to deal with families who are suffering as they care for their ill family members [1, 3, 4]. In addition, they must often work under internal and external constraints. Consequently, psychiatric nurses may experience moral distress caused by caring for people with mental illness and helping their families. This article aims to share the descriptions of psychiatric and mental health nursing practice and moral distress.

SEARCH METHODS

Qualitative and quantitative studies and relevant literature were identified using the PubMed, CINAHL, ScienceDirect, and by hand search in the library. Key words that were used to search the literature are moral distress, ethical issue, moral dilemma, ethical problems, moral difficulties, moral stress and psychiatric nursing. The studies that related to ethical problems and moral distress in Cite this article as: Kertchok R. Ethical issues and moral distress in psychiatric and mental health nursing: a literature review.

J Health Res ? vol.29 no.3 June 2015 http://www.jhealthres.org

Table 1 Number of studies for review

Category Studies in total Studies that met criteria

1. Challenges in psychiatric and mental health nursing (Key words: Psychiatric nursing, mental health nursing practice, and challenge in mental health) 7,207 350

2. Ethical issues in psychiatric and mental health nursing (Keywords: Ethical problem, ethical difficulty, ethical issues, and psychiatric nursing)

2.1 Compulsory treatment

2.2 Institute constrains

2.3 Dealing with family’s need

2.4 Power imbalances among healthcare providers

2.5 Perceived inability to maintain safety

2.6 Conflict with patient’s needs

2.7 Lack of evidence based treatment

2.8 Time limitation

364 129

3. Moral distress (Key words: Moral distress, psychiatric nursing, moral stress, moral value, and moral conflict)

3.1 Situations associated with moral distress

3.2 Consequences of Moral

3.3 Distress

3.4 Experiencing moral distress in psychiatric and mental health nursing practice, including psychiatric and mental health nursing practice, were selected in order to analyze themes related to ethical issues and moral distress. The search was limited to material published from 2000 to 2014. The exception to this is the inclusion of four articles presenting classic ideas and concepts on psychiatric and mental health nursing and ethics. The articles obtained in full text were selected. Inclusion criteria of the studies for the review include: 1) studies were required to apply a qualitative or quantitative design; 2) studies were required to explain addressing of ethical issues in psychiatric and mental health nursing; 3) studies had investigated mental health nurses’ experience of moral distress; 4) studies had to be presented in English.

FINDINGS

In total, 536 articles that met the criteria were selected for review. The findings were organized into three major categories and eleven sub-categories. These categories and sub-categories are presented in Table 1.

CHALLENGES IN PSYCHIATRIC AND

MENTAL HEALTH NURSING

Challenges in psychiatric and mental health nursing are likely the same worldwide [1]. Psychiatric nurses have to encounter many challenges in their work [3]. In psychiatric and mental health nursing, psychiatric nurses have to face many different conditions and concerns. The conditions include maintenance of optimal health and well-being and prevention of physical and psychological illness; impaired self-care and functioning related to mental and emotional disturbances; deficits in functioning of cognitive, emotional, and biological systems; self-concept and lifestyle changes; emotional problems; physical symptoms that occur along with psychotic symptoms; suicide; stigma; illness crises; developmental problems; severe disability; and bizarre and violent patient behaviors and difficulties relating to others [1-5]. These conditions lead to difficulties in caring for patients. For example, Cutcliffe and Links [5] noted that when a patient wants to die or commit suicide, psychiatric nurses must decide how to respond.

They should show concern and uphold a person’s right to die, as wanting to die can be a reasonable thought, based on contemporary perspectives. Another example is when psychiatric patients display violent behaviors, but are unwilling to be separated and placed in a seclusion room or restrained. In such cases, psychiatric nurses should act according to nursing and legal regulations. Psychiatric nurses have to consider the situation on a legal right to privacy or proper supervision for violent behaviors, or both [6]. Furthermore, Fernandez and Leze [7] noted that nowadays there are many prisons with prisoners who have psychiatric disorders that need to receive psychiatric care. The nature of prisons involves conditions, rupture with the outside world, and adapting to a convict culture. This leads to difficulties in managing prisoners without proper access to treatment and an appropriate environment.

These researchers reported how a participant explained the difficulty as, “What are complicated are the serious cases of psychiatric disorder: psychotics, schizophrenics. It’s very difficult to talk about alcohol or drugs with someone who’s not necessarily in the same reality as you and the rest of the world…it’s difficult working with them because it’s hard to get them to shift mindset…” (p.1566). The researchers also reported that moral issues faced when providing care in prisons included helping patients to take responsibility for their actions and recognize their guilt as well as encouraging self-esteem when a patient is considering suicide and viewing the prison with a humanist perspective [7].

Moreover, psychiatric nurses have to deal with family members of psychiatric patients in mental healthcare. Weimand and her colleagues [8] found that a major responsibility of nurses in mental health service is supporting patients’ relatives. They also reported that most participants perceived that working with patients is routine, while supporting relatives is a challenge, because it can influence their work [8]. Similarly, a grounded theory study conducted by Kertchok, Yunibhand and Chaiyawat [9] reported that the role in providing care to psychiatric patients by Thai psychiatric nurses is helping the patients return to a normal life within their families by collaborating with family members. That means that the psychiatric nurses can provide quality nursing care to their clients and work with families in order to live together happily in a community. The researchers also suggest that to build participation in caring with family members is not easy; first, psychiatric nurses need to establish trust before moving forward to other steps such as strengthening connections, promoting readiness to care, and supporting care itself.

In addition, psychiatric nurses need to talk with family members several times about nursing activities until they understand and accept participating in caring for their patients. Other challenges should also be emphasized by mental health professionals, such as lack of interest in the field of nursing, lack of incentives for working in mental health nursing, stigma associated with caring for mental illness patients, insufficient nursing staff, lack of work safety and security, and inadequate training and support staff, particularly in community mental health service. For example, Strurm [10] conducted an ethnographic study of psychiatric community health nursing to explore ethical conflicts experienced by community health nurses. The researcher found that psychiatric community nurses have to provide care for persons with medical and psychiatric diagnoses, which can exhibit very complicated needs. One of their study’s participants explained that, “He is suffering from the patient who just was met for the first time. She/he does not know how to care for the patient who has B. P. problem. However, she/he knew that the patient had a normal B.P at that time”

This case indicates that nurses’ competency in providing high quality care is needed in community settings. The research also reported that some psychiatric nurses expressed that there is talk about related factors that influenced their providing care, such as insurance restrictions. The patients or relatives don’t want to pay more for completed treatments. The patients want to receive care only for their medical condition and not for emotional or psychotic symptoms. A consequence is that psychotic symptoms are escalating, which can be a challenge for psychiatric community nurses, who thus need greater support by improving holistic nursing care and other health resources. Another condition that can be found in psychiatric hospitals is inadequate psychiatric nursing staff. There is still the question, “What is enough?” Hanrahan [11] writes that serious mental illness and relapse rates are increasing. Psychiatric patients require psychiatric nurses experienced in observation and intervention to keep inpatient environments safe.

However, nursing staffs are still inadequate in psychiatric hospitals, which raises the risk of adverse outcomes. These challenges can be found mostly in low-middle income countries [1] [12]. Psychiatric nurses must face many challenges, and this is why mental health nursing has been recognized as a stressful career, in particular, caused by moral distress [13].

ETHICAL ISSUES IN PSYCHIATRIC AND

MENTAL HEALTH NURSING

Psychiatric and mental health nursing is a special area of nursing practice that focuses on the care and rehabilitation of people with mental and behavioral disorders [14]. Psychiatric nurses use the principles of human behavior to care for people with mental illness. The physiological, psychological, health ethics and social sciences are used to explore the needs of the clients and to take a holistic approach to care [2, 15]. Psychiatric nurses combine knowledge, experience, and skill for caring for those with mental illness in acute, sub-acute, and rehabilitation phases [6, 8, 16]. They also emphasize and play important roles to protect and enhance patients’ safety, self-care ability, social skills, decision-making, family participation, and compliance to treatments [17]. There are, however, situations that lead to ethical dilemmas and moral distress in psychiatric nursing, such as the following.

Compulsory treatment

In psychiatric nursing practice, psychiatric nurses work with patients who are suffering from psychotic symptoms. There are a variety of situations that lead to moral distress as they provide daily psychiatric nursing care, in particular, applying restraints, care for electro convulsive therapy (ECT), separating a patient into a seclusion room, participating in group therapy, admission, and medication [17, 18]. Psychiatric nurses acknowledge they must provide treatments or therapies, but at the same time, they must always show concern for a patient’s dignity and autonomy.

Sometimes, patients with severe psychotic symptoms will not comply with a request. The psychiatric nurse must then force the patient to receive their treatment. One study participant explained that they have experienced ethical dilemmas by disturbing patients’ privacy, such as a patient using the toilet. Consequently, nurses can feel anxiety, stress, and conflict about playing their role of compelling patients to follow treatments [6,18].

Institute constraints

In psychiatric nursing practice, psychiatric nurses are experiencing internal and external obstacles such as insufficient nursing staff, excessive workload, difficult working conditions, lack of supervision, and inadequate-service training [19]. This can force psychiatric nurses to confront ethical quandaries while caring for their patients [6,8, 16]. This research noted that all participants said that it was difficult to protect a patient’s privacy and maintain a safe environment because washrooms do not have door handles and shower stalls are glass, which may be dangerous for the patients [18, 19].

Dealing with families’ needs Psychiatric nurses are exposed to complex situations when dealing with family members who are directly or indirectly carrying burdens related to caring for psychotic patients [8]. They have to face difficulties such as relatives’ unfulfilled needs.

Weimand et al. [8] also reported that psychiatric nurses have positive relationships with patients and families, especially when the patients expressed their aggressive behaviors. They tried to encourage the families to have a positive attitude to the patient by telling them about psychotic symptoms that might occur at any time. The psychiatric nurses also helped the patients to get good response from their families. This is an ethical issue of caring for patients with mental illness, which can cause psychiatric nurses to experience moral distress [8, 20].

Power imbalance among healthcare providers

A qualitative study focused on investigating the moral distress of psychiatric nurses in acute care where they care for patients who struggle with severe psychiatric illness. Deady and McCarthy [21] found that an ethical dilemma that can lead to moral distress among psychiatric nurses is professional and legal conflict. The researchers reported that psychiatric nurses disagreed with the professional judgment of multidisciplinary teams. The psychiatric nurses felt that some physicians and other professionals used their power or status within mental health law over clinical decision-making, which is inappropriate for the patients.

Perceived inability to maintain safety

Safety is a complex concept, comprising physical, psychological and environmental safety, and psychiatric nurses must be equally concerned about patient and staff safety. Musto and Schreiber [20] studied moral distress in adolescent mental health nursing. They found that psychiatric nurses experienced moral distress because they perceived an inability to maintain the safety of adolescents suffering from mental illness. They felt that maintaining patient safety is an important responsibility, but there was only so much they could do. However, this study also found that psychiatric nurses tried to do the best for their patients, engage in dialogue and find the best resolutions to problems.

Conflict with patient’s needs

Another study reveals that psychiatric nurses faced an ethical quandary about controlling patients’ needs, in particular, sexual needs. The research reported that psychiatric nurses felt medical staff should be responsible for managing a patient’s sexual urges and problems [18 -20]. Lack of evidence based treatment

Quality of care is very important in psychiatric nursing. Psychiatric nurses must maintain a standard of care when caring for people with mental illness. However, Deady and McCarthy [18, 20, 21] reported that psychiatric nurses experienced moral distress because they felt that they were under-resourced and provided nursing care for the patients without evidence-based practice. They also noted that psychiatric nurses perceived that their patients should receive more effective treatments.

Time limitation

Sturm [10] conducted an ethnographic study on psychiatric community health nurses’ care to better understand their moral distress and ethical actions while providing care for patients. The purpose of this research was to explore, describe and document the practices of psychiatric community health nurses. Observation and telephone interviews were conducted to explore ethical practice of nine psychiatric community health nurses. One of the results reveals that seven nurses reported experiencing moral distress when they knew that they could give care to patients, but not provide it over an appropriate period of time.

In summary, these ethical issues in psychiatric and mental health nursing are so important that psychiatric nurses need to emphasize them using proper clinical judgment. The ethical issues, including compulsory treatments, institute constraints, families’ needs, power imbalance among health care providers, perceived inability to maintain safety, conflict with patients’ needs, lack of evidence based treatment, and time limitation may relate to a patient’s quality of life as well as moral distress among psychiatric nurses.

MORAL DISTRESS

Moral distress is an ethical problem that is a consequence of caring for people with health problems. It is recognized in healthcare professionals, in particular, nursing professionals in their nursing practice. Consequently, it is a significant nursing problem [22, 23]. Moral distress is an important phenomenon that needs to be explored to gain insight into what happens in order to discover ways to combat this phenomenon. Jameton [24] defined it as “When one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6).

Jameton [25] also divided moral distress into two types: initial distress and reactive moral distress. Initial distress involves “The feeling of frustration, anger, and anxiety people experience when faced with institutional obstacles and conflict with others about personal values. Reactive distress is the distress that people feel when they do not act upon their initial distress” (p.544).

In addition, Nathanial [26] defined moral distress as “The pain or anguish affecting the mind, body, or relationship in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action: yet, as a result of real or perceived constrains, participates in perceived moral wrong doing.” (p. 421)

For this article, moral distress refers to the anguish affecting the mind, body and relationship, including frustration, anger, anxiety, helplessness, despair, crying, loss of sleep, and loss of appetite of psychiatric nurses resulting from awareness of moral problems, acknowledgement of moral responsibility, and making a moral judgment to act, but without the ability to act as an advocate for their clients because of internal and external constraints [21, 26, 27].

Situations associated with moral distress

In nursing practice, nurses are facing a variety of moral quandaries every day that might be the result of influences of the growth of science, knowledge and more advanced high-technology treatments. Moral distress can be found in various situations of caring for patients with health problems [20, 21, 23, 25, 28-32]. The situations that lead to moral distress are: nursing care for patients who are in an end-of-life phase or caring for a hopelessly ill person; solving a family’s needs even though the actions could be detrimental for the patient or when in disagreement with a family’s perspective; knowing they should, but forced to because of hospital administration concerns about a lawsuit; carrying out a physician’s instructions even though they are inappropriate or aggressive treatments; trying to provide care for a patient to reduce pain, but unable to because of physician fears that increasing medicinal doses will cause death [22, 31-33]; receiving inadequate resources such as time, drugs, staff, equipment, and poor supervision [34]; dealing with family members who refuse to make a decision about a dying patient; working with low-qualified staff [22]; facing power imbalance among healthcare providers; requiring unnecessary tests and deception; [32] and caring for children with illness in a high-tech PICU [28]. According to the situations, healthcare providers need to understand moral distress and its causes to find ways to alleviate the situations.

Consequences of moral distress

Moral distress is a significant problem in nursing practice. Corley [35] found that the impacts associated with moral distress of nurses working in critical care can be divided into three categories: first, impact on nurses suffering from mental anguish and burn-out, so decide to leave nursing; second, impact on patients caused by lack of advocacy and appropriate care; and third, impact on an organization caused by high nurse turnover, difficulties in recruiting nurses, decreasing quality of care, low patient satisfaction, and reputation accreditation. These findings are consistent with those in a study by Burston and Tuckett [36] which stated that outcomes of moral distress in nursing can lead to negative aspects among nurses such as emotional exhaustion, a sense of powerlessness, becoming callous, bitter and cynical, avoiding patients, and avoiding conflicts. Consequently, moral distress can affect quality of care, patient satisfaction, and staff retention and shortages, all consistent with a study conducted by Nathaniel [26].

This study also reported that a consequence of moral distress is moving from the original workplace to another area. Moreover, Maluwa et al. [34] studied moral distress in nursing practice among 20 nurses in Lilongwe District of Malawi. The study showed that nurses who experienced moral distress faced physical and relationship impacts, including lack of sleep, physical pain (e.g., headache), lack of appetite, sadness, irritation, and anger toward family members. These studies provide some understanding about the consequences of moral distress in mostly general nursing practices.However, in psychiatric nursing, which differs from general nursing in nursing expertise and activities or interventions, moral distress consequences may differ. This is why the consequences of moral distress in psychiatric mental health nursing must be further explored.

Experiencing moral distress in psychiatric and mental health nursing

Few studies have examined moral distress among psychiatric nurses. Musto and Schreiber [20], in their study on moral distress in adolescent mental health nursing, focused on developing a substantive theory on mental health nurses’ behavior when they experience moral distress. The study revealed that twelve mental health nurses experiencing moral distress felt a lack of ability and uncertainty to maintain patients’ safety. Furthermore, Sturm, in his ethnographic study research that explored ethics and care among psychiatric community health nurses, found that seven nurses reported experiencing moral distress when they knew that they could give care to patients, but not over an appropriate period of time [10].

Later, they felt upset, stressed, in conflict with the situation, and frustration. These findings are consistent with studies conducted by Austin, Bergum and Goldberg [27] and Deady and McCarthy [21]. They used a hermeneutic phenomenological approach to explore the descriptions of mental health nurses’ experience of moral distress and found that mental health nurses experienced feelings of frustration, anger and sadness that they could not respond to patients’ needs, feelings of uncertainty, lack of safety, disrespect, and serious institutional constraints, which related to personal and professional distress as well as lack of connection with others, or loneliness. Moreover, Deady and McCarthy [21] found that coping strategies that psychiatric nurses used while experiencing moral distress include avoiding conflict, going along with cultural pressure, denying problems, refusing to work with colleagues, and changing jobs because of problems with peers, managers, supervisors, or counselors.

These studies reflect how health professionals experience moral distress, particularly psychiatric nurses who work with psychiatric patients and also dealing with patients’ family members. Still, the studies are few, and there is little literature on strategies or resources to provide support and reduce moral distress.

CONCLUSION

Psychiatric and mental health nursing is a nursing specialty that focuses on the care and rehabilitation of people with mental illness. Psychiatric nurses encounter many challenges during their work, in particular, ethical dilemmas. There are various situations that influence ethical quandaries and moral distress in mental health professionals such as psychiatric nurses [37-40]. There is still very little literature discussing the consequences of moral distress and how it can affect patients’ and their families’ satisfaction. As many nurses are now leaving this specialty because of the moral dilemmas and their effects, further studies on this subject are required to develop higher quality care for patients with mental illness and better assistance for their families, as well as enable psychiatric nurses to be more aware of the implications of their moral decisions and ethical actions. This article suggests that moral distress needs to be decreased by a holistic solution and should be considered in psychiatric and mental health nursing practice.

Moral Distress in Psychiatric and Mental Health Nursing

ACKNOWLEDGEMENTS

The author wishes to acknowledge Faculty of

Nursing, Chulalongkorn University, and Faculty of

Nursing, University of Alberta, for providing

support in time and material resources to conduct

this article.

CONFLICT OF INTEREST

The author would like to declare that there is no

conflict of interest in this study.

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