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.

Keywords

Moral dilemmas moral distress moral doubt psychiatric acute care psychiatric nursing

Introduction

All clinical nurses are confronted with multifaceted ethical dilemmas on a daily basis. However, psychiatric patients in acute care settings may be particularly vulnerable given their mental illness, which may cause patients to disagree with diagnosis and treatment; do self-harm and suicidal tendencies; have vague and varied understanding of the illness, coercive treatment, dilemmas re prioritising, patient participation, and conflicting interests with patients and relatives; and so on.^1

–4

Ideological and professional differences within the field may moreover lead to professional, ethical and personal dilemmas in the carer. Within Norwegian mental healthcare legislation, there is a strong focus on patient participation, patient dignity and minimal use of coercion. The latter issue is in line with European trends.⁵ Although Norway is a welfare state with free medical care, structural changes and economic restrictions combined with a growing criticism of treatment in mental care may cause pangs of conscience and moral distress among healthcare staff.

Jameton⁶ coined the term moral distress which he defined as negative feelings that arise ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’⁶ (p. 6). Wilkinson⁷ added internal constraints (as self-doubt, being socialised into following orders and lack of courage) as sources of moral distress. In line with other researchers,^8
–10 we find that in complex care settings, it may be difficult to know what the morally right course of action is.

Based on our empirical findings, we therefore will argue for a broader definition of the concept in which contexts where caregivers face moral dilemmas or experience moral doubt are included. Moral dilemmas make people feel morally compromised. However, non-persistent moral distress may at times be a wake-up call and cause ethical reflection and thus prevent moral blindness and be a reminder of moral obligations and keep us alert to moral dilemma contexts.^11,12 Lack of moral distress in morally challenging situations may be seen as problematic as it may signify a lack of moral ‘antennas’.

The existential basis for our discussion is the understanding that we have a moral responsibility when meeting the other person. According to Løgstrup,¹³ this is an ‘ethical demand which is given its content where one [person’s] life is entangled with another’s’ and one is ‘to care for the other’s life the way the entanglement dictates’ (p. 20). ‘A sense of responsibility animates ethics’ (p. 29, Hatab 1997 in Austin¹⁴).

Even episodes of mild distress may have adverse cumulative effect when occurring on a regular basis.⁸ Unresolved moral distress may lead to feelings of guilt, powerlessness, shame, despondency, anger, angst and self-criticism.^15,16 Nurses who experience moral distress tend to withdraw emotionally from patients¹⁷ and disconnect from themselves and others.¹² To frequently experience morally stressful situations may cause ‘moral residue’ resulting in increased levels of moral distress, the so-called crescendo effect.¹⁸ Common related physical symptomatology are headaches, stomach pain, sleeplessness, weight changes and palpitations.^16,19,20 Thus, moral distress is a significant cause of staff turnover^17,21,22 and burn-out^20,23 and, ultimately, is harmful to patients.²³

Main features distinguishing moral distress from other constructs, such as emotional distress, burn-out or post-traumatic stress, are the perceived violation of one’s professional integrity together with a feeling of personal core values and duties being violated.¹⁸

Although moral distress may strongly influence nurses within acute psychiatric care, an insider perspective on the moral challenges in psychiatric care and how nurses cope with these are insufficiently studied.^20,21,22,24 Existing studies mainly focus on nurses working within critical and acute somatic care.^9,21,22 Researchers have studied ethical challenges experienced in relation to coercion and forced medication,^1,25,26 but there is insufficient knowledge on broader ethical challenges experienced by clinicians in mental healthcare.²⁷

The number of interprofessional papers on moral distress in psychiatric care are sparse²⁸ and only few are written specifically within acute psychiatric nursing.^22,29 Our study focuses on nurses only.

This study is motivated by an uneasiness based on clinical experiences indicating that nurses may experience moral distress without recognising it. If unaware, we may fail to recognise underlying moral conflicts and the impact moral distress may have on patient care and on the individual nurse. Moral distress may cause even greater harm if not addressed.³⁰ In naming our experiences, we become more aware of them; what we can put into words, we are better able to act upon.³¹ This article’s aim is to describe sources of moral distress and what characterise moral distress in acute mental care nursing settings.

The research questions are as follows:

What sources of moral distress are found within psychiatric acute care settings?

What features of moral distress are expressed by nurses working within psychiatric acute care settings?

Research method

A qualitative design was chosen, with individual in-depth interviews. This to acquire insights into the interviewees’ subjective experiences, attitudes, thoughts and motives.^32,33 A purposive sampling strategy was used to identify potential participants in two mental health hospitals in southern Norway. Inclusion criteria: registered nurses with varied length of work experience in the field.

A total of 16 nurses were interviewed (Table 1), an adequate number to secure information power³⁴ as the interviewees all possessed the specific characteristics needed to answer the study’s research questions.

Table 1.

Background and number of nurse interviewees.

Years of psychiatric nurse experience	Number of nurses	Psychiatric specialists	Male nurses	Female nurses
0–5 years	2		1	1
5–10 years	6	4	2	4
10–15 years	2	2		2
15–20 years	2	2		2
20+ years	4	4		4

The interviews were audio recorded and transcribed verbatim. Interviewees were encouraged to share their thoughts and recount experiences. Follow-up questions and ‘mirroring’ of statements were used to develop, clarify and verify statements.

Literature searches

Repeated electronic searches were conducted with the assistant of an expert librarian through PubMed, CINAHL, PsycINFO, Oria and Google Scholar. The search terms were variations of the terms moral stress, moral distress, mental health, psychiatric care in general or mental health nursing, and psychiatric or mental health hospitals or units.

Data analysis

The analysis was thematic and hermeneutic in character where depth of understanding was attained through a circular investigation of the interviews and literature texts.³⁵ Braun and Clarke³⁶ define thematic analysis as ‘a method for identifying, analysing and reporting patterns (themes) within data’ (p. 79). Their six thematic analysis phases were used: (1) Familiarisation with the data sets, (2) Coding and (3) Collating codes into potential themes. Phases 4 (reviewing themes) and 5 (defining and naming themes) were done collaboratively by all authors. (6) The first author wrote a preliminary paper text which then was discussed and developed further collaboratively.

Rigour was obtained through four analysts. The researchers originated from different professional backgrounds, two with an insider view as psychiatric nurses with experience from acute settings and two from other fields of expertise, thus having little previous knowledge about the topic. This way the authors balanced each other and as a group avoided bias. This added value to the analysis.

Strengths and limitations

The majority of the interviewees were psychiatric nurse specialists with many years’ experience from acute psychiatric care. As participation was voluntary, we cannot say whether the views presented are representative for all nurses in the hospital units in question. Although our study is limited and local, we believe the insights offered are transferable to other acute care psychiatric nursing contexts and thus may help decrease the current paucity of knowledge within this field.

Ethical considerations

The study was approved by the Norwegian Social Science Data Services. All interviewees were informed orally and in writing that participation was confidential and voluntary and that they were free to withdraw from the project at any time. All signed an informed consent form.

Results

The interviewees faced complex moral dilemmas and situations which may cause moral distress. This matches the broadened definition of moral distress on which this study is based. The interviewees’ moral sensitivity seems to be both a premise for and cause of moral distress although they held divergent views and had different experiences of moral concerns. An interesting feature is how practical problems and institutional constraints created moral distress and at times also ethical dilemmas. Three main themes came to the fore: Experienced dilemmas between nurses’ perceptions of capacity and patients’ needs, risk of violence and dilemmas concerning coercion, and experienced physical and mental reactions to moral distress.

Experienced dilemmas between nurses’ perceptions of capacity and patients’ needs

Most of the interviewees found insufficient time a source of moral distress described as bad conscience and feelings of inadequacy and failing their patients:

Those who shout the highest demand the most attention…this makes for little time for for instance patients with schizophrenia with many negative symptoms, who hear voices and retreat to their room…these are the patients who particularly give me bad conscience. (I13)

One described how she when tired became distant and unable to have the patient participation she wanted. Reduced staffing, more patients and pressure for quicker discharges made it more difficult to assess the situation and meet the patients’ needs.

Time was described as essential for giving quality acute psychiatric care: time to reassure patients; to supervise secluded patients; and for therapeutic conversations, motivation, relationship building and clinical assessments. Potential suicide or self-harm were basic worries and were experienced as a great responsibility. Inadequate time for therapeutic conversations made the interviewees doubt the quality of their own assessments: ‘It doesn’t help much to check on someone sitting on her bed 20 times during a shift if you don’t have time to figure out what goes on inside her head’ (I6).

Untrained personnel and inadequate staffing made task delegation and follow-up of suicidal patients, patients in need of seclusion or with heightened risk of violence difficult. Untrained personnel may neither understand the gravity of situations nor feel the same kind of responsibility as the permanent staff:

I have seen patients under permanent watch where the personnel are sitting with the door slightly ajar focusing on their mobile phone, while the patients are in bed with the duvet over their heads. (I4)

Thus, working with untrained colleagues greatly increased the nurses’ responsibility and worry, a situation they had communicated to the leadership.

Many worried about being unable to sense changes in patients, to misconstrue signals or be inattentive or dismissive. Inadequate time for proper talks with patients during a watch, or to read the report or treatment plan, to go for walks with patients and so on created feelings of inadequacy, bad conscience and frustration.

Risk of violence and dilemmas concerning coercion

The interviewees found that patients tend to be more gravely ill with more use of synthetic drugs and lower threshold for physical violence than a few years ago. This is combined with fewer seclusion rooms and fewer staff. This made episodes of threats and violence more prolific:

It is very difficult, it is the patients’ safety and the staff’s safety, while there is a continuous pressure to use as little coercion as possible – that is perhaps our greatest moral dilemma. (I2)

Several interviewees had faced serious verbal and physical threats and been hit, kicked and clawed by patients. Some seemed to belittle such experiences as something they had to expect or get used to, while others found the burden of being afraid under-communicated. The interviewees tended to blame themselves after episodes of disruptive behaviour and wonder if they could have been prevented.

Sometimes it was difficult to know how to act towards boundary testing or violent patients as the current treatment philosophy is to let patients ‘defume’ to avoid coercive treatment. This created ethical dilemmas as it influenced negatively on co-patients and could cause discord and doubt among the staff. Even so, the nurses wanted to be courageous and not guided by fear. Being responsible for co-patients’ and colleagues’ safety could, however, be exhausting. The strain was exacerbated by a strict economic regimen and having to defend engaging extra staff when needed.

Coercive treatment was mainly characterised as necessary and a caring measure towards patients who suffered greatly, self-harmed or were threatening. Anti-psychotic medication was understood as an important part of treatment during acute psychiatric phases and as a necessary evil. Yet, the interviewees found it emotionally stressful to participate in coercive measures even when convinced that the patient needed the treatment, and draining to be on the receiving end of patients’ despair, anger and frustration in connection with treatment:

Coercive medical regimens when delusions are strong and patients suffer from side-effects, that is painful and stressful. (I6)

Although I deep inside perhaps understand that she had to have that medicine, it is abusive towards her when so many people enter…at times I find that some cases are doubtful. (I5)

Even so, doubts rarely made the interviewees refuse to participate in treatment. Loyalty and adherence to instructions were emphasised: ‘It is difficult to execute coercive [treatment measures] you do not agree with, but of course we do it…for me this is a moral dilemma’ (I2).

While some interviewees had qualms about participating in coercive treatment, others reflected that the responsibility lay with the physician and that they themselves only followed orders. One said that she still regretted not having refused to coercively administer medicines which she and others felt should have been postponed. However, she admitted that she probably still today would not have refused to follow doctor’s orders.

Use of coercion when the situation could have been otherwise solved if better staffed or the unit’s routines had been more focused on individual patients’ needs made the nurses uncomfortable. One related how he found it morally stressful when a patient who needed to be freed from straps was left too long due to the unit’s routines. The use of coercion was also difficult if disruptive behaviour was caused by a co-worker’s personality or communication style.

Refusing to limit patients’ autonomy was another factor causing moral distress as this could lead to patients disgracing themselves in social media and thus damage personal and work relationships. This placed the nurses squeezed between the patients’ wishes, their families’ worry and the doctors’ orders.

Decreased use of coercion is seen as strengthening patients’ dignity through fewer limitations and less control of patients. Morally challenging situations made the nurses reflect on their actions and choice of coping strategies, a mental activity they saw as important to counteract violation of their patients’ dignity when possible. One of the nurses said it was important to her to remain critical and not becoming institutionalised. Media’s increased criticism of psychiatric treatment was found to be an extra burden and harmful for families’ and patients’ trust in the treatment system.

Experienced physical and mental reactions to moral distress

Moral distress mainly seemed to have negative consequences both in the interviewees’ professional and private lives. Several had been – and still were – plagued by bad conscience and feelings of guilt, of being uncomfortable and doubting their own actions: ‘Sometimes I find it difficult to know if medicating is the right thing to do; I will probably never be able to be sure what is best. That is uncomfortable’ (I13).

Others described feelings of frustration, anger, sadness, inadequacy and loss of meaning. Some felt mentally tired, without initiative and wanting to pull away from social settings when off duty: ‘I create a kind of shield between me and my surrounding’ (I14). Several interviewees said they experienced emotional numbness and feeling fragmented. Others talked about being emotionally ‘flat’, cold and empty: ‘It is a little scary, really, that I am a little cold, am able to not think about it. How humane is one then, basically?’ (I13). Moral distress was also seen as causing high blood pressure and problems sleeping: ‘I have been on sick leave due to stress, got high blood pressure. I sometimes feel that I cannot breathe, that no-one listens’ (I4). Several had contemplated quitting their jobs, one was going to take a year off.

Discussion

In this study, moral distress is described in light of nurses’ experiences. Our results support the presupposition that moral distress is present in acute mental healthcare and indicate that moral distress may be caused by multiple events.

Moral distress due to insufficient recourses

Although inadequate resources are a known phenomenon in healthcare settings, how this leads to moral distress in acute psychiatric contexts is little described. Our findings indicate that inadequate time and competency may lead to superficial treatment, reduced follow-up of suicidal patients, more disruptive behaviour and use of coercion. These practical problems and institutional constraints create moral distress. These constraints may also lead to moral doubt and ethical dilemmas, which again creates moral distress.

Although nurses are responsible for the quality of their nursing care, our interviewees found they had little influence on decision-making and framework factors. This is an acknowledged source of moral distress.^17,23,37 An increasing patient population with graver illnesses in combination with budgetary cuts and diminishing resources also lead to moral distress through frustrating nurses from adhering to their professional and ethical convictions. Irish nurses in acute psychiatric units were found to experience moral distress when they believed that the standard of care was below their personal and professional criteria for best practice.²² Extensive use of auxiliary personnel forces nurses to spend their time keeping an eye on untrained co-workers rather than on patients which counteracts their utilising their professional competency.

As already indicated, lack of human and time resources is a root cause for moral distress in acute psychiatric nursing.^20,24 The consequences of inability to give patients the attention they need may be fatal as this is a high-risk patient group. The underlying risk of suicide and self-harm in patients may add to the nurses’ feelings of vulnerability, worry and guilt.

Creating a therapeutic nurse–patient relationship is the core element of psychiatric nursing.^24,38 However, Hummelvoll and Severinsson³⁹ found that ‘the acute and unpredictable character of the working situation in combination with short hospital stays result in a tentative and summary nursing care characterized by “therapeutic superficiality”’ (p. 17). This gives rise to stress in nurses as it ‘constitutes a hindrance to meeting the patient as a person’³⁹ (p. 17).

Hence, lack of time may result in the claims and wishes of patients who shout the highest and most clearly articulate their needs being given priority. So do patients who threaten or display disruptive behaviour. This may lead to other patients’ need of assurance and feeling safe being ignored, placing the nurses in a squeeze between their professional and humanistic ideal and the reality of clinical practice. Nurses work in close proximity to vulnerable patients. Proximity ethics helps us focus on the moral obligation and responsibility that is created in the meeting with the other person, an obligation which Løgstrup¹³ defined as a person’s ‘ethical demand’. Utility and efficacy considerations may lead to nurses having to compromise such demands.

With more human and general resources, many situations could have been otherwise resolved. The use of untrained staff and low staff ratio which gives little time for trained nurses to spend adequate time with patients might be factors in patients’ violent and aggressive behaviours.^40,41 However, the effect of inadequate resources seems to be underemphasised, which is in line with findings from a nursing home study.⁴²

Exposure to violence – a source of moral stress

Violent and disruptive behaviour are main causes of stress in acute psychiatric care, and exposure to violence can have an adverse effect on the psychological and physical health of staff.^40,43,44 Our study shows that coping with disruptive patients may be both a stress factor and a moral concern which may lead to moral distress. With the exception of a study on adolescent mental health nursing⁴⁵ that shows that actual or perceived inability to maintain safety may lead to moral distress, this is a point we have not found described elsewhere in a substantive way.

Psychiatric nursing’s ideals of assuring their patients, containing their own feelings and giving emotional support in the face of violence and manipulation are important to our interviewees. Violence and disruptive behaviour ‘adversely affect patient outcomes in that staff may be reluctant to engage with such individuals because of anxiety about being hurt or experiencing further intimidation’⁴⁰ (p. 40). A Canadian study⁴³ shows that violent patients may make healthcare personnel less empathetic and compassionate towards their patients, which goes against nurses’ caring ideals. After violent episodes, nurses may, as described by our interviewees, doubt their own care practice and question whether they could have acted differently and thus achieved a better outcome.

While our interviewees describe being responsible for colleagues’ and patients’ safety, they do not verbalise any such responsibility between themselves. The impression is that they see being brave, unafraid and uncowardly as moral qualities. Emotional dissonance is in itself a risk factor for developing health problems.⁴⁶

In addition to caring for everyone’s safety, the interviewees found a growing pressure to reduce the use of coercion and resources. Such incompatible demands may create moral distress. Thus, system-level responsibilities like political ideals and regulations become the individual healthcare workers’ responsibility.²

Doubt, loyalty and moral distress

As in other studies,^25,47 coercion in general is rarely mentioned as a moral challenge. This is in line with Molewjik et al.’s²⁶ findings that nurses were among the professions who found it least problematic to utilise coercive measures. Long years of experience within acute psychiatric care may partly explain their pragmatic attitude. Interviewees with more experience agreed that coercion can be seen as care and a safety measure.²⁶ In line with the study by Hem et al.,¹ our interviewees seemed to find coercion to be necessary and even as good care at times. However, coercion could create moral distress when deemed to be excessive or inappropriate. New kinds of ethical dilemmas in clinical practice, as when patients disgrace themselves in social medias, unclear boundaries and divergent practices among staff may also lead to moral distress.

Coercive administration of medicine is a source of moral doubt and distress among our interviewees. In spite of their doubts and the emotional stress from forcing medication on patients, refusal to administer treatment ordered by doctors is rare. This may spring from the nurses working within a biomedical understanding where medications harbour a central place. However, the nurses are participants in a culture increasingly criticised for coercive treatment regimens and for a traditional understanding of psychiatric illness. Hence, trends within the psychiatric nursing profession may contribute to doubts concerning best practice caused by the counter-reaction to one-sided emphasis on biomedical research and revitalisation of humanistic values.⁴⁸ The participation in the present treatment culture will probably be met with more questions and criticism in years to come, something which might become an added source of moral distress.

We find the way loyalty is accentuated by our interviewees interesting. The impression is that loyalty to doctors’ orders and to the ‘system’ is stronger than a regard for their own conscience and role as patient advocates, even when they disagree with the ideology the treatment represents.^2,49 We wonder whether this understanding of loyalty may cause moral distress.

Our interviewees hold that internal constraints as lack of energy and moral courage deter them from voicing their concerns. To experience lack of moral courage may also be part of moral distress. To question the treatment ordered or colleagues’ actions may moreover seem threatening by co-workers and, as an interviewee pointed out, be difficult in a treatment culture where everyone is dependent on each other. Staff members who actively try to influence decisions already made or the conduct of their colleagues are rare.⁴⁷ The need to fit in is strong as the consequences of not doing so result in professional isolation and further frustration.²²

Other interviewees seemingly placed the responsibility of coercive treatment on the doctors and viewed themselves as ‘only following orders’. One might query whether this is a coping mechanism to make oneself immune against moral conflicts? May loyalty in some shield them from moral distress, while blind loyalty in others may cause moral distress? In any case, a lack of responsibility and obligation would go against nurses’ professional and moral integrity, and being mentally present, empathetic and emotionally supportive are abilities needed when caring for gravely ill psychiatric patients.

The features of moral distress

Our analysis indicates that psychological and/or physical reactions to moral distress may lead to poorer quality nursing care, which again may lead to a bad conscience and moral distress. Conscience is closely related to moral distress and harm to moral integrity. ‘To have to deaden one’s conscience in order to keep working in healthcare are statistically significantly related to the risk of becoming burnt out’⁵⁰ (p. 25). However, our findings also indicate that our conscience may function as a safeguard as it motivates to ethical reflection and to disclose unethical practice, unsafe treatment and care, something which illustrates that some, non-persistent moral distress may also be valuable.

Sundin-Huard and Fahy⁵¹ found that nurses who experience moral distress and who attempt to be vulnerable patients’ advocates without success experienced intensified moral distress, frustration and anger. Moral distress may furthermore lead to desensitisation to the moral aspects of care.⁵² Hence, it is particularly problematic if moral distress results in nurses distancing and disconnecting from patients and themselves.¹² Interviewees’ references to feeling numb, emotionally ‘flat’, cold and fragmented may be understood as such reactions. Rushton¹⁶ holds that clinicians who experience ‘emotional disengagement, shutting down, numbing, and disconnecting’ (p. 37) carry unresolved moral distress.

To feel moral distress while being unable to put into words what causes these experiences may create an even stronger feeling of being uncomfortable and experiencing inadequacy. Our findings as well as those of other studies indicate that it can be difficult for nurses to verbalise their moral and ethical reflections.^1,42,47,53 Thus, detachment and physical moral distress ‘symptoms’ may be caused by inadequacy when it comes to express ones’ feeling in words.

Conclusion

Moral distress may be caused by a variety of reasons and lead to a variety of reactions. Multifaceted ethical dilemmas and close proximity to the patients’ suffering make acute psychiatric care nurses particularly exposed to moral distress as they find themselves squeezed between their patients’ needs, personal and professional standards, and loyalty to the ‘system’. They are furthermore exposed to violence, the use of coercion and insufficient recourses which make giving quality care difficult. Our findings indicate that also the provision of good care in the shadow of violence may lead to moral distress. Internal constrains as doubt, loyalty and lack of courage and energy to oppose the ‘system’ may stop nurses from voicing their moral concerns. Moral distress may lead to a positive awakening regarding moral dilemmas but may also cause bad conscience and frustration, anger, sadness, feelings of inadequacy, loss of meaning, mental tiredness, emotional numbness, sleeplessness and high blood pressure. This mélange of sources for moral distress are little described, and our study shows how important it is to do more research on this phenomenon in acute psychiatric contexts. It also shows the usefulness of the broadened and more robust understanding of the concept as used in this study.

This study’s empirical approach has given insights into relationships between and consequences of ethical challenges in acute psychiatric treatment as well as nurses’ experiences of internal and external constraints in clinical practice. These insights, which we find important to understand moral distress in acute psychiatric care, have not been previously described. Our findings indicate the importance of nurses listening to their moral disquiet and develop moral courage and a language for ethical discourse that may strengthen moral resilience and prevent moral distress.

Further research is needed on the broadened concept of moral distress presented in this study when experiencing moral dilemmas and moral doubt. As only 3 of the 16 interviewees were men, it may be interesting in a future study to look for gender difference where more male nurses are represented.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Trine-Lise Jansen

References

Hem

Molewijk

Pedersen

. Ethical challenges in connection with the use of coercion: a focus group study of health care personnel in mental health care. BMC Med Ethics 2014; 15: 82.

Jansen

Hanssen

. Patient participation: causing moral stress in psychiatric nursing? Scand J Caring Sci 2017; 3: 388–394.

Bigwood

Crowe

. ‘It’s part of my job, but it spoils the job’: a phenomenological study of physical restraint. Int J Ment Health Nurs 2008; 17: 215–222.

Kontio

Välimäki

Putkonen

, et al.

Patient restrictions: are there ethical alternatives to seclusion and restraint?

Nurs Ethics 2010; 17(1): 65–76.

Turnpenny

Petri

Finn

, et al. Mapping and understanding exclusion: institutional, coercive and community-based services across Europe (Project report). Brussels: Mental Health Europe, 2018.

Jameton

. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984.

Wilkinson

. Moral distress in nursing practice: experience and effect. Nurs Forum 1988; 23: 16–29.

Campell

Ulrich

Grady

. A broader understanding of moral distress. In: Ulrich

Grady

(eds), Moral distress in the health professions. Cham: Springer, 2018, pp. 59–77.

Morley

. What is ‘moral distress’ in nursing and how should we respond to it? PhD Thesis, The University of Bristol, Bristol, 2018.

10.

Johnstone

Hutchinson

. ‘Moral distress’: time to abandon a flawed nursing construct? Nurs Ethics 2015; 22(1): 5–14.

11.

Lützen

Kvist

. Moral distress: a comparative analysis of theoretical understandings and inter-related concepts. HEC Forum 2012; 24: 13–25.

12.

Hanna

. Moral distress: the state of the science. Res Theory Nurs Pract 2004; 18(1): 73–93.

13.

Løgstrup

. The ethical demand. Notre Dame, IN: University of Notre Dame Press, 1997, p. 20.

14.

Austin

. Moral distress and the contemporary plight of health professionals. HEC Forum 2012; 24: 27–38.

15.

Corley

. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650.

16.

Rushton

. Moral resilience: transforming moral suffering in healthcare. Oxford: Oxford University Press, 2018, p. 37.

17.

Huffman

Rittenmeyer

. How professional nurses working in hospital environments experience moral distress: a systematic review. Crit Care Nurs Clin North Am 2012; 24(1): 91–100.

18.

Epstein

Hamric

. Moral distress, moral residue, and the crescendo effect. J Clin Ethics 2009; 20(4): 330–342.

19.

De Villers

DeVon

. Moral distress and avoidance behavior in nurses working in critical care and noncritical care units. Nurs Ethics 2012; 20(5): 589–603.

20.

Delfrate

Ferrara

Spotti

, et al. Moral Distress (MD) and burnout in mental health nurses: a multicenter survey. Med Lav 2018; 109(2): 97–109.

21.

Lamiani

Borghi

Argentero

. When healthcare professionals cannot do the right thing: a systematic review of moral distress and its correlates. J Health Psychol 2017; 22(1): 51–67.

22.

Deady

McCarthy

. A study of situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress. Perspect Psychiatr Care 2010; 46(5): 209–220.

23.

McCarthy

Gastmans

. Moral distress: a review of the argument-based nursing ethics literature. Nurs Ethics 2015; 22(1): 131–152.

24.

Austin

Bergum

Goldberg

. Unable to answer the call of our patients: mental health nurses’ experience of moral distress. Nurs Inq 2003; 19(3): 177–183.

25.

Lind

Kaltiala-Heino

Suominen

, et al. Nurses’ ethical perception about coercion. J Psychiatr Ment Health Nurs 2004; 11(4): 379–385.

26.

Molewjik

Kok

Husum

, et al. Staff’s normative attitudes towards coercion: the role of moral doubt and professional context: a cross-sectional survey study. BMC Med Ethics 2017; 18: 37.

27.

Bruun

Lystbaek

Stenager

, et al. Ethical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010-2015: a qualitative content analyses. BMC Med Ethics 2018; 19(1): 62.

28.

Austin

Kagan

Rankel

, et al. The balancing act: psychiatrists’ experience of moral distress. Med Health Care Philos 2008; 11(1): 89–97.

29.

Lützen

Blom

Ewalds-Kvist

, et al. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics 2010; 17(2): 213–224.

30.

Howe

. Fourteen important concepts regarding moral distress. J Clin Ethics 2017; 28: 3–14.

31.

Van Manen

. Moral language and pedagogical experience. J Curriculum Stud 2000; 32(2): 315–327.

32.

Malterud

. Kvalitative forskningsmetoder for medisin og helsefag [Qualitative research in medicine and health professions]. 4.ed. Oslo: Universitetsforlaget, 2017.

33.

Brinkmann

Kvale

. InterViews. 3rd ed. Thousand Oaks, CA: SAGE, 2014.

34.

Malterud

Siersma

Guassora

. Sample size in qualitative interview studies: guided by information power. Qual Health Res 2016; 26(13): 1753–1760.

35.

Gadamer

. Truth and method. 2nd revised ed. London: Sheed and Ward, 1989.

36.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77–101.

37.

Epstein

Delgado

. Understanding and addressing moral distress. Online J Issues Nurs 2010; 15(3).

38.

Peplau

. Interpersonal relations in nursing. New York: Putnam, 1952 (Reissued by Macmillan, London, 1988).

39.

Hummelvoll

Severinsson

. Imperative ideals and the strenuous reality: focusing on acute psychiatry. J Psychiatr Ment Health Nurs 2001; 8: 17–24.

40.

Currid

. Experiences of stress among nurses in acute mental health settings. Nurs Stand 2009; 23(44): 40–46.

41.

Hylen

Engstrøm

, et al. Providing good care in the shadow of violence: an interview study in nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues Ment Health Nurs 2019; 40: 148–157.

42.

Gjerberg

Hem

Førde

, et al. How to avoid and prevent coercion in nursing homes: a qualitative study. Nurs Ethics 2013; 20(6): 632–644.

43.

Stevensson

Jack

O’Mara

, et al. Registered nurses’ experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study. BMC Nurs 2015; 14: 35.

44.

Baby

Glue

Carlyle

. ‘Violence is not part of our job’: a thematic analysis of psychiatric mental health nurses’ experiences of patient assaults from a New Zealand perspective. Issues Ment Health Nurs 2014; 35(9): 647–655.

45.

Musto

Schreiber

. Doing the best I can do: moral distress in adolescent mental health nursing. Issues Ment Health Nurs 2012; 33(3): 137–144.

46.

Indregard

Knardahl

Nielsen

. Emotional dissonance, mental health complaints, and sickness absence among health- and social workers. The moderating role of self-efficacy. Fronth Psychol 2018; 9: 592.

47.

Pelto-Piri

Engstrøm

. The ethical landscape of professional care in everyday practice as perceived by staff: a qualitative content analysis of ethical diaries written by staff in child and adolescent psychiatric in-patient care. Child Adolesc Psychiatry Ment Health 2012; 96(1): 18.

48.

Hummelvoll

Granerud

. Teoretiske og ideologiske innflytelser på utviklingen av psykiatrisk sykepleie etter 1960 – litteraturgjennomgang [Theoretical and ideological impacts on the development of psychiatric nursing after 1960 – a literature review]. Vård I Norden 2010; 4: 38–42.

49.

Kjølsrud

. Profesjonsetiske utfordringer i et helseforetak [Professional ethical challenges in healthcaresystems]. PhD Thesis, University of Agder, Kristiansand, 2013.

50.

Gustafsson

Eriksson

Strandberg

, et al. Burnout and the perceptions of conscience among health care personnel: a pilot study. Nurs Ethics 2010; 17(1): 23–38.

51.

Sundin-Huard

Fahy

. Moral distress, advocacy and burnout: theorizing the relationships. Int J Nurs Prac 1999; 5(1): 8–13.

52.

Hamric

. Empirical research on moral distress: issues, challenges and opportunities. HEC Forum 2012; 21: 39–49.

53.

Hanssen

. Facing differentness. Leipzig: Verlag Dr. Müller, 2010.