Abstract
Moral distress is a term that has dominated the health care literature for some time (Ohnishi et al., 2019). The common definition, by Ohnishi et al. (2019), occurs when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation” (p. 1473). In recent months, moral distress has been described within the context of acute care providers under extreme stress and strain precipitated by the coronavirus disease 2019 (COVID-19) pandemic (Čartolovni et al., 2021). Moral distress rises from moral sensitivity or the awareness of ethically conflictual situations.
In contrast is the term moral injury, which involves “a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty” (Čartolovni, 2021, p. 590). Shay (2011) identified components of moral injury that included a betrayal of “what is morally right” by someone who holds the legitimate authority in a high stakes situation (p. 183). There are suggestions that posttraumatic stress disorder, particularly in combat veterans, might be a manifestation of the more extreme moral injury (Bartzak, 2015).
While there is somewhat limited empirical evidence on the topic of moral injury as it pertains to populations other than combat veterans, research is emerging for this more severe manifestation of moral injury as a result of extreme demands on health care providers from the COVID-19 pandemic (Carmassi et al., 2020; Raudenská et al., 2020). This editorial will focus on psychiatric nurses and the related, less acute concept of moral distress as it predates the COVID-19 pandemic and chronically influences professional morale, nursing retention, and educational models.
Deady and McCarthy (2010) noted that health care providers frequently find themselves in situations in which they feel constrained while attempting to make the best ethical care choice or trying to advocate for patients. Being unable to act according to moral code can result in feelings of anger, frustration, and anxiety (Deady & McCarthy, 2010). The resulting powerlessness, guilt, self-criticism, and low self-esteem can lead to physical manifestations of moral distress, including sleep disturbances, crying, or loss of appetite. Peter and Liaschenki (2004) believe that nurses are particularly vulnerable to moral conflict because they are continually present during care conflicts and crises, unlike other health care professionals who might be initially involved in the process but then removed from the conflict, stepping away. Nurses often do not have that option.
Many situations describing moral conflicts have been in medical surgical environments, such as critical or acute care units. Few studies have identified the prevalence of moral distress in psychiatric nurses (Deady & McCarthy, 2010). Researchers who have looked at this have noted that in psychiatric nursing the practice of restraining patients, forcing medication, and coercion are, for some, conflictual (Fish & Culshaw, 2005). Konttila et al. (2021) noted that among nurses working in psychiatric settings exposure to violence is a strong predictor of well-being at work. This is linked to health care organization management and the ethical environment of the institution. These researchers strongly link moral distress to the ethical beliefs and practices of the health care environment where psychiatric nursing occurs (Konttila et al., 2021).
Deady and McCarthy (2010) confirmed that psychiatric nurses who participated in their qualitative research experienced moral distress. They found that this emerged from both internal and external sources, and they identified three predominant situations that gave rise to moral distress: professional and legal conflict, professional autonomy and scope of practice, and standards of care and client autonomy.
Within multidisciplinary teams, professional judgment or clinical decision-making conflicts led to moral distress (Deady & McCarthy, 2010). Nurses noted that those in charge often dismissed or chose not to address moral concerns related to patient care (Deady & McCarthy, 2010). Nurses struggled with sharing their professional disagreements around patient care with more powerful professionals who dismissed the concerns (Deady & McCarthy, 2010). This communication process requires a closer look, as the researchers suggested that moral distress resulted when nurses’ concerns or disagreements were dismissed by others in authority (Deady & McCarthy, 2010).
Professional autonomy and scope of practice issues were not conflictual if “restraint, forced medication, seclusion, or electroconvulsive therapy” were perceived as “prescribed by medical staff, legal, and applied appropriately” (Deady & McCarthy, 2010, p. 213). Research participants noted that using coercive practices when medical interventions were insufficient, late, or prescribed for nonmedical reasons tended to result in moral distress. Nurses believed that those in power were absent, and nurses were left with clinically deteriorating patients.
Challenging patient management issues involving standards of care and client autonomy can be stressful if it involves critiquing a peer’s practice. Observing a colleague’s lower standard of care and confronting this potentially results in moral conflict, given that such a challenge can precipitate isolation from the work group and other adverse results. Moral distress potentially evolves from lower standards of care, reflecting the problems of the broader system of care, including poor staffing or poor resources.
Deady and McCarthy (2010) described their participants as experiencing self-doubt, guilt, frustration, anger, and depression. Unease and anger were commonly experienced when “there was a lack of opportunity to discuss or resolve moral conflicts or concerns” (p. 215). These researchers noted that participants tended to “immunize” themselves to the moral conflict by adapting, denying, or changing jobs. Many used compartmentalizing as a strategy to get through the work day and distance from the problem.
Obviously, the qualitative results described in the Deady and McCarthy (2010) research are socially complex and culturally nuanced. Pachkowski (2018) advocated linking ethical competence and nursing education and emphasized that nurses who are experiencing more distress should be encouraged to process, evaluate, and understand the ethical dilemma causing the moral distress. Several researchers advocated for managers who valued discussing and addressing the moral conflicts that inevitably emerge in psychiatric nursing care (Deady & McCarthy, 2010; Pachkowski, 2018).
Quite simply, Ohnishi et al. (2019) noted that it is essential to remove communication or practice obstacles disruptive to ethical practice by changing the rules or the system to facilitate ethical practice. This recommendation has broad implications for a health care system that ideally values its nurses, helps them resolve conflicts of care, and creates an environment that consciously mitigates the risk of moral distress.