Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
Assignment Practicum: Week 1 Journal Entry – Analyzing an Ethical Decision
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.
Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay

Assignment Practicum: Week 1 Journal Entry – Analyzing an Ethical Decision
Review Article 227
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ETHICAL ISSUES AND MORAL DISTRESS
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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. Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay. 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 Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay.
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].  Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay.
 
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. Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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. 2015; 29(3): 227-34.
mailto:[email protected] Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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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 (Key
words: Ethical problem, ethical difficulty, ethical issues, and
psychiatric nursing)Assignment Practicum: Week 1 Journal Entry – Analyzing an Ethical Decision
2.1 Compulsory treatment Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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 Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
3.3 Distress
3.4 Experiencing moral distress in psychiatric and mental
health nursing
1,827 57
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 Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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. Assignment Practicum: Week 1 Journal Entry – Analyzing an Ethical Decision
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 Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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
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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 Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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, Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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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. Assignment Practicum: Week 1 Journal Entry – Analyzing an Ethical Decision Ethical Issues and Moral Distress in Psychiatric and Mental Health Nursing Essay
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