scholarly journals Coping with moral distress on acute psychiatric wards: A qualitative study

2021 ◽  
pp. 096973302110102
Author(s):  
Trine-Lise Jansen ◽  
Marit Helene Hem ◽  
Lars Johan Danbolt ◽  
Ingrid Hanssen

Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience.

2019 ◽  
Vol 27 (5) ◽  
pp. 1315-1326 ◽  
Author(s):  
Trine-Lise Jansen ◽  
Marit Helene Hem ◽  
Lars Johan Dambolt ◽  
Ingrid Hanssen

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.


2018 ◽  
Vol 28 (6) ◽  
pp. 900-915 ◽  
Author(s):  
Reidun Norvoll ◽  
Marit Helene Hem ◽  
Hilde Lindemann

Coercion in mental healthcare does not only affect the patient, but also the patient’s families. Using data from interviews with 36 family members of adult and adolescent people with mental health problems and coercion experiences, the present narrative study explores family members’ existential and moral dilemmas regarding coercion and the factors influencing these dilemmas. Four major themes are identified: the ambiguity of coercion; struggling to stay connected and establishing collaboration; worries and distress regarding compulsory care; and dilemmas regarding initiating coercion. Subsequently, coercion can reduce, but also add burden for the family by creating strains on family relations, dilemmas, (moral) distress, and retrospective regrets; this is reinforced by the lack of information or involvement and low-quality care. Subsequently, it is a moral obligation to develop more responsive health services and professionals who provide more guidance and balanced information to increase the possibilities for voluntary alternatives and informed decision making.


Sociology ◽  
2020 ◽  
Vol 54 (5) ◽  
pp. 920-935
Author(s):  
Gaja Maestri ◽  
Pierre Monforte

Since the ‘refugee crisis’ in 2015, civil society across Europe has participated in an unprecedented wave of support towards migrants. This article focuses on the volunteers engaged in this movement and explores how they relate emotions of compassion and evaluations about the ‘deservingness’ of refugees. We do so by analysing the moral dilemmas British volunteers face in their interaction with refugees, and the strategies they develop to avoid the difficulties that emerge when judging who the ‘deserving’ refugees are. We illustrate how these coping strategies lead them to emphasise the practicality of their role and to move beyond logics of deservingness. We argue that these dilemmatic situations reshape the meaning of compassionate acts in ambivalent ways: while reinforcing a tendency to create an emotional distance, they also allow volunteers to challenge idealised representations of refugees and foreground the political nature of their vulnerability.


2017 ◽  
Vol 26 (3) ◽  
pp. 646-662 ◽  
Author(s):  
Georgina Morley ◽  
Jonathan Ives ◽  
Caroline Bradbury-Jones ◽  
Fiona Irvine

Aims: The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. Background: Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. Design: Systematic literature review and narrative synthesis (November 2015–March 2016). Data sources: Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO® 1967–Present, CINAHL® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts. Review methods: Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. Results: In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. Conclusion: We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.


2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
E Arbag ◽  
M. Aluş Tokat ◽  
S Fata

Abstract Study question What are the emotions, thoughts and coping strategies of women with infertility problems on changes in treatment during the COVID-19 pandemic? Summary answer Treatment-related procedures keep changing directions, exposing the women to high level of uncertainty. Changes in treatments may be perceived as threats to achieving parenting goals. What is known already Both infertility and the treatment process constitute a stressful experience. Literature reports that couples describe infertility as the most difficult challenge to overcome in their lives. In addition, it has been reported that women experience more anxiety, stress, and depression than men during this period. Societies and individuals affected by large-scale disasters, such as global pandemics, can develop stress-related disorders. Current data indicate that closure of fertility clinic during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among patients undergoing fertility treatments and was perceived as an uncontrollable and stressful event. Study design, size, duration The research was designed as a qualitative study. The data were collected from two Internet forums between October - December 2020. Blogs most frequently used by women with infertility in Turkey were simultaneously selected. The comments of 30 women were included. Participants/materials, setting, methods Data were screened by using the directed qualitative content analysis. After selecting the blog, emotions, thoughts, and coping strategies expressed by 30 women whose treatment was canceled due to the Covid-19 pandemic or who continued treatment during this period were included in the analysis. The themes created were adapted to Lazarus and Folkman’s Transactional Model of Stress and Coping. Main results and the role of chance The thematic analysis of the expression of women with infertility problems in accordance with the Transactional Model of Stress and Coping stages of Lazarus and Folkman resulted in 4 themes: psychological changes, cognitive changes, changes in social life, and coping strategies. Some women perceived changes in treatments positively, and stopping the treatments due to the uncertainty of the pandemic and its effect on pregnancy and the baby made them feel safe. The majority of women appraised the closure of fertility clinics negatively impacted their lives. They experienced despair, uncertainty, disappointment, anxiety, anger, sadness, and exhaustion from waiting. Also, some participants did not find it right to delay the treatments and felt that the healthcare personnel postponed the treatments to avoid infection. Women experienced feelings of anger, distrust, and threats toward the health authorities. Moreover, the women in our study stated that they were always at home due to the pandemic, far from friends and family, and therefore did did not feel need for self-care and considered themselves ugly. The expressions of women mostly include emotion-based coping strategies. They used activities such as praying, exercising, distracting, noticing the positive side of postponing, and stopping treatments during the pandemic, accepting, and meditating. Limitations, reasons for caution Clinics closed due to the pandemic or limited procedures caused fewer women to come to the clinics. At the same time, it is not accepted for anyone other than working in the clinic to come to the clinics for scientific studies. Therefore, comments of women have been reached through blogs. Wider implications of the findings It is believed that approaches based on Lazarus and Folkman’s model helped the health professionals to determine potential stressors for women with infertility during the pandemic, and identified areas that required strengthening and improved personal coping strategies. Trial registration number not applicable


2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Mathilde Prezelin-Reydit ◽  
Abdallah Guerraoui ◽  
Thibault Dolley-Hitze ◽  
Benoît Vendrely ◽  
François Chantrel ◽  
...  

Abstract Background and Aims The health crisis linked to the COVID-19 epidemic has required lockdown measures in France and changes in practices in dialysis centers. The objective was to assess the depressive and anxiety symptoms during lockdown in hemodialysis patients and their caregivers, to assess their coping strategies during this period and to assess the symptoms of depression, anxiety and post traumatic stress beyond confinement. Method We sent, during lockdown period, between April and May 2020, self-questionnaires to voluntary subjects (patients and caregivers), treated by hemodialysis or who worked in hemodialysis in one of the 14 participating centers in France. We analyzed their perception of dialysis sessions (beneficial or worrying), their stress level (VAS rated from 0 to 10), their anxiety and depressive symptoms (HADS). Factors associated with stress, anxiety and depression were analyzed with multiple logistic regression models. We will look for associations between coping strategies, participant characteristics and symptoms of stress, anxiety and depression using chi-square tests. A second questionnaire was sent out in October to collect symptoms of depression, anxiety and post-traumatic stress beyond confinement. Symptoms will be described and factors associated with stress, anxiety and depression will be analyzed with multiple logistic regression models. Results 669 patients and 325 caregivers agreed to participate. 70% of participants found it beneficial to come to dialysis during confinement. The proportions of subjects with a stress level ≥ 6 linked to the epidemic, confinement, fear of contracting COVID-19 and fear of infecting a loved one were respectively 23.9%, 26.2%, 33.4% and 42%. 39.2% presented with certain (13.7%) or doubtful (19.2%) anxious symptoms. 21.2% presented a certain (7.9%) or doubtful (13.3%) depressive symptomatology. Age, gender, history of psychological disorders and perception of dialysis sessions were associated with levels of stress, anxiety and depression. 685 subjects participated in the second part of the study (68.9% of the participants of the first part). Analyzes of this data are in progress. Conclusion During the lockdown period, in France, the majority of hemodialysis patients and caregivers found it beneficial to come to dialysis. One in 3 subjects had anxiety symptoms and one in 5 subjects had depressive symptoms. It will be interesting to investigate if there was an association between the coping strategies implemented by the participants and their level of stress, anxiety and depression during confinement and to analyze the evolution of the anxiety-depressive symptoms over time.


2019 ◽  
Vol 104 (7) ◽  
pp. e2.47-e2
Author(s):  
Nicola Wilson ◽  
Elaine Liston ◽  
Lauren Williams

SituationA five week old infant admitted to a tertiary paediatric hospital with coryzal symptoms on a background of Edwards Syndrome (Trisomy 18) and congenital cardiac disease. Despite her grave prognosis, she was intubated and ventilated. She spent many months in hospital, eventually having surgical repair of her cardiac defect which had little or no effect on her clinical condition. She was discharged to a children’s hospice after seven months in our hospital (with short periods at home and her local hospital), at the age of eight months, for end of life care. As pharmacists actively involved in her care, but with limited input to her ethical situation, we suffered moral distress.BackgroundEdwards Syndrome is a rare genetic condition which occurs in 1 in 5000 live births. Infants are severely disabled. Accurate figures for miscarried or terminated pregnancies are not available. Only 8% of babies survive beyond one year unless they have a less severe form (mosaic or partial).1 Our patient had a post-natal diagnosis and her parents were determined that she be given every opportunity that would be offered to a non-Edwards child. We are three pharmacists who work in paediatric intensive care and paediatric cardiology. We were actively involved in the care of this patient and her family for several months. Although we work closely with the multidisciplinary team, we were not included in discussions about appropriateness of interventions. We were however, expected to speak to her parents about medicines on a regular basis, including during a very difficult and prolonged wean of sedation which was causing physical distress to the patient and her parents.OutcomeBeing involved in interventions which are unlikely to improve or extend a patient’s life is difficult, but especially so when you have had little or no influence on the original decision. The eventual outcome was exactly as predicted on admission: she was discharged to a hospice and expected to deteriorate slowly. Her discharge was written by one of the PICU pharmacists and her parents were counselled by another, so we were involved until the end of her admission.DiscussionAs a pharmacy team, we only have each other to talk to: our distress cannot compare to that of medical or nursing staff who are more closely involved in the patient. We are limited in what we can discuss outside of work due to patient confidentiality. With the relatively recent introduction of pharmacist independent prescribing in our PICU and cardiology wards, we are often asked to prescribe outwith our comfort zone and are able to refuse. As our prescribing roles become more embedded, our comfort zone will expand and we will be expected to prescribe in morally ambiguous situations such as this one. Studies have shown that community pharmacists are prone to moral distress,2 as they work in a highly regulated profession and their actions are often bound by laws and contracts over which they have little control, and in hospital we suffer the same fate.3ReferencesWu J, Springett A, Morris JK. Survival of trisomy 18 (Edwards syndrome) and trisomy 13 (Patau Syndrome) in England and Wales: 2004–2011. Am J Med Genet Part A 2013;161A:2512–2518.Astbury JL, Gallagher CT, O’Neill RC. The issue of moral distress in community pharmacy practice: background and research agenda. International Journal of Pharmacy Practice 2015;23(5);361–6.Prentice T, Janvier A, Gillam L, et al. Moral distress within neonatal and paediatric intensive care units: a systematic review. Archives of Disease in Childhood 2016;1012(8):701–8.


2017 ◽  
Vol 26 (1) ◽  
pp. 201-211 ◽  
Author(s):  
Ellen Ramvi ◽  
Venke Irene Ueland

Background: For the experience of end-of-life care to be ‘good’ many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse–next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient. Research problem: From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care? Research design: A critical qualitative approach was used, based on four focus group interviews. Participants: A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated. Ethical considerations: The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began. Findings and discussion: Two descriptive themes emerged from the inductive analysis: ‘A feeling of mistrust, control and rejection’ and ‘Being between hope and denial of next of kin and the desire of the patient to die when the time is up’. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses’ moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones. Conclusion: There is complex moral distress related to the nurse–next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care.


2019 ◽  
Vol 27 (5) ◽  
pp. 1297-1314 ◽  
Author(s):  
Georgina Morley ◽  
Caroline Bradbury-Jones ◽  
Jonathan Ives

Background The phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice. Research aim To explore the concept of moral distress in nursing both empirically and conceptually. Methodology Feminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis. Ethical considerations The study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom. Findings The empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas. Discussion We suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress. Conclusion The empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’.


PMLA ◽  
1984 ◽  
Vol 99 (1) ◽  
pp. 72-88 ◽  
Author(s):  
June Perry Levine

The posthumous homosexual fiction of E. M. Forster indicates a marked impulse in all his work: the tame in pursuit of the savage. The connection is to be, in part, emotional but will have political meaning as well. In Forster's situations, power—which resides in the world of the tame—is suspect because it rests on institutionalized force; in contrast, the sexual potency of the savage arises out of his being a “natural” man in the Rousseauean sense. This tension parallels the dynamics of Forster's private life, but its manifestation in his art does not simply reflect a personal preoccupation: the literature of attempted liaison with the savage serves a public position—egalitarian, anti-imperialistic, and internationalist—as well as a romantic ideal. In Maurice, in “The Life to Come” and “The Other Boat,” and even in his first three novels, the sexual and political ideas reflect the intention, albeit somewhat disguised, to subvert the prevailing ethos.


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