Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care.

AIM: To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD). DESIGN: Grounded theory, a qualitative methodology. METHODS: Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016. FINDINGS: The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity. CONCLUSION: Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care. IMPACT: Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.

Moving from conceptual ambiguity to knowledgeable action: using a critical realist approach to studying moral distress.

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature - and subsequently the health care ethics lexicon - in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques - critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of 'constraint' and 'agency'. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach.

Toward interventions to address moral distress: navigating structure and agency.

BACKGROUND: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. DISCUSSION: Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. CONCLUSION: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by-and influence-the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.

Doing the best I can do: moral distress in adolescent mental health nursing.

The purpose of this research was to explore the process used by mental health nurses working with adolescents to ameliorate the experience of moral distress. Using grounded theory methodology, a substantive theory was developed to explain the process. All the incidents that led to the experience of moral distress were related to safety and resulted in the nurses asking themselves the question, "Is this the best I can do?" Engaging in dialogue was the primary means nurses used to work through the experience of moral distress. Engaging in dialogue was an ongoing process, and nurses sought out dialogue with a variety of people as they tried to make sense of their experience. Participants identified qualities of dialogue that were helpful or unhelpful as they sought to resolve their moral distress. Participants who had a positive experience of dialogue were able to answer the "Is this the best I can do" question satisfactorily and continue working with adolescents with a renewed focus on the therapeutic relationship. Participants who had a negative experience of dialogue are unable to answer the question and either left the unit or agency or talked about leaving.