Responses and Results to Ethical Problems by Psychiatric Nurses in Japan

Moral distress among acute mental health nurses: A systematic review

Moral distress has been identified as an occupational hazard for clinicians caring for vulnerable populations. The aim of this systematic review was (i) to summarize the literature reporting on prevalence of, and factors related to, moral distress among nurses within acute mental health settings, and (ii) to examine the efficacy of interventions designed to address moral distress among nurses within this clinical setting. A comprehensive literature search was conducted in October 2022 utilizing Nursing & Allied Health, Embase, CINAHL, PsychInfo, and PubMed databases to identify eligible studies published in English from January 2000 to October 2022. Ten studies met inclusion criteria. Four quantitative studies assessed moral distress among nurses in acute mental health settings and examined relationships between moral distress and other psychological and work-related variables. Six qualitative studies explored the phenomenon of moral distress as experienced by nurses working in acute mental health settings. The quantitative studies assessed moral distress using the Moral Distress Scale for Psychiatric Nurses (MDS-P) or the Work-Related Moral Stress Questionnaire. These studies identified relationships between moral distress and emotional exhaustion, depersonalization, cynicism, poorer job satisfaction, less sense of coherence, poorer moral climate, and less experience of moral support. Qualitative studies revealed factors associated with moral distress, including lack of action, poor conduct by colleagues, time pressures, professional, policy and legal implications, aggression, and patient safety. No interventions targeting moral distress among nurses in acute mental health settings were identified. Overall, this review identified that moral distress is prevalent among nurses working in acute mental health settings and is associated with poorer outcomes for nurses, patients, and organizations. Research is urgently needed to develop and test evidence-based interventions to address moral distress among mental health nurses and to evaluate individual and system-level intervention effects on nurses, clinical care, and patient outcomes.

Psychiatric nurses' experience of moral distress: Its relationship with empowerment and coping

BACKGROUND

Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored.

RESEARCH AIM

The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses' experience of moral distress, and strategies for coping with moral distress.

RESEARCH DESIGN

A descriptive cross-sectional correlational study.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted.

ETHICAL CONSIDERATIONS

The study was approved by the institutional review board at the author's affiliated university.

FINDINGS

Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses' moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively.

CONCLUSIONS

In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance.

Moral injury and associated context, contributors and consequences within mental healthcare professionals: a scoping review

OBJECTIVES

We sought to examine the contributory factors as well as consequences of moral injury amongst healthcare workers within mental healthcare settings.

METHODS

Several databases were searched for relevant studies from database inception until May 2023. Keywords and concepts included moral injury and distress in mental healthcare and psychiatry. We identified 961 studies, of which 48 were assessed for eligibility. Eventually, 35 studies were included in the review. Papers were selected for inclusion if 1) they included mental healthcare professionals (MHP) regardless of practice setting, 2) moral injury as experienced by MHP was one of their main variables of interest, 3) were written in English. Year of publication, location of study, participant characteristics, study design, settings in which injury occur (context), factors contributing to moral injury (contributors), and its effects on MHP (consequences) were extracted from the studies.

RESULTS

The majority of studies were conducted in the West (n = 26, 74.3%). Contributors to moral injury were found at the individual (e.g. poor competence), practice setting (e.g. lack of resources), and organizational levels (e.g. inconsistent policies). Moral injury had negative repercussions for the individual (e.g. psychological and physical symptoms), healthcare teams (e.g. lack of trust and empathy), and healthcare system (e.g. staff attrition).

CONCLUSIONS

Seen through the moral habitability framework, interventions must include an acknowledgment of the influence of various factors on the ability of MHP to enact their moral agency, and seek to establish safe moral communities within a supportive moral climate.

Moral distress among critical care nurses: A cross-cultural comparison

BACKGROUND

Although, moral distress presents a serious problem among critical care nurses in many countries, limited research has been conducted on it. A validated scale has been developed to evaluate moral distress and has enabled cross-cultural comparison for seeking its root causes.

RESEARCH AIMS

This study aimed to (1) clarify the current status of moral distress among nurses who worked in critical care areas in Japan, (2) compare the moral distress levels among nurses in Japan with previously reported results from the United States (US), and (3) explore the factors associated with moral distress.

RESEARCH DESIGN

A nationwide cross-sectional study was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

We conducted a self-administered questionnaire survey using the Measure of Moral Distress-Healthcare Professionals (MMD-HP) among critical care nurses who were randomly selected from hospitals across Japan. The mean differences between the two countries were compared using a Student's t-test with summary statistics. The factors associated with higher levels of moral distress were examined using a multiple regression analysis.

ETHICAL CONSIDERATIONS

The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214 and M2019-045).

RESULTS

We obtained 955 valid responses from 94 facilities. In Japan, the items with the highest moral distress scores were those related to aggressive/inappropriate treatment. The total MMD-HP score was significantly higher in Japanese nurses compared to US nurses (122.8 ± 70.8 vs 112.3 ± 73.2). Some factors, such as leadership experience, were associated with higher moral distress.

DISCUSSION

The top root causes of moral distress were similar to potentially inappropriate treatments in both countries.

CONCLUSION

This study revealed the factors associated with higher moral distress and its characteristics in each country. These results can be used for reducing moral distress in the future.

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

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.

The role of online ethics consultation on mental health

BACKGROUND

Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice.

RESEARCH OBJECTIVE

To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness.

ETHICAL CONSIDERATIONS

The research was conducted in accordance with the Declaration of Helsinki.

RESEARCH DESIGN

This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan.

PARTICIPANTS

The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users.

FINDINGS

The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive.

DISCUSSION

The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants.

CONCLUSION

This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses' moral distress, building ethics into decision-making.