Patient participation: causing moral stress in psychiatric nursing?

Patient Participation in Mental Health Care - Perspectives of Healthcare Professionals and Patients: A Scoping Review

AIM

This scoping review aims to synthesize findings from fourteen selected articles to provide a comprehensive understanding of patient participation in mental healthcare.

METHOD

The review analyzed articles employing various qualitative methodologies, including interviews and observations, to explore patient and healthcare professional perspectives. Articles were selected based on their relevance to the topic of patient participation in mental health care.

RESULTS

The analysis revealed diverse perspectives on patient participation. Patients' preferences varied, with some preferring shared decision-making while others preferred minimal involvement. Barriers to shared decision-making included fear of judgment and substance misuse concerns. Strategies to manage disagreements and foster trusting relationships were identified. Challenges in implementing patient and public involvement in mental health services were noted, including stigma and inadequate professional training. Interprofessional collaboration was deemed fundamental, although fragmented care pathways and communication breakdowns persisted. Structural conditions and professional expectations significantly influenced patient participation, with a paternalistic approach perpetuating power imbalances.

CONCLUSION

Despite challenges, the findings underscored the importance of empowering patients in treatment decision-making, promoting collaborative relationships, and addressing barriers to enhance patient-centered care in mental health settings. Insights from this review contribute to the discourse on patient-centered care, emphasizing the need for holistic approaches prioritizing patient dignity and well-being.

Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography

The current research examines potentially morally injurious events (PMIEs) faced by healthcare professionals working in forensic and psychiatric environments. A systematic literature review was conducted to identify peer-reviewed articles reporting on sources of moral injury or similar concepts (e.g., moral distress) for healthcare workers in such settings. Thirty articles were included and analyzed using a meta-ethnographic approach. Synthesis yielded three third-order factors, each reflecting a moral dichotomy: (a) "between profession and system," (b) "between relations with patients and relations with others," and (c) "between principles and practices." Findings illustrated the hierarchical relationships between dichotomies, with discordance between values of the healthcare profession and features of the healthcare system providing the conditions for PMIEs to occur. The review advances conceptual understandings of PMIEs in forensic and psychiatric settings, illustrating the multilayered dimensions within which morally injurious events are experienced. Theoretical and practical implications are offered that may support the early detection and prevention of moral injury in healthcare professionals.

Challenges in using patient involvement principles in substance use treatment

BACKGROUND

Health professionals are responsible for implementing patient involvement (PI) in the choice of treatment approach. Previous studies within the field of substance use disorder (SUD) treatment have shown positive patient experiences with PI. However, little is known about challenges experienced by health professionals in converting principles of PI into clinical practice.

AIMS

To explore challenges with PI in the treatment of SUD.

METHOD

Five health professionals working in a Norwegian institution for inpatient treatment of SUD were included and took part in a semi-structured interview. Data were analysed using a systematic text condensation approach.

RESULTS

PI in SUD was perceived as challenging due to conceptual unclarities as well as treatment dilemmas that may challenge the notion of PI as a universal and unified ideological foundation of substance use treatment.

CONCLUSIONS

The findings point to a need to critically examine the PI concept and to take a flexible approach in adjusting PI principles to good clinical practice. A framework is launched, allowing the reported challenges in implementing PI in clinical practice to be accepted, acknowledged, and recognized by clinicians as well as by administrators and heads of clinical units.

A psychosocial exploration of resistances to service user involvement in United Kingdom National Health Service (NHS) mental health services

Policy promotes the active participation of those with lived experience of mental health difficulties in UK NHS mental health services, from the level of collaborative care-planning to service delivery, leadership and development. However, research indicates different forms of resistance to the implementation of such service user involvement. This article reports the findings of a qualitative, interview-based study which used Foucauldian discourse analysis and psychoanalytic theory to understand how resistances are produced through the interplay of clinical mental health professionals' subjectivity and their organisational context. Service user involvement was found to highlight conflicts within clinicians' roles. Central to this conflict was an ambivalent relationship to the power associated with these roles. Power could protect professionals from work related stresses, but could also be used to dominate, silence and coerce service users in ways that conflicted with the core function of providing care. Whilst important, raising awareness of such conflict will arouse discomfort and resistance where psychological defences are challenged. A parallel is drawn with psychotherapeutic change, in which resistance must be understood and worked with as part of meaningful change.

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.

How may cultural and political ideals cause moral distress in acute psychiatry? A qualitative study

BACKGROUND

There is growing public criticism of the use of restraints or coercion. Demands for strengthened patient participation and prevention of coercive measures in mental health care has become a priority for care professionals, researchers, and policymakers in Norway, as in many other countries. We have studied in what ways this current ideal of reducing the use of restraints or coercion and attempting to practice in a least restrictive manner may raise morals issues and create experiences of moral distress in nurses working in acute psychiatric contexts.

METHODS

Qualitative interview study, individual and focus group interviews, with altogether 30 nurses working in acute psychiatric wards in two mental health hospitals in Norway. Interviews were recorded and transcribed. A thematic analytic approach was chosen.

RESULTS

While nurses sense a strong expectation to minimise the use of restraints/coercion, patients on acute psychiatric wards are being increasingly ill with a greater tendency to violence. This creates moral doubt and dilemmas regarding how much nurses should endure on their own and their patients' behalf and may expose patients and healthcare personnel to greater risk of violence. Nurses worry that new legislation and ideals may prevent acutely mentally ill and vulnerable patients from receiving the treatment they need as well as their ability to create a psychological safe climate on the ward. Furthermore, persuading the patient to stay on the ward can cause guilt and uneasiness. Inadequate resources function as external constraints that may frustrate nurses from realising the treatment ideals set before them.

CONCLUSIONS

Mental health nurses working in acute psychiatric care are involved in a complex interplay between political and professional ideals to reduce the use of coercion while being responsible for the safety of both patients and staff as well as creating a therapeutic atmosphere. External constraints like inadequate resources may furthermore hinder the healthcare workers/nurses from realising the treatment ideals set before them. Caught in the middle nurses may experience moral distress that may lead to physical discomfort, uneasiness and feelings of guilt, shame, and defeat. Pressure on nurses and care providers to reduce or eliminate the use of coercion and reduction of health care spending are incompatible demands.

Analysis of influencing factors of nurse-patient disputes based on patient characteristics: A cross-sectional study

Aim

To explore the prevalence of nurse‐patient disputes and the influencing factors based on an analysis of patient characteristics.

Design

A cross‐sectional study.

Methods

This study used the convenience sampling method. Three self‐designed questionnaires based on clinical experience and literature review were used to collect the current status of nurse‐patient disputes and to assess patients’ humanistic qualities and patients’ recognition of nursing work. The Big Five personality questionnaire was used to assess the five personality traits of patients.

Results

Of the patients, 9.6% reported having a dispute with nurses. The results of binary logistic regression analysis indicated that patients’ humanistic quality, recognition of nursing work and agreeableness in personality traits had a negative predictive effect on nurse‐patient disputes, while family monthly income and neuroticism in personality traits positively predicted disputes.

Conceptualizing patient participation in psychiatry: A survey describing the voice of patients in outpatient care

Background

While increasingly discussed in somatic care, the concept of patient participation remains unsettled in psychiatric care, potentially impeding person‐centred experiences.

Objective

To describe outpatient psychiatric care patients’ conceptualization of patient participation.

Design

An exploratory survey.

Setting and participants

Patients in four psychiatric outpatient care units.

Variables

Patients conceptualized patient participation by completing a semi‐structured questionnaire, including optional attributes and free text. Data were analysed using statistics for ordinal data and content analysis for free text.

Results

In total, 137 patients (69% of potential respondents) completed the questionnaire. The discrete items were favoured for conceptualizing patient participation, indicating a primary connotation that participation means being listened to, being in a reciprocal dialogue, learning about one's health care and managing one's symptoms. Additional free‐text responses acknowledged the attributes previously recognized, and provided supplementary notions, including that patient participation is about mutual respect and shared trust.

Discussion

What patient participation is and how it can be facilitated needs to be agreed in order to enable preference‐based patient participation. Patients in outpatient psychiatric care conceptualize participation in terms of both sharing of and sharing in, including taking part in joint and solo activities, such as a reciprocal dialogue and managing symptoms by yourself.

Conclusion

While being a patient in psychiatric care has been associated with a lack of voice, an increased understanding of patient participation enables person‐centred care, with the benefits of collaboration, co‐production and enhanced quality of care.

Patient contribution

Patients provided their conceptualization of patient participation in accordance with their lived experience.

Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion

This discursive paper aims to clarify what roles mental health nurses identify as being within their scope of practice in clinical settings. It also aims to highlight any consumer benefits arising from these roles. Role theory and its relationship with identity are critically discussed as a framework to explain how contemporary mental health nursing roles are poorly understood and undervalued within mental health services. In order to meet the aims of the paper literature written in the last five years by clinical mental health nurses reporting their roles, and outcomes of those roles were searched. This literature was then considered through the lens of social constructionism that premises truths are accessed and then constructed though relationship based language. Six core mental health nursing roles were identified across international settings. The MHN is a psychotherapist. The MHN is a consumer advocate. The MHN is a physical health therapist. The MHN is a psycho-pharmacological therapist. The MHN is a relationship focussed therapist and finally the MHN is an aggression management therapist. While European and American nurses reported consumer benefit emerging from these roles those from Australia and the United Kingdom did not. The roles reported on were largely instrumental ones that offered little clarity towards the identity of our profession, nor its worth to consumers or funders of services. Mental health nurses will only have their true breadth of clinical capabilities recognized where there is a consistent construction emerging from clinicians in clinical settings on the efficacy of their clinical work.

More 'milk' than 'psychology or tablets': Mental health professionals' perspectives on the value of peer support workers

Background

Though growing numbers of peer support workers are employed in the UK National Health Service (NHS), conflicts persist between core values of peer support and values which exert power within these services.

Objectives

To explore what NHS mental health professionals value about the peer support worker role.

Design

Five professionals from different professions and mental health settings were interviewed twice. The first interviews explored their experiences of working with peers. Transcripts were analysed using discourse analysis and psychosocial theory. Second interviews allowed participants to respond to the analysis and influence subsequent analysis.

Results

Mental health professionals valued peers for the deeply empathic, relational approach they brought, based in their subjective experience. Peer work was also valued for the affect‐focused quality of this work, and the challenge peers pose to existing values in mental health services. The values of peer support troubled dominant ways of working based in forms of knowledge that favour objectivity and hence encountered challenges.

Conclusions

Peers fulfil the role of amplifying the status of diverse forms of knowledge, values and related ways of working that have become marginalized in NHS mental health services. It is important that peers are not seen as an isolated solution to the marginalization of these forms of knowledge and values, but that their way of working becomes reflected in other roles whilst evoking change throughout these services.

Patient or Public Contribution

Patient and Public Involvement groups were consulted both in the design and analysis stages of the study.

Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands

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.

Patient Participation in Nursing Care: Views From Ghanaian Nurses, Nursing Students, and Patients

Previous studies on patient participation reported inconclusive benefits of patient participation in health care. Consequently, the World Health Organization is actively highlighting the need for the participation of patients and their families in their care. The aim of this study was to explore the views of nurses, nursing students, and patients on patient participation in Ghanaian hospitals. Sixty-five participants made up of 15 patients, 25 registered general nurses, and 25 undergraduate nursing students were involved in the study. Data collection was done through interviews and focus group discussions. Content analysis was utilized in analyzing the data to generate four main categories. These categories were as follows: (a) meaning of patient participation in Ghana, (b) patient participation encouraged more during discharge education, (c) patient participation in nursing care higher in private and smaller hospitals, and (d) perceived facilitators and inhibitors of patient participation in nursing care. Participants in this study indicated that patient participation in nursing care meant involvement of patient in treatment decisions and nursing care procedures. Participants agreed that patient participation in nursing care was mostly encouraged during discharge education. Participation was perceived to be higher in private and smaller hospitals. Wealth and higher education were perceived as facilitators of patient participation while workload and high patient acuity were perceived as inhibitors.

Nurses experiences of ethical dilemmas: A review

BACKGROUND

Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today's hospital cultures. Nursing is rooted in a holistic approach with an ethical obligation to maintain and respect the individual's dignity and integrity. However, working within time limits and heavy workload leads to burnout and ethical insensitivity among nurses, and may challenge nurses' options to act on the basis of ethical and moral grounds in the individual care situation.

AIM

The aim of this study is to describe and discuss ethical dilemmas described and experienced by nurses in clinical practice today.

METHOD

The study was performed as a literature review following the matrix method allowing to synthesize literature across methodological approaches. A literature search was performed, including relevant studies published between 2011 and 2016. A total of 15 articles were included and analyzed focusing on their description of ethical dilemmas.

ETHICAL CONSIDERATION

We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources.

RESULTS

The analysis revealed three themes, relating to important aspects of nursing practice, such as the nurse-patient relationship, organizational structures, and collaboration with colleagues. The findings are summarized in the following three themes: (1) balancing harm and care, (2) work overload affecting quality, and (3) navigating in disagreement. Ethically difficult situations are evident across settings and in very diverse environments from neonatal care to caring for the older people. Organizational structures and being caught in-between professional values, standardization, and busyness was evident, revealing the complexity of nursing practice and the diversity of ethical dilemmas, concerns, and distress experienced by clinical nurses.

CONCLUSION

Nursing practice is challenged by organizational structures and the development of the health care system, inhibiting nurses' professional decision-making and forcing them to compromise basic nursing values.

Exploration of the Association between Nurses' Moral Distress and Secondary Traumatic Stress Syndrome: Implications for Patient Safety in Mental Health Services

Work-related moral distress (MD) and secondary traumatic stress syndrome (STSS) may be associated with compromised health status among health professionals, reduced productivity, and inadequate safety of care. We explored the association of MD with the severity of STSS symptoms, along with the mediating role of mental distress symptoms. Associations with emotional exhaustion and professional satisfaction were also assessed. This cross-sectional survey conducted in 206 mental health nurses (MHNs) was employed across public sector community and hospital settings in Cyprus. The analysis revealed that MD (measured by the modified Moral Distress Scale) was positively associated with both STSS (measured by the Secondary Traumatic Stress Scale) and mental distress symptoms (assessed by the General Health Questionnaire-28). The association of MD with STSS symptoms was partially mediated by mental distress symptoms. This association remained largely unchanged after adjusting for gender, age, education, rank, and intention to quit the job. Our findings provide preliminary evidence on the association between MD and STSS symptomatology in MHNs. Situations that may lead health professionals to be in moral distress seem to be mainly related to the work environment; thus interventions related to organizational empowerment of MHNs need to be developed.