道德困扰和精神科护理

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Moral distress is a term that has dominated the health care literature for some time (Ohnishi et al., 2019). The common definition, by Ohnishi et al. (2019), occurs when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation” (p. 1473). In recent months, moral distress has been described within the context of acute care providers under extreme stress and strain precipitated by the coronavirus disease 2019 (COVID-19) pandemic (Čartolovni et al., 2021). Moral distress rises from moral sensitivity or the awareness of ethically conflictual situations.

In contrast is the term moral injury, which involves “a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty” (Čartolovni, 2021, p. 590). Shay (2011) identified components of moral injury that included a betrayal of “what is morally right” by someone who holds the legitimate authority in a high stakes situation (p. 183). There are suggestions that posttraumatic stress disorder, particularly in combat veterans, might be a manifestation of the more extreme moral injury (Bartzak, 2015).

While there is somewhat limited empirical evidence on the topic of moral injury as it pertains to populations other than combat veterans, research is emerging for this more severe manifestation of moral injury as a result of extreme demands on health care providers from the COVID-19 pandemic (Carmassi et al., 2020; Raudenská et al., 2020). This editorial will focus on psychiatric nurses and the related, less acute concept of moral distress as it predates the COVID-19 pandemic and chronically influences professional morale, nursing retention, and educational models.

Deady and McCarthy (2010) noted that health care providers frequently find themselves in situations in which they feel constrained while attempting to make the best ethical care choice or trying to advocate for patients. Being unable to act according to moral code can result in feelings of anger, frustration, and anxiety (Deady & McCarthy, 2010). The resulting powerlessness, guilt, self-criticism, and low self-esteem can lead to physical manifestations of moral distress, including sleep disturbances, crying, or loss of appetite. Peter and Liaschenki (2004) believe that nurses are particularly vulnerable to moral conflict because they are continually present during care conflicts and crises, unlike other health care professionals who might be initially involved in the process but then removed from the conflict, stepping away. Nurses often do not have that option.

Many situations describing moral conflicts have been in medical surgical environments, such as critical or acute care units. Few studies have identified the prevalence of moral distress in psychiatric nurses (Deady & McCarthy, 2010). Researchers who have looked at this have noted that in psychiatric nursing the practice of restraining patients, forcing medication, and coercion are, for some, conflictual (Fish & Culshaw, 2005). Konttila et al. (2021) noted that among nurses working in psychiatric settings exposure to violence is a strong predictor of well-being at work. This is linked to health care organization management and the ethical environment of the institution. These researchers strongly link moral distress to the ethical beliefs and practices of the health care environment where psychiatric nursing occurs (Konttila et al., 2021).

Deady and McCarthy (2010) confirmed that psychiatric nurses who participated in their qualitative research experienced moral distress. They found that this emerged from both internal and external sources, and they identified three predominant situations that gave rise to moral distress: professional and legal conflict, professional autonomy and scope of practice, and standards of care and client autonomy.

Within multidisciplinary teams, professional judgment or clinical decision-making conflicts led to moral distress (Deady & McCarthy, 2010). Nurses noted that those in charge often dismissed or chose not to address moral concerns related to patient care (Deady & McCarthy, 2010). Nurses struggled with sharing their professional disagreements around patient care with more powerful professionals who dismissed the concerns (Deady & McCarthy, 2010). This communication process requires a closer look, as the researchers suggested that moral distress resulted when nurses’ concerns or disagreements were dismissed by others in authority (Deady & McCarthy, 2010).

Professional autonomy and scope of practice issues were not conflictual if “restraint, forced medication, seclusion, or electroconvulsive therapy” were perceived as “prescribed by medical staff, legal, and applied appropriately” (Deady & McCarthy, 2010, p. 213). Research participants noted that using coercive practices when medical interventions were insufficient, late, or prescribed for nonmedical reasons tended to result in moral distress. Nurses believed that those in power were absent, and nurses were left with clinically deteriorating patients.

Challenging patient management issues involving standards of care and client autonomy can be stressful if it involves critiquing a peer’s practice. Observing a colleague’s lower standard of care and confronting this potentially results in moral conflict, given that such a challenge can precipitate isolation from the work group and other adverse results. Moral distress potentially evolves from lower standards of care, reflecting the problems of the broader system of care, including poor staffing or poor resources.

Deady and McCarthy (2010) described their participants as experiencing self-doubt, guilt, frustration, anger, and depression. Unease and anger were commonly experienced when “there was a lack of opportunity to discuss or resolve moral conflicts or concerns” (p. 215). These researchers noted that participants tended to “immunize” themselves to the moral conflict by adapting, denying, or changing jobs. Many used compartmentalizing as a strategy to get through the work day and distance from the problem.

Obviously, the qualitative results described in the Deady and McCarthy (2010) research are socially complex and culturally nuanced. Pachkowski (2018) advocated linking ethical competence and nursing education and emphasized that nurses who are experiencing more distress should be encouraged to process, evaluate, and understand the ethical dilemma causing the moral distress. Several researchers advocated for managers who valued discussing and addressing the moral conflicts that inevitably emerge in psychiatric nursing care (Deady & McCarthy, 2010; Pachkowski, 2018).

Quite simply, Ohnishi et al. (2019) noted that it is essential to remove communication or practice obstacles disruptive to ethical practice by changing the rules or the system to facilitate ethical practice. This recommendation has broad implications for a health care system that ideally values its nurses, helps them resolve conflicts of care, and creates an environment that consciously mitigates the risk of moral distress.

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道德困扰是一段时间以来一直主导医疗保健文献的术语（Ohnishi 等人，2019 年）。Ohnishi 等人的通用定义。(2019)，发生在“一个人知道该做什么是正确的事情，但制度限制使得几乎不可能采取正确的行动方针。发现道德困境会导致负面情绪、倦怠和/或辞职”（第 1473 页）。最近几个月，在 2019 年冠状病毒病 (COVID-19) 大流行（Čartolovni 等人，2021 年）引发的极端压力和压力下，急性护理提供者的道德困境有所描述。道德困境源于道德敏感性或对道德冲突情况的认识。

与之相反的是“道德伤害”一词，它涉及“深刻的情感创伤，对于那些见证人类强烈痛苦和残忍的人来说是独一无二的”（Čartolovni，2021，第 590 页）。Shay (2011)确定了道德伤害的组成部分，其中包括在高风险情况下拥有合法权威的人背叛“道德上正确的东西”（第 183 页）。有人建议，创伤后应激障碍，特别是在战斗退伍军人中，可能是更极端的道德伤害的表现（Bartzak，2015）。

虽然关于道德伤害主题的经验证据有限，因为它与退伍军人以外的人群有关，但由于 COVID-19 大流行对医疗保健提供者的极端需求，正在研究这种更严重的道德伤害表现（Carmassi 等人，2020年；Raudenská 等人，2020 年）。这篇社论将重点关注精神科护士和相关的、不那么尖锐的道德困境概念，因为它早于 COVID-19 大流行，并长期影响职业士气、护理保留和教育模式。

Deady 和 McCarthy (2010)指出，医疗保健提供者经常发现自己在尝试做出最佳道德护理选择或试图为患者辩护时感到受限。无法按照道德准则行事会导致愤怒、沮丧和焦虑的感觉（Deady & McCarthy，2010 年）。由此产生的无力感、内疚感、自我批评和低自尊会导致道德困扰的身体表现，包括睡眠障碍、哭泣或食欲不振。彼得和利亚申基 (2004)相信护士特别容易受到道德冲突的影响，因为他们在护理冲突和危机期间不断出现，不像其他卫生保健专业人员可能最初参与该过程，但随后从冲突中移开，走开。护士通常没有这种选择。

许多描述道德冲突的情况都出现在医疗外科环境中，例如重症监护室或急诊室。很少有研究确定精神科护士普遍存在道德困扰（Deady & McCarthy，2010 年）。研究过这一点的研究人员注意到，在精神科护理中，约束患者、强迫用药和胁迫的做法对某些人来说是相互冲突的（Fish & Culshaw，2005 年）。康蒂拉等人。(2021)注意到在精神病院工作的护士中，接触暴力是工作幸福感的一个强有力的预测因素。这与医疗保健组织管理和机构的道德环境有关。这些研究人员将道德困扰与精神科护理发生的医疗保健环境的道德信念和实践紧密联系起来（Konttila 等人，2021 年）。

Deady 和 McCarthy (2010)证实，参与定性研究的精神科护士经历了道德困扰。他们发现这来自内部和外部来源，他们确定了导致道德困扰的三种主要情况：专业和法律冲突、专业自主和实践范围，以及护理标准和客户自主。

在多学科团队中，专业判断或临床决策冲突导致道德困扰（Deady & McCarthy，2010 年）。护士指出，负责人经常解雇或选择不解决与患者护理相关的道德问题（Deady & McCarthy，2010 年）。护士们努力与更强大的专业人士分享他们在患者护理方面的专业分歧，而这些专业人士忽视了这些问题（Deady & McCarthy，2010 年）。这种沟通过程需要仔细观察，因为研究人员认为，当护士的担忧或分歧被其他权威人士驳回时，会导致道德困扰（Deady & McCarthy，2010 年）。

如果“约束、强制用药、隔离或电休克疗法”被视为“由医务人员开具处方、合法且应用适当”，则专业自主权和执业范围问题不会发生冲突（Deady & McCarthy，2010 年，第 213 页）。研究参与者指出，当医疗干预不充分、迟到或因非医疗原因开出处方时，使用强制措施往往会导致道德困扰。护士们认为当权者缺席，护士留下了临床恶化的病人。

如果涉及批评同行的做法，则涉及护理标准和客户自主权的具有挑战性的患者管理问题可能会带来压力。观察同事的低标准照料并正视这一点可能会导致道德冲突，因为这样的挑战可能会导致与工作组的隔离和其他不利结果。道德困境可能源于较低的护理标准，反映了更广泛的护理系统的问题，包括人员配备不足或资源不足。

Deady 和 McCarthy (2010)将他们的参与者描述为经历自我怀疑、内疚、沮丧、愤怒和抑郁。当“缺乏讨论或解决道德冲突或疑虑的机会”（第 215 页）时，通常会感到不安和愤怒。这些研究人员指出，参与者倾向于通过适应、拒绝或更换工作来“免疫”道德冲突。许多人使用划分作为一种策略来度过工作日并远离问题。

显然，Deady 和 McCarthy (2010)研究中描述的定性结果具有社会复杂性和文化细微差别。Pachkowski (2018)主张将伦理能力和护理教育联系起来，并强调应该鼓励经历更多痛苦的护士处理、评估和理解导致道德痛苦的伦理困境。一些研究人员提倡重视讨论和解决精神科护理中不可避免地出现的道德冲突的管理者（Deady & McCarthy，2010 年；Pachkowski，2018 年）。

很简单，Ohnishi 等人。(2019)指出，必须通过改变规则或制度来促进道德实践，消除破坏道德实践的沟通或实践障碍。该建议对于理想地重视护士、帮助他们解决护理冲突并创造有意识地减轻道德困扰风险的环境的医疗保健系统具有广泛意义。

原文链接：

https://doi.org/10.1177/10783903211051998

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