Analyzing an Ethical Decision
http://www.jhealthres.org J Health Res vol.29 no.3 June 2015
ETHICAL ISSUES AND MORAL DISTRESS
IN PSYCHIATRIC AND MENTAL HEALTH NURSING:
A LITERATURE REVIEW
Ratchaneekorn Kertchok*
Faculty of Nursing, Chulalongkorn University, Bangkok 10330, Thailand
ABSTRACT:
This review focuses on ethical issues in psychiatric and mental health nursing and moral distress that
occurs with psychiatric nurses. Literature published between 2000 and 2014 was identified using the
PubMed, CINAHL, ScienceDirect, and by hand search in the library before being analyzed under themes
related to ethical issues and moral distress in psychiatric and mental health nursing. A summary of the
existing literature related to challenges in psychiatric mental health nursing practiced; ethical issues in
psychiatric and mental health nursing; moral distress, its definition, associated situations and
consequences, and moral distress literature; and the findings need to be shared to increase awareness
of the moral distress experienced in psychiatric and mental health nursing. However, the related
literature does not address support strategies to help reduce moral stress. There is a growing need to
better understand moral distress in psychiatric mental health nursing in order to identify ways to
support encountered situations.
Keywords: Moral distress, Mental health, Nursing, Ethical issue
DOI: 10.14456/jhr.2015.10 Received: August 2014; Accepted: December 2014
INTRODUCTION
Mental illness is a significant problem across
countries and worldwide. People with mental illness
need to be treated and rehabbed by mental health
professionals. It can be a challenge for these
practitioners when providing care for people with
mental illness. Mental illness is defined as
“A diagnosable mental disorder that affects
thinking, mood, behaviors, relationships
with others, and ability to function”, (p 503)
[1] .
Psychiatric nurses are a group of mental health
professionals who take actively important roles in
providing care for people with mental illness [2].
Psychiatric nurses uphold nursing regulations/
codes, ethics, and institutional rules that guide them
in providing care for clients. They also need to work
with multidisciplinary teams when caring for clients
to achieve optimal health and well-being [3].
* Correspondence to: Ratchaneekorn Kertchok
E-mail: rkertchok@yahoo.com
In the real world of psychiatric nursing practice, however, psychiatric nurses have to confront
complex situations when caring for patients with
severe mental illness at all stages (acute, sub-acute,
and rehabilitation phase). They also have to deal
with families who are suffering as they care for
their ill family members [1, 3, 4]. In addition, they
must often work under internal and external
constraints. Consequently, psychiatric nurses may
experience moral distress caused by caring for
people with mental illness and helping their
families. This article aims to share the descriptions
of psychiatric and mental health nursing practice and
moral distress.
SEARCH METHODS
Qualitative and quantitative studies and
relevant literature were identified using the PubMed,
CINAHL, ScienceDirect, and by hand search in the
library. Key words that were used to search the
literature are moral distress, ethical issue, moral
dilemma, ethical problems, moral difficulties, moral
stress and psychiatric nursing. The studies that
related to ethical problems and moral distress in
Cite this article as: Kertchok R. Ethical issues and moral distress in psychiatric and mental health nursing: a
literature review. J Health Res. 2015; 29(3): 227-34.
228
J Health Res vol.29 no.3 June 2015 http://www.jhealthres.org
Table 1 Number of studies for review
Category Studies in total Studies that met
criteria
1. Challenges in psychiatric and mental health nursing (Key
words: Psychiatric nursing, mental health nursing practice,
and challenge in mental health)
7,207 350
2. Ethical issues in psychiatric and mental health nursing (Key
words: Ethical problem, ethical difficulty, ethical issues, and
psychiatric nursing)
2.1 Compulsory treatment
2.2 Institute constrains
2.3 Dealing with family’s need
2.4 Power imbalances among healthcare providers
2.5 Perceived inability to maintain safety
2.6 Conflict with patient’s needs
2.7 Lack of evidence based treatment
2.8 Time limitation
364 129
3. Moral distress (Key words: Moral distress, psychiatric nursing,
moral stress, moral value, and moral conflict)
3.1 Situations associated with moral distress
3.2 Consequences of Moral
3.3 Distress
3.4 Experiencing moral distress in psychiatric and mental
health nursing
1,827 57
nursing practice, including psychiatric and mental
health nursing practice, were selected in order to
analyze themes related to ethical issues and moral
distress. The search was limited to material
published from 2000 to 2014. The exception to this
is the inclusion of four articles presenting classic
ideas and concepts on psychiatric and mental health
nursing and ethics. The articles obtained in full text
were selected. Inclusion criteria of the studies for the
review include: 1) studies were required to apply a
qualitative or quantitative design; 2) studies were
required to explain addressing of ethical issues in
psychiatric and mental health nursing; 3) studies had
investigated mental health nurses’ experience of
moral distress; 4) studies had to be presented in
English.
FINDINGS
In total, 536 articles that met the criteria were
selected for review. The findings were organized
into three major categories and eleven sub-
categories. These categories and sub-categories are
presented in Table 1.
CHALLENGES IN PSYCHIATRIC AND
MENTAL HEALTH NURSING
Challenges in psychiatric and mental health
nursing are likely the same worldwide [1].
Psychiatric nurses have to encounter many
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