Analyzing an Ethical Decision.

Review Article 227 J Health Res  vol.29 no.3 June 2015




Ratchaneekorn Kertchok*

Faculty of Nursing, Chulalongkorn University, Bangkok 10330, Thailand


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


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: [email protected]

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.


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.mailto:[email protected]


J Health Res  vol.29 no.3 June 2015

Table 1 Number of studies for review

Category Studies in total Studies that met


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



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 are likely the same worldwide [1].

Psychiatric nurses have to encounter many

challenges in their work [3]. In psychiatric and

mental health nursing, psychiatric nurses have to

face many different conditions and concerns. The

conditions include maintenance of optimal health

and well-being and prevention of physical and

psychological illness; impaired self-care and

functioning related to mental and emotional

disturbances; deficits in functioning of cognitive,

emotional, and biological systems; self-concept and

lifestyle changes; emotional problems; physical

symptoms that occur along with psychotic

symptoms; suicide; stigma; illness crises;

developmental problems; severe disability; and

bizarre and violent patient behaviors and difficulties

relating to others [1-5]. These conditions lead to

difficulties in caring for patients. For example,

Cutcliffe and Links [5] noted that when a patient

wants to die or commit suicide, psychiatric nurses

must decide how to respond. They should show

concern and uphold a person’s right to die, as

wanting to die can be a reasonable thought, based on

contemporary perspectives. Another example is

when psychiatric patients display violent behaviors,

but are unwilling to be separated and placed in a

seclusion room or restrained. In such cases,

psychiatric nurses should act according to nursing

and legal regulations. Psychiatric nurses have to

consider the situation on a legal right to privacy or

proper supervision for violent behaviors, or both [6].

Furthermore, Fernandez and Leze [7] noted that

nowadays there are many prisons with prisoners

who have psychiatric disorders that need to receive

psychiatric care. The nature of prisons involves

229 J Health Res  vol.29 no.3 June 2015

conditions, rupture with the outside world, and

adapting to a convict culture. This leads to

difficulties in managing prisoners without proper

access to treatment and an appropriate environment.

These researchers reported how a participant

explained the difficulty as,

“What are complicated are the serious cases

of psychiatric disorder: psychotics,

schizophrenics. It’s very difficult to talk

about alcohol or drugs with someone who’s

not necessarily in the same reality as you and

the rest of the world…it’s difficult working

with them because it’s hard to get them to

shift mindset…” (p.1566).

The researchers also reported that moral issues

faced when providing care in prisons included

helping patients to take responsibility for their

actions and recognize their guilt as well as

encouraging self-esteem when a patient is

considering suicide and viewing the prison with a

humanist perspective [7].

Moreover, psychiatric nurses have to deal with

family members of psychiatric patients in mental

healthcare. Weimand and her colleagues [8] found

that a major responsibility of nurses in mental health

service is supporting patients’ relatives. They also

reported that most participants perceived that

working with patients is routine, while supporting

relatives is a challenge, because it can influence their

work [8]. Similarly, a grounded theory study

conducted by Kertchok, Yunibhand and Chaiyawat

[9] reported that the role in providing care to

psychiatric patients by Thai psychiatric nurses is

helping the patients return to a normal life within

their families by collaborating with family members.

That means that the psychiatric nurses can provide

quality nursing care to their clients and work with

families in order to live together happily in a

community. The researchers also suggest that to

build participation in caring with family members is

not easy; first, psychiatric nurses need to establish

trust before moving forward to other steps such as

strengthening connections, promoting readiness to

care, and supporting care itself. In addition,

psychiatric nurses need to talk with family members

several times about nursing activities until they

understand and accept participating in caring for

their patients.

Other challenges should also be emphasized by

mental health professionals, such as lack of interest

in the field of nursing, lack of incentives for working

in mental health nursing, stigma associated with

caring for mental illness patients, insufficient

nursing staff, lack of work safety and security, and

inadequate training and support staff, particularly in

community mental health service. For example,

Strurm [10] conducted an ethnographic study of

psychiatric community health nursing to explore

ethical conflicts experienced by community health

nurses. The researcher found that psychiatric

community nurses have to provide care for persons

with medical and psychiatric diagnoses, which can

exhibit very complicated needs. One of their study’s

participants explained that,

“He is suffering from the patient who just

was met for the first time. She/he does not

know how to care for the patient who has B.

P. problem. However, she/he knew that the

patient had a normal B.P at that time”

This case indicates that nurses’ competency in

providing high quality care is needed in community

settings. The research also reported that some

psychiatric nurses expressed that there is talk about

related factors that influenced their providing care,

such as insurance restrictions. The patients or

relatives don’t want to pay more for completed

treatments. The patients want to receive care only

for their medical condition and not for emotional

or psychotic symptoms. A consequence is that

psychotic symptoms are escalating, which can be a

challenge for psychiatric community nurses, who

thus need greater support by improving holistic

nursing care and other health resources. Another

condition that can be found in psychiatric hospitals

is inadequate psychiatric nursing staff. There is still

the question, “What is enough?” Hanrahan [11]

writes that serious mental illness and relapse rates

are increasing. Psychiatric patients require

psychiatric nurses experienced in observation and

intervention to keep inpatient environments safe.

However, nursing staffs are still inadequate in

psychiatric hospitals, which raises the risk of

adverse outcomes. These challenges can be found

mostly in low-middle income countries [1] [12].

Psychiatric nurses must face many challenges, and

this is why mental health nursing has been

recognized as a stressful career, in particular,

caused by moral distress [13].



Psychiatric and mental health nursing is a

special area of nursing practice that focuses on the

care and rehabilitation of people with mental and

behavioral disorders [14]. Psychiatric nurses use the

principles of human behavior to care for people with

mental illness. The physiological, psychological,


J Health Res  vol.29 no.3 June 2015

health ethics and social sciences are used to explore

the needs of the clients and to take a holistic

approach to care [2, 15]. Psychiatric nurses combine

knowledge, experience, and skill for caring for those

with mental illness in acute, sub-acute, and

rehabilitation phases [6, 8, 16]. They also emphasize

and play important roles to protect and enhance

patients’ safety, self-care ability, social skills,

decision-making, family participation, and

compliance to treatments [17]. There are, however,

situations that lead to ethical dilemmas and moral

distress in psychiatric nursing, such as the following.

Compulsory treatment

In psychiatric nursing practice, psychiatric

nurses work with patients who are suffering from

psychotic symptoms. There are a variety of

situations that lead to moral distress as they provide

daily psychiatric nursing care, in particular,

applying restraints, care for electro convulsive

therapy (ECT), separating a patient into a seclusion

room, participating in group therapy, admission, and

medication [17, 18]. Psychiatric nurses

acknowledge they must provide treatments or

therapies, but at the same time, they must always

show concern for a patient’s dignity and autonomy.

Sometimes, patients with severe psychotic

symptoms will not comply with a request. The

psychiatric nurse must then force the patient to

receive their treatment. One study participant

explained that they have experienced ethical

dilemmas by disturbing patients’ privacy, such as a

patient using the toilet. Consequently, nurses can

feel anxiety, stress, and conflict about playing their

role of compelling patients to follow treatments [6,


Institute constraints

In psychiatric nursing practice, psychiatric

nurses are experiencing internal and external

obstacles such as insufficient nursing staff,

excessive workload, difficult working conditions,

lack of supervision, and inadequate-service training

[19]. This can force psychiatric nurses to confront

ethical quandaries while caring for their patients [6,

8, 16]. This research noted that all participants said

that it was difficult to protect a patient’s privacy and

maintain a safe environment because washrooms do

not have door handles and shower stalls are glass,

which may be dangerous for the patients [18, 19].

Dealing with families’ needs

Psychiatric nurses are exposed to complex

situations when dealing with family members who are

directly or indirectly carrying burdens related to

caring for psychotic patients [8]. They have to face

difficulties such as relatives’ unfulfilled needs.

Weimand et al. [8] also reported that psychiatric

nurses have positive relationships with patients and

families, especially when the patients expressed their

aggressive behaviors. They tried to encourage the

families to have a positive attitude to the patient by

telling them about psychotic symptoms that might

occur at any time. The psychiatric nurses also helped

the patients to get good response from their families.

This is an ethical issue of caring for patients with

mental illness, which can cause psychiatric nurses to

experience moral distress [8, 20].

Power imbalance among healthcare providers

A qualitative study focused on investigating the

moral distress of psychiatric nurses in acute care

where they care for patients who struggle with

severe psychiatric illness. Deady and McCarthy [21]

found that an ethical dilemma that can lead to moral

distress among psychiatric nurses is professional

and legal conflict. The researchers reported that

psychiatric nurses disagreed with the professional

judgment of multidisciplinary teams. The

psychiatric nurses felt that some physicians and

other professionals used their power or status within

mental health law over clinical decision-making,

which is inappropriate for the patients.

Perceived inability to maintain safety

Safety is a complex concept, comprising

physical, psychological and environmental safety,

and psychiatric nurses must be equally concerned

about patient and staff safety. Musto and Schreiber

[20] studied moral distress in adolescent mental

health nursing. They found that psychiatric nurses

experienced moral distress because they perceived

an inability to maintain the safety of adolescents

suffering from mental illness. They felt that

maintaining patient safety is an important

responsibility, but there was only so much they

could do. However, this study also found that

psychiatric nurses tried to do the best for their

patients, engage in dialogue and find the best

resolutions to problems.

Conflict with patient’s needs

Another study reveals that psychiatric nurses

faced an ethical quandary about controlling patients’

needs, in particular, sexual needs. The research

reported that psychiatric nurses felt medical staff

should be responsible for managing a patient’s

sexual urges and problems [18 -20].

Lack of evidence based treatment

Quality of care is very important in psychiatric

nursing. Psychiatric nurses must maintain a standard

of care when caring for people with mental illness.

231 J Health Res  vol.29 no.3 June 2015

However, Deady and McCarthy [18, 20, 21]

reported that psychiatric nurses experienced moral

distress because they felt that they were under-

resourced and provided nursing care for the patients

without evidence-based practice. They also noted

that psychiatric nurses perceived that their patients

should receive more effective treatments.

Time limitation

Sturm [10] conducted an ethnographic study on

psychiatric community health nurses’ care to better

understand their moral distress and ethical actions

while providing care for patients. The purpose of

this research was to explore, describe and document

the practices of psychiatric community health

nurses. Observation and telephone interviews were

conducted to explore ethical practice of nine

psychiatric community health nurses. One of the

results reveals that seven nurses reported

experiencing moral distress when they knew that

they could give care to patients, but not provide it

over an appropriate period of time.

In summary, these ethical issues in psychiatric

and mental health nursing are so important that

psychiatric nurses need to emphasize them using

proper clinical judgment. The ethical issues,

including compulsory treatments, institute

constraints, families’ needs, power imbalance

among health care providers, perceived inability to

maintain safety, conflict with patients’ needs, lack

of evidence based treatment, and time limitation

may relate to a patient’s quality of life as well as

moral distress among psychiatric nurses.


Moral distress is an ethical problem that is a

consequence of caring for people with health

problems. It is recognized in healthcare

professionals, in particular, nursing professionals in

their nursing practice. Consequently, it is a

significant nursing problem [22, 23]. Moral distress

is an important phenomenon that needs to be

explored to gain insight into what happens in order

to discover ways to combat this phenomenon.

Jameton [24] defined it as

“When one knows the right thing to do, but

institutional constraints make it nearly

impossible to pursue the right course of

action” (p. 6).

Jameton [25] also divided moral distress into

two types: initial distress and reactive moral distress.

Initial distress involves

“The feeling of frustration, anger, and

anxiety people experience when faced with

institutional obstacles and conflict with

others about personal values. Reactive

distress is the distress that people feel when

they do not act upon their initial distress”


In addition, Nathanial [26] defined moral

distress as

“The pain or anguish affecting the mind,

body, or relationship in response to a

situation in which the person is aware of a

moral problem, acknowledges moral

responsibility, and makes a moral judgment

about the correct action: yet, as a result of

real or perceived constrains, participates in

perceived moral wrong doing.” (p. 421)

For this article, moral distress refers to the

anguish affecting the mind, body and relationship,

including frustration, anger, anxiety, helplessness,

despair, crying, loss of sleep, and loss of appetite of

psychiatric nurses resulting from awareness of

moral problems, acknowledgement of moral

responsibility, and making a moral judgment to act,

but without the ability to act as an advocate for their

clients because of internal and external constraints

[21, 26, 27].

Situations associated with moral distress

In nursing practice, nurses are facing a variety

of moral quandaries every day that might be the

result of influences of the growth of science,

knowledge and more advanced high-technology

treatments. Moral distress can be found in various

situations of caring for patients with health problems

[20, 21, 23, 25, 28-32]. The situations that lead to

moral distress are: nursing care for patients who are

in an end-of-life phase or caring for a hopelessly ill

person; solving a family’s needs even though the

actions could be detrimental for the patient or when

in disagreement with a family’s perspective;

knowing they should, but forced to because of

hospital administration concerns about a lawsuit;

carrying out a physician’s instructions even though

they are inappropriate or aggressive treatments;

trying to provide care for a patient to reduce pain,

but unable to because of physician fears that

increasing medicinal doses will cause death [22, 31-

33]; receiving inadequate resources such as time,

drugs, staff, equipment, and poor supervision [34];

dealing with family members who refuse to make a

decision about a dying patient; working with low-

qualified staff [22]; facing power imbalance among

healthcare providers; requiring unnecessary tests


J Health Res  vol.29 no.3 June 2015

and deception; [32] and caring for children with

illness in a high-tech PICU [28]. According to the

situations, healthcare providers need to understand

moral distress and its causes to find ways to alleviate

the situations.

Consequences of moral distress

Moral distress is a significant problem in

nursing practice. Corley [35] found that the impacts

associated with moral distress of nurses working in

critical care can be divided into three categories:

first, impact on nurses suffering from mental

anguish and burn-out, so decide to leave nursing;

second, impact on patients caused by lack of

advocacy and appropriate care; and third, impact on

an organization caused by high nurse turnover,

difficulties in recruiting nurses, decreasing quality

of care, low patient satisfaction, and reputation

accreditation. These findings are consistent with

those in a study by Burston and Tuckett [36] which

stated that outcomes of moral distress in nursing can

lead to negative aspects among nurses such as

emotional exhaustion, a sense of powerlessness,

becoming callous, bitter and cynical, avoiding

patients, and avoiding conflicts. Consequently,

moral distress can affect quality of care, patient

satisfaction, and staff retention and shortages, all

consistent with a study conducted by Nathaniel [26].

This study also reported that a consequence of moral

distress is moving from the original workplace to

another area. Moreover, Maluwa et al. [34] studied

moral distress in nursing practice among 20 nurses

in Lilongwe District of Malawi. The study showed

that nurses who experienced moral distress faced

physical and relationship impacts, including lack of

sleep, physical pain (e.g., headache), lack of

appetite, sadness, irritation, and anger toward family

members. These studies provide some

understanding about the consequences of moral

distress in mostly general nursing practices.

However, in psychiatric nursing, which differs from

general nursing in nursing expertise and activities or

interventions, moral distress consequences may

differ. This is why the consequences of moral

distress in psychiatric mental health nursing must be

further explored.

Experiencing moral distress in psychiatric and

mental health nursing

Few studies have examined moral distress

among psychiatric nurses. Musto and Schreiber

[20], in their study on moral distress in adolescent

mental health nursing, focused on developing a

substantive theory on mental health nurses’ behavior

when they experience moral distress. The study

revealed that twelve mental health nurses

experiencing moral distress felt a lack of ability and

uncertainty to maintain patients’ safety. Furthermore,

Sturm, in his ethnographic study research that

explored ethics and care among psychiatric

community health nurses, found that seven nurses

reported experiencing moral distress when they

knew that they could give care to patients, but not

over an appropriate period of time [10]. Later, they

felt upset, stressed, in conflict with the situation, and

frustration. These findings are consistent with

studies conducted by Austin, Bergum and Goldberg

[27] and Deady and McCarthy [21]. They used a

hermeneutic phenomenological approach to explore

the descriptions of mental health nurses’ experience

of moral distress and found that mental health nurses

experienced feelings of frustration, anger and

sadness that they could not respond to patients’

needs, feelings of uncertainty, lack of safety,

disrespect, and serious institutional constraints,

which related to personal and professional distress

as well as lack of connection with others, or

loneliness. Moreover, Deady and McCarthy [21]

found that coping strategies that psychiatric nurses

used while experiencing moral distress include

avoiding conflict, going along with cultural

pressure, denying problems, refusing to work with

colleagues, and changing jobs because of problems

with peers, managers, supervisors, or counselors.

These studies reflect how health professionals

experience moral distress, particularly psychiatric

nurses who work with psychiatric patients and also

dealing with patients’ family members. Still, the

studies are few, and there is little literature on

strategies or resources to provide support and reduce

moral distress.


Psychiatric and mental health nursing is a

nursing specialty that focuses on the care and

rehabilitation of people with mental illness.

Psychiatric nurses encounter many challenges

during their work, in particular, ethical dilemmas.

There are various situations that influence ethical

quandaries and moral distress in mental health

professionals such as psychiatric nurses [37-40].

There is still very little literature discussing the

consequences of moral distress and how it can affect

patients’ and their families’ satisfaction. As many

nurses are now leaving this specialty because of the

moral dilemmas and their effects, further studies on

this subject are required to develop higher quality

care for patients with mental illness and better

assistance for their families, as well as enable

psychiatric nurses to be more aware of the

implications of their moral decisions and ethical

233 J Health Res  vol.29 no.3 June 2015

actions. This article suggests that moral distress

needs to be decreased by a holistic solution and

should be considered in psychiatric and mental

health nursing practice.


The author wishes to acknowledge Faculty of

Nursing, Chulalongkorn University, and Faculty of

Nursing, University of Alberta, for providing

support in time and material resources to conduct

this article.


The author would like to declare that there is no

conflict of interest in this study.


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