School of Nursing, Trinity Western University, Langley, BC, Canada.
School of Nursing, University of Victoria, Victoria, BC, Canada.
J Adv Nurs. 2021 May;77(5):2458-2471. doi: 10.1111/jan.14776. Epub 2021 Feb 20.
To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD).
Grounded theory, a qualitative methodology.
Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016.
The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity.
Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care.
Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.
探索急性保健心理健康环境中的医疗保健提供者如何在道德上具有挑战性的情况下进行导航，实施道德代理，与道德标准一致地实践并减轻道德困境（MD）。
扎根理论，一种定性方法。
在 2015 年至 2017 年的 18 个月中，我们审查了文件，进行了观察并采访了来自住院和急诊部门的多学科参与者（N=27）。参与者要么提供直接护理（N=14），要么担任领导职务（N=13）。使用不断比较，编码，备忘录和理论化，对数据进行了迭代分析，直到 2016 年 7 月达到饱和为止。
医疗保健专业人员实施道德代理的基本社会过程，即“冒险暴露”，发生在系统不人道的背景下，这是 MD 的不断根源。参与者冒险暴露，在平衡专业义务，临床专业知识和组织流程与自己在系统中的脆弱性的同时，努力做到道德实践。冒险暴露由“推回”，“通过团队关系工作”和“与不人道作斗争”组成。
医疗保健专业人员的道德代理发生在结构（组织约束）和代理（人员）的交点上。鉴于此，MD 的干预措施应针对医疗保健的各个层面，以支持道德代理，促进道德实践并改善护理。
紧缩措施等社会政治因素破坏了直接护理层面的道德实践。道德代理的实施是动态的，会影响 MD 的体验：得到领导或同事支持实施道德代理的参与者指出，他们不会陷入 MD。整个医疗保健系统都需要支持道德代理的干预措施，以减轻 MD 的体验。研究结果增强了我们对行动在 MD 体验中的作用的理解。
