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UBC Theses and Dissertations

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UBC Theses and Dissertations

Risking vulnerability : enacting moral agency in the is/ought gap in mental health care Musto, Lynn Corinne


The definition of moral distress (MD) was put forward 35 years ago to explain the distress nurses felt when they experienced moral compromise. Making a moral judgment, enacting moral agency, and having constraints on agency have been identified as central to the experience. The known consequences of MD for health care professionals (HCPs), health care organizations, and patient care, are significant. Yet, researchers have struggled to develop meaningful interventions. The enactment of moral agency and constraints on agency are linked together in the experience. Constraints have been identified as being internal to the HCP, or external to the HCP and rooted in the context in which HCPs work. I argue that constraints on agency are dynamic (Musto & Rodney, 2016) and that gaining clarity on MD requires exploring the experience at the intersection of structure and agency. I engaged in this study to explore how HCPs navigated ethically challenging situations in complex acute mental health settings. I conducted this research using grounded theory (GT) methods. Grounded theory (GT) methodology allowed me to focus on the processes participants engaged in when they confronted ethical challenges. The study was multidisciplinary, conducted across two urban acute care mental health sites. I gathered data through semistructured interviews and observation. The basic social problem participants attempted to negotiate was systemic inhumanity, or the inability of the health care system to consistently extend respect, compassion, and dignity to individuals struggling with mental health issues. The resulting model, Risking Vulnerability: Enacting Moral Agency in the Is/Ought Gap, explains how participants were able to act as moral agents in the particular context they were embedded in. Participants negotiated ethical challenges relationally, by risking vulnerability; that is, holding their professional obligations, clinical expertise, and organizational processes in tension with their own vulnerability in the system. This study highlights the importance for organizations to create a relational space in which HCPs are safe to explore ethical questions about how policies and practices may dehumanize individuals struggling with mental health issues. Thereby contribute to conflicts between care that is actually given (Is) and care that aligns with professional moral obligations (Ought).

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