Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care

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.