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Nursing staff are constantly trying to strike a balance between self-protection and concern for others. We place huge emphasis on doing our job well and doing the right thing. But with staff working in increasingly pressurised conditions, these apparently simple aims can sometimes be impossible to attain. 

How you respond to this depends on you as an individual, but unsurprisingly many nursing staff have reported feeling stressed, unappreciated, frustrated, angry, scared or anxious.  

This isn’t about a lack of resilience. It’s not even about you. This is about the situation you find yourself working in.

What is moral distress? 

Moral distress occurs when you know the ethically correct action to take but you are constrained from taking it. During a crisis or disaster, the frequency and severity of moral distress increases, so the events of the last 18 months will have had a significant impact.  

But while the fight against COVID-19 has brought moral distress to more people’s attention, it’s not specific to the pandemic. It could also be brought about by people’s reaction to inadequate staffing levels or an inappropriate skill mix in your workplace.

The impact can threaten our core values

Other common triggers include working in end-of-life care, value conflicts, challenging team dynamics and duty conflicting with safety concerns, among others.  

These issues are all too familiar to many of us in the nursing workforce, and the impact can profoundly threaten our core values.  

It’s important not to ignore this complex and challenging problem which could hinder your ability to advocate for patients or result in you feeling you have no choice other than to leave your job or the profession.  

No-one is immune 

Moral distress is especially prevalent among nursing staff caring for critically ill patients, but no-one is immune, and it doesn’t matter what role you have.  

Many nursing staff have been so focused on keeping their colleagues and relatives physically and mentally well throughout the pandemic, they’re now completely exhausted and find they simply have no more reserves. 

Staff in care homes who have shown their absolute dedication to keeping residents safe could also be susceptible to moral distress, having cared for residents who have died, while dealing with how they perceive they are viewed by other health professionals, the media and the public. 

It’s not limited to nursing staff either – the British Medical Association has also recognised the issue, as have our nursing colleagues in the American Nursing Association. 

You are not alone 

We’ve recently seen an increase in numbers of members with moral distress, and prolonged distress can lead to moral injury.  

Moral injury isn’t a mental illness and it’s different to post traumatic stress disorder, which has to be diagnosed by a psychiatrist.

However, experiencing moral injury may increase your risk of developing mental health problems.  

To prevent moral injury developing in the first place, it’s important to take breaks and utilise annual leave, as well as effective clinical and managerial supervision.

It is vital that your organisations support you to enable these preventative measures to happen.  

Never be afraid or ashamed to access formal and informal services that support your mental health and wellbeing

For the many nursing staff already experiencing moral injury it’s important to recognise it and the impact it can have. Rest and recuperation are essential, as is having clear and accountable mechanisms in place to raise concerns.  

If you think you’re experiencing moral injury, remember you’re not alone.

Never be afraid or ashamed to access formal and informal services that support your mental health and wellbeing, including the RCN counselling service.

This is an issue that must be dealt with and I would urge you to seek support.

Staff safety crucial following pandemic 

We’ve focused on staff recovery and patient safety in our recently published principles for return to service following the pandemic 

The debate on the timing and process for returning to “normal” service levels must have patient-need at its centre, but that cannot come at the expense of members’ wellbeing.   

Occupational health services must be available at the point of need to support the psychological and physical wellbeing of staff. It’s also essential that employers recognise the signs of decreased psychological wellbeing and educate the workforce about them and act to avoid occurrences of moral injury and its associated risks.  

We also want all employers to fund sufficient, timely and ongoing access to confidential counselling, bereavement and psychological trauma support for all staff. Staff must be able to self-refer to these services and be given time off to attend.  

Rest and recuperation for health care staff must be central to decision-making on getting patients safely back to diagnostics and missed treatment. There must be funded and supported time-out - not limited to annual leave, for all staff. 

Staff must be able to raise concerns, particularly around patient safety and situations where their own mental health and wellbeing is at risk.  

The professional nursing voice must drive decisions and ensure services are only restarted when patient and staff health and wellbeing has been risk assessed in all sectors.   

Visit the RCN's Healthy workplace, healthy you webpages.

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