Opinion

Moral distress in nursing practice

We talk about the need for a resilient profession, but we are asking too much of inadequately supported nurses, says nursing lecturer John McKinnon.
Distressed nursing

We talk about the need for a resilient profession, but we are asking too much of inadequately supported nurses, says nursing lecturer John McKinnon

Healthcare is in a turbulent place as society expects nurses to remain clinically robust while adapting to changes.

That those changes have the potential to undermine care quality or nurses health is too often a secondary consideration (RCN 2013).

Sound nursing practice demands adjustments to meet patient need (McKinnon 2011) ,but the care system must not obstruct and undermine sound practice. My recent study shows this is what is happening (McKinnon 2016).

Quantity over quality emphasis

Examples include data collection systems that emphasise quantity rather than quality in practice, malfunctioning equipment, eight-hour support services for 24/7 care, uncovered sick leave, poor levels of staffing and skill mix.

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We talk about the need for a resilient profession, but we are asking too much of inadequately supported nurses, says nursing lecturer John McKinnon

Healthcare is in a turbulent place as society expects nurses to remain clinically robust while adapting to changes.

Distressed nursing
Distressed nurses needing practice adjustments. Photo: Alamy

That those changes have the potential to undermine care quality or nurses’ health is too often a secondary consideration (RCN 2013).

Sound nursing practice demands adjustments to meet patient need (McKinnon 2011) ,but the care system must not obstruct and undermine sound practice. My recent study shows this is what is happening (McKinnon 2016).

Quantity over quality emphasis

Examples include data collection systems that emphasise quantity rather than quality in practice, malfunctioning equipment, eight-hour support services for 24/7 care, uncovered sick leave, poor levels of staffing and skill mix.

These negative influences on practice are invisible to uninformed observers in politics or the public at large. Yet as frontline practitioners, nurses are in an invidious position. They are an ethically motivated workforce. They must ‘steal’ time and energy originally reserved for care to fill deficits in support systems.

In cases of poor outcomes nurses can be easy targets for the public who feel poorly served and for managers and politicians who failed to listen or act on concerns raised.

The consequence has been discussed in terms of low staff morale, an accepted norm now in many nursing teams. However, low morale is an inadequate term to describe a toxic process threatening the integrity of a professional community.

Burston and Tuckett (2013) describe ‘moral distress’ as the inability to do what is right in the face of knowing what is right. Moral distress is allied to frustration, which draws in and ferments other negative feelings.

Preoccupation with multitasking and the feeling of losing ground against waves of competing demands can make nurses lose the ability to empathise as they become preoccupied with their own unmet needs.

Over time a loss of autonomy and self-esteem leads to feelings of worthlessness, despair and eventually burnout (McKinnon 2016). Frustration may mean anger, which breaks through in inappropriate settings, impacting on fragile relationships with patients, families and other nurses.

Building frustrations

These frustrated feelings are major contributors to poor health and increased sick leave among nurses, feeding a desire to leave the profession (Li et al 2013).

As a nurse, I despair at the failure to attend to these problems. As an academic I may talk about building resilience in the future nursing workforce, but as a patient I want to know what sort of society expects so much from its nurses while failing to provide the means to sustain them.

I hope someone is listening.

References

  • Burston AS and Tuckett AG (2013) Moral distress in nursing: contributing factors outcomes and interventions. Nursing Ethics. 20, 3, 312-324.
  • Lewandowski CA (2003) Organisational factors contributing to worker frustration: the precursor to burnout. Journal of Sociology & Social Welfare. 30, 4, 175-185.
  • Li J et al (2011) Reward frustration at work and intention to leave the nursing profession – prospective results from the European longitudinal NEXT study. International Journal of Nursing Studies 48, 5, 628-635.
  • McKinnon J (2011) The nurse-patient relationship in Linsley P, Kane R and Owen S (eds) Nursing for Public Health: Promotion, Principles, and Practice, Oxford University Press, 64-74.
  • McKinnon J (2016) Harnessing Emotion to Inform Clinical Practice. Unpublished PhD thesis. London, Institute of Education. UCL.
  • Royal College of Nursing (2013) Mid Staffordshire NHS Foundation Trust Public Enquiry Report: Response of the Royal College of Nursing. London, RCN

John McKinnon is senior lecturer in nursing in the faculty of health and social sciences at the University of Lincoln

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