Chapter 2: Stressors and challenges

Personal values

What the ethics experts say
Dr. Cynda Rushton, ethics expert, talks about how mindfulness can help nurses calm the stress of their job.(3:22)Video transcript

“With COVID-19, we're carrying a heaviness that we've never carried before. It's created barriers to how we connect with patients and families, and it's not a change any of us are welcoming. It just weighs on us on so many levels.” - Nurse

Having a sense of control contributes to our self-confidence and predictability and helps us to complete the daily tasks of our job. With the pandemic, what has been helpful for us in the past may not be working for us right now. We may find ourselves off-balance and feeling a loss of control; we may be dealing with ethical dilemmas or moral distress; and experiencing feelings of guilt or failure. 

Moral distress occurs when you know the right thing to do but the situation or facility constraints stand in the way. It often reflects the experience of people working in healthcare who feel silenced and unable to express their distress and grief. It is often present in ethical dilemmas.

How personal values are being affected

Changes in relationships and roles

  • PPE can create a barrier to connecting and communicating with patients and families.  
  • Visitor restrictions may change our role with residents and patients to include becoming a substitute family member. This changes the patient/resident-provider relationship. This can influence how we make decisions.


Ethical dilemmas and moral distress

Changes to public health restrictions and clinical guidelines for COVID-19 patients can create ethical dilemmas. Many of these issues relate to decision-making, goals of care, treatment plans, information sharing and end-of-life care. For example:

  • We may be confronted with a COVID-19 patient, or multiple patients, and have no clear course of action.  There may be disagreement within the team about how to proceed. 
  • We are forced to call security to enforce new visitor restrictions with family members and friends which goes against basic tenets of care.  


Responsibility, expectations and failure

When someone dies, we may find ourselves going over the death as we try to determine whether anything was missed or if anything could have been done differently. Finding ways to come to terms with limitations - our own and those of the healthcare system - while also working to support and improve people’s health and well-being, is no easy task.   

 

Reasonable guilt and exaggerated guilt 

What’s the difference?

Click on the switch button to find out.

Reasonable guiltExaggerated guilt

Working in stressful, high pressure situations with many moving pieces can naturally lead to missteps. Guilt can serve to encourage accountability for our actions. If we reflect on how we would approach a similar situation differently, it can improve our practice and caregiving.

 

While reflecting on a situation can help us to improve our practice, focusing on it can preoccupy us with unhelpful self-criticism.

 















Helpful approach

Pay attention to feelings of guilt. Try to think about it as if you were helping a friend with their guilt. This helps assess whether our guilt is reasonable or exaggerated.


Reflective exercise

Is there something else going on that that explains my disproportionate guilt? 

What are my beliefs about my responsibility for other people’s suffering? 

Is my guilt shielding me from other feelings, such as fear or anxiety?

What may help?

  • Because ethical dilemmas are complex, share concerns with a co-worker, supervisor, counsellor, or spiritual care practitioner to help reduce isolation and powerlessness.
  • Accept that you are human and in a situation with many unknowns that can't be controlled. 
  • Consider consulting a professional ethicist (if this service is available in your setting) for an objective third party opinion when making decisions in complex clinical situations.
  • If your workplace provides time and space for staff to come together to talk about the impact of ethical dilemmas, use this time to explore your experience and to request support. It is an important step towards staff retention and grief support. 

See also:“What is ‘moral distress’ in nursing? How, can and should we respond to it?”