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Contents lists available at ScienceDirect
Australasian Emergency Care
journal homepage: www.elsevier.com/locate/auec
Research paper
Changing nursing practice in response to musculoskeletal l pain and
injury in the emergency nursing profession: What are we missing?
Jill Beattie a , Kelli Innes a , Kelly-Ann Bowles b , Cylie Williams c , Julia Morphet a,∗
a
b
c
Monash University Nursing and Midwifery, Wellington Road, Clayton, Victoria, 3800, Australia
Department of Paramedicine, Monash University, Peninsula Campus, 47-49 Moorooduc Hwy, Frankston Victoria, 3199, Australia
Monash University, School of Primary and Allied Health Care, Peninsula Campus, 47-49 Moorooduc Hwy, Frankston Victoria, 3199, Australia
a r t i c l e
i n f o
Article history:
Received 22 February 2021
Received in revised form 12 April 2021
Accepted 2 May 2021
Keywords:
Musculoskeletal pain and injury
Emergency nursing
Nursing practice
Change
Stress
Moral distress
a b s t r a c t
Background: Musculoskeletal disorders in emergency nurses result in physical, psychological and financial
strain. Contributing factors include: environmental, organisational, patient-related, medical emergencies, nurse’s knowledge and health status. Stress and moral distress impact on nurses changing manual
handling practices.
Methods: Part of a cross-sectional survey of Australian emergency nurses, this study used content analysis
to identify occurrence of change to practice and enablers to reporting injury. Secondary interpretive
analysis using moral distress theory informed an alternative understanding of why nurses may not change
their practice in response to injury.
Results: Most respondents made practice changes and reported pain/injury; 23% did not change, and 45.7%
did not report. Respondents considered change impossible due to high demands and lack of resources; a
position where nurses may have felt pressured to carry out unsafe manual handling practices. When conflicted between reporting a perceived insignificant injury, with feelings of guilt, nurses can feel devalued.
Moral distress can occur when nurses and managers are conflicted between providing care and caring
for self.
Conclusions: A culture of trust, respect and open communication decreases stress/moral distress, enables
safer manual handling and reporting of pain/injury. Moral distress is an invisible workplace challenge
that needs to be met for staff wellbeing.
© 2021 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
What is known about this topic?
• Musculoskeletal pain and injury are common and can be debilitating.
• Predisposing factors include organisational, cultural, patientrelated, nursing-related, physical environment, and medical
emergencies.
What this paper adds or contributes?
• Not all nurses change their practices as a result of pain/injury.
• Moral distress theory can inform an alternative level of understanding of the enablers and barriers to changing practice
following pain/injury.
∗ Corresponding author at: Monash University, Nursing & Midwifery, Wellington
Road, Claytion, Victoria, 3800, Australia.
E-mail address: [email protected] (J. Morphet).
• Stress and moral distress can result in decreased decision-making
ability and performance.
• Unresolved moral distress may lead to fatigue, absenteeism,
burnout, poor communication, lack of trust, defensiveness, and
lack of collaboration.
• Moral distress is, until recently, an invisible challenge to emergency staff wellbeing.
Introduction
Workplace injury and musculoskeletal disorders, particularly in the health care industry account for the majority of
worker’s compensation claims and result in time off work, with
physical, psychological and financial strain [1]. Up to 40% of lifting/transferring injuries may be prevented by using mechanical
lifting equipment. Yet mechanical devices are unable to prevent injuries resulting from repositioning, transferring, or catching
falling patients [2]. Movement of patients in emergency situations
is often poorly managed, and training rarely includes manual han-
https://doi.org/10.1016/j.auec.2021.05.001
2588-994X/© 2021 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Beattie J, et al, Changing nursing practice in response to musculoskeletal l pain and injury in the emergency
nursing profession: What are we missing? Australasian Emergency Care, https://doi.org/10.1016/j.auec.2021.05.001
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dling in emergencies, despite recognition that activities such as
transferring, and lifting patients from the floor are high risk activities [3].
Recommendations by Jones [4] include the passing of legislation to prohibit manual lifting by health care workers, a maximum
manual lifting weight limit of no more than 16 kg (35 lb) and use
of an emergency department (ED) assessment tool to determine
readiness to safely care for morbidly obese patients. However, as
cautioned by Safe Work Australia [5], “There is no safe weight set
for all workers in all circumstances because there are too many factors contributing to the risk, not just the weight of the item”(p.28) .
Further, the Australian Nursing and Midwifery Federation (ANMF)
has a ‘No Lift’ Policy stating that “The manual lifting of patients
must be eliminated in all but exceptional circumstances, for example, life threatening situations where it still should be minimised
so far as reasonably practicable” [6](p.1) · Even with a No Lift Policy,
the ANMF statement appears to support manual lifting of patients
in emergency situations.
As noted by Perhats et al. [7], workplace safety practices need
to specifically address the unpredictable, urgent, and often lifethreatening situations presenting to the ED, which can cause
increased stress in nurses. Thus, there is a need to not only
address interventions beyond mechanical lift equipment, but also
to address the increased stress of working in emergency situations
[2]. In this paper we explore the impact of stress on lifting practices
and offer an alternative view to why nurses may not change their
practice in response to workplace injury.
staff feel they cannot practice according to their knowledge, values,
and professional standards due to workplace culture, systems, and
physical and social constraints, moral distress can result in feelings
of frustration, anger and guilt. Subsequently, physical and mental
health issues may arise [14]. Unresolved moral distress may lead to
fatigue, absenteeism, and burnout, resulting in poor communication, lack of trust, defensiveness, and lack of collaboration between
staff members [15], all of which places staff at increased risk of
injury.
Research aim – purpose
This paper explores nursing practice change, or lack of change,
and enablers and barriers to reporting, in response to workplace
musculoskeletal pain/injury in the ED. The secondary aim was to
explore why some nurses do not change their practices, even when
they have been injured at work.
Methods
Research design
This study was part of a larger cross-sectional survey study
of Australian emergency nurses which included closed and openended questions. This paper reports the descriptive findings related
to change, or lack of change to practice, and reporting, or lack of
reporting, workplace injury. An interpretive approach drawing on
the theoretical construct of moral distress is then used to explore
underlying reasons for lack of change/reporting.
Stress and moral distress
The literature confirms a number of variables contributing to the
risk of sustaining musculoskeletal injury due to nursing activities
in the ED [4,7–9]. These include the physical environment (e.g. confined working spaces); organisational factors (e.g. lack of equipment,
inadequate staffing levels, and work-time pressures); patientrelated factors (e.g. increased physical size of patients, decreased
mobility and mental status); cultural factors (e.g. challenging and
unsupportive staff-to-staff and staff-to-manager relationships);
nursing-related factors (e.g. lack of safe patient handling knowledge/skills, pre-existing injury, work-related stress); and medical
emergencies.
Consequently, increasing physical and psychosocial demands
contribute to increased stress in emergency nurses, potentially
decreasing cognitive capacity. A decrease in cognitive capacity can
result in stress-related behaviours such as poor decision making, lack of support by managers, and can impact nurses ability
to implement policy and/or safe manual handling activities [10].
This view is supported by Adriaenssens et al. [9], suggesting that
“unsafe acts [e.g. poor manual handling] are not random events, but
have their immediate origins in psychological states of mind (e.g.,
ways of reasoning, expectations, motives, plans, haste, emotional
preoccupation)”(p.1318) . With increasing stress, behaviour and practice change is difficult, with staff maintaining habitual practices
potentially putting themselves at risk of injury [10]. Increased
stress in middle and executive managers can lead to a failure to
address nurses’ concerns.
Our understanding of whether or not nurses change their practices as a result of workplace pain and/or injury can be increased if
we look beyond descriptive explanations and apply the theory of
moral distress [11]. Introduced by Jameton [12], moral distress may
occur “when one knows the right thing to do [e.g. correct manual
handling], but institutional constraints [e.g. high-acuity and lack
of resources] make it nearly impossible to pursue the right course
of action"(p.6) . Pendry [13] extends this definition to include internal constraints, which can result when nurses’ belief systems are
not considered, resulting in internal conflict. Consequently, when
Participants and setting
Eligibility included registered and enrolled nurses working in
Australian EDs. The College of Emergency Nursing Australasia
(CENA) facilitated recruitment by sending an email invitation to
all members. An embedded link to the online survey was included.
The first page of the survey explained the voluntary and anonymous
nature of participation and no personal identifying information was
required. Consent was obtained by the participant clicking “next”,
and completing the survey. Thus, implied consent was obtained
prior to continuing.
Data collection
The online survey was open between 15/01/2020 until
02/03/2020. Questions relevant to this study included demographics and whether or not participants had experienced
musculoskeletal pain or injury at work. Open-ended questions
sought information about: whether or not participants had experienced pain/injury, and if they did, whether pain/injury led to a
change in practice; if no change was made, why this was the case;
and what were the enablers and barriers to reporting workplace
injury.
Data analysis
Descriptive statistics reported demographic data, and text from
open-ended questions were imported into the NVivo11 Pro qualitative data management system [16]. Content analysis was conducted
by one of the researchers to identify categories and frequency of
occurrence [17] related to change to practice, lack of change to practice, reporting workplace injury, and failure to report workplace
injury. Using NVivo 11 Pro enabled an audit trail of analysis which
was discussed, clarified, and refined by two of the other researchers.
Secondary analysis was then conducted by re-examining the
descriptive data using the key components of moral distress for
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Table 1
Participant demographics.
Table 2
Ways in which respondents changed their practice.
Responses n = 175
n (%) or Mean (SD)
Gender
Male
Female
Prefer not to answer
Age group
Under 25
25−29
30−34
35−39
40−44
45−49
50−54
55−59
60−64
65−69
Principal place of practice
Victoria
Queensland
New South Wales
South Australia
Western Australia
Tasmania
Northern Territory
Australian Capital Territory
Location of practice
Metropolitan
Regional
Rural
Remote
Role in emergency department
Nurse Unit Manager
Associate Nurse Unit Manager
Nurse Practitioner
Clinical Nurse Specialist
Registered Nurse/Clinical Nurse
Enrolled Nurse
Nurse Educator/Clinical Support Nurse
Clinical Nurse Consultant
Time spent in emergency service areas
Admin/Research/Management/Education
Triage
Resuscitation Cubicles
General Cubicles
Fast Track
Waiting Room
Procedures Rooms
n (%)
32 (18.3)
142 (81.1)
1 (0.6)
n (%)
6 (3.4)
22 (12.6)
28 (16.0)
22 (12.6)
20 (11.4)
26 (14.9)
16 (9.1)
23 (13.1)
10 (5.7)
2 (1.1)
n (%)
64 (36.6)
40 (22.9)
23 (13.1)
21 (12.0)
17 (9.7)
6 (3.4)
2 (1.1)
2 (1.1)
n = 174 (%)
110 (63.2)
41 (23.6)
21 (12.1)
2 (1.1)
n (%)
10 (5.7)
9 (5.1)
10 (5.7)
37 (21.1)
92 (52.6)
4 (2.3)
12 (6.9)
1 (0.6)
Mean % of Time (SD)
17.37 (28.58)
17.70 (18.34)
20.28 (19.48)
28.47 (29.96)
9.24 (16.04)
3.34 (6.03)
3.50 (7.78)
Practice change
Respondent n = 93 (%) a
Focus more on wellbeing: modifying how job is done
(less bending, twisting; cautious lifting in
emergencies; care of back; modifying patient
transfers; working slower with more thought; taking
less risks
Used lifting equipment
Enlisted colleague assistance
Decreased unnecessary manual loads, reduced bed
movement
Refuse risky tasks to avoid long term injury
Unable to physically assist patients as before
Decreased working hours, including double shifts,
overtime, time spent in clinical nursing
Changed/thinking of changing working role e.g.,
education, research, academia
Increase patients’ independence
Ergonomic assessment/support e.g., sit-stand desk
when in office
Extensive occupational health, safety/No lift
education; educating staff on smart practices
Regular stretching/exercise at work
Only participate in resuscitation when no other option
Let the patient ‘fall’ (instead of catching them) rather
than risk self-injury
Enlist family members’ assistance
Hospital terminated respondent
Keep to myself as I do not want to draw attention to
myself
More cautious around mental health patients
With minimal adjustable computer screens, changed
multifocal glasses to avoid neck hyperextension
Loss of weight
“Orthotic shoes”
Have not been able to return to work yet due to injury
55 (59.1)
a
11 (11.8)
11 (11.8)
8 (8.6)
4 (4.3)
3 (3.2)
3 (3.2)
3 (3.2)
3 (3.2)
2 (2.2)
2 (2.2)
2 (2.2)
2 (2.2)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
1 (1.1)
Respondents gave more than one example of change to practice.
throughout their career as an emergency nurse (n = 139/165;
84.2%). Of those, ninety-three participants (n = 93/139; 66.9%)
reported a change to practice. The most frequent change was
focussing more on own wellbeing by modifying the way in which
respondents worked (n = 55/93; 59%), use of lifting equipment
(n = 11/93; 11.8%) and enlisting the assistance of colleagues, patient
care assistants and wardsmen (n = 11/93; 11.8%). Table 2 illustrates
other ways in which respondents changed their practice as a result
of pain/injury.
Conversely, a number of respondents (n = 32/139; 23%) reported
that they did not make a change to practice as a result of the
pain/injury. The most frequent reason was that respondents found
change to be very difficult because of the EDs high volume, high
pressure, with back unfriendly trolleys and high levels of manual
handling required (n = 7/32; 21.9%). While participants reported
not changing clinical practice, they did however instigate a number of self-care changes, mostly outside of work, such as exercise
and stretching, heat packs, rest, regular massage, and changing
footwear (n = 6/32; 18.8%). Patient factors such as increasing levels
of obesity, care and direction refusal, and assault by patients were
also identified as challenges to change in practice (n = 4/32; 12.5%).
A number of responses focussed on the incident or injury, without
comment on why a change in practice as a clinician did not occur
e.g., had surgery to repair injury (ID139) (Table 3). Other participants made comments that did not relate to the question of change
(14/139; 10.1%).
health professionals as a framework to identify areas of possible
moral distress [18]. These included: complicity in wrongdoing (the
pressure to act wrongly); lack of voice (unheard or devalued professional insights); wrongdoing associated with professional values
(violations of ethical professional practice); repetitive situations;
and patient, unit, and system level causes [18](p.121) .
Ethics
Ethical approval was received by the Monash University Human
Research Ethics Committee, Victoria, Australia (Project ID: 12628,
date: 22/11/2019).
Results
Participant demographics are reported in Table 1.
Change in practice as a clinician in response to workplace
pain/injury
Enablers to reporting the occurrence of pain/injury
The majority of participants who answered this question
(69/127; 54.3%) reported that they were able to report the occurrence of pain or injury. Of those, the most frequent enablers to
The majority of participants who answered this question
reported experiencing work-related musculoskeletal pain/injury
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Table 3
Reasons pain/injury did not lead to practice change.
Table 4
Enablers to reporting pain/injury.
Reasons for not changing
Respondent n = 32
(%) a
Difficult to change: too busy, too slow; high volume,
high pressure, highly stimulating environment; back
unfriendly trolleys, high levels of manual handling
required; 12 -h shifts; hard floors
Instigated self-care: exercise regimen, built core
strength outside work which resolved back pain;
physiotherapy, heat packs, rest, regular massage,
Pilates and stretches at home, increasing fitness,
changed shoe type (no practice change identified)
Patient factors: obesity; unexpectedly grabbing
nurses; assault; refusing care/direction during lift
(no other practice change identified)
Equipment not available or faulty
Pain medication (no other practice change identified)
Lack of support: Told to take Panadol and rest; told to
just get on with it (no other practice change
identified)
Acceptance that nursing work is heavy/difficult;
general wear/tear of the work which often heals
with rest (no practice change identified)
Accidental injury e.g., unexpected and seemingly
innocuous tasks
Refusal to change the practice which caused the injury
e.g., not going to stop CPR for wrist injury caused by
CPR; will continue to run up the stairs at work to
keep fit, even though this caused the groin injury
Short duration of pain (no practice change identified)
Musculoskeletal things tend to work themselves out
over time (no practice change identified)
Pre-existing genetic disorder (no practice change
identified)
Had surgery to repair injury (no practice change
identified)
7 (21.9)
a
6 (18.8)
4 (12.5)
3 (9.4)
2 (6.3)
2 (6.3)
Enablers to reporting
Respondent n = 69 (%) a
The expectation to follow procedure: utilisation of
electronic incident reporting systems; meeting
workplace health, safety and Workcover
requirements
Unable to complete shift or work due to pain and/or
physical limitations
Open policy and departmental culture of trust, respect,
open communication
Self-protection to ensure a record in case of ongoing
issues requiring future treatment or time off work
Required medical assistance at the time or soon after
injury
Witnessed by colleagues
Manager needed to be aware of why nurse was off
work
Didn’t want to make it worse by working more
29 (42.0)
a
15 (21.7)
14 (20.3)
7 (10.1)
6 (8.7)
4 (5.8)
2 (2.9)
1 (1.4)
Respondents gave more than one example of change to practice.
2 (6.3)
2 (6.3)
2 (6.3)
manager with an injury perceived as not as significant as “other
people’s problems” (ID30).
Lack of support (ID1, ID9, ID67, ID119, ID121) was also a barrier to reporting pain/injury. Some managers were perceived as
being “not receptive to feedback, reports and concerns” (ID3).
Some respondents “didn’t think [their report or injury] would
be taken seriously” (ID5), or that anything would be done from
reporting (ID33, ID90). ID90 appeared particularly disillusioned by
a perceived lack of support, reporting that managers “have bigger concerns than an individual nurse’s complaints of pain. I am
replaceable and cheap. The flooring isn’t”. One respondent reported
“to say that my work and management was accommodating would
be a lie” (ID129).
Where respondents were unclear about the cause of the pain
or injury, they did not report it. Reasons for lack of clarity were
delays in presentation of pain/injury (ID34, ID40, ID115), with no
direct link to an event at work (ID27, ID43, ID51, ID53, ID145),
and assumptions that it was general “wear and tear” from working
(ID70, ID132).
The perception that pain and injury are part of the job (ID58)
and/or ageing (ID143) also prevented participants from reporting.
This belief was highlighted by ID49 writing “You feel weak reporting and expecting change, or care, or even time off, for something
that everyone is going through”. This belief was echoed by ID151
reporting “there are so many staff in the same situation there is
no point complaining about it”. With this underlying belief, some
respondents’ perception was that there was “nothing” that prevented them from reporting pain/injury (ID85, ID104). However,
accepting the belief that ongoing workplace pain was expected and
something they had to adapt their work for (ID85, ID159), may have
unconsciously, been preventing them from reporting.
Another barrier to reporting pain and injury was fear. Fear was
revealed in a number of ways: Fear of being transferred out of ED
(ID69, ID126); fear of being allocated unfairly to different areas of
the ED (ID87); fear of retrenchment and job loss (ID91, ID39); fear
of becoming a liability (ID69); fear of causing trouble (ID83); fear
of losing job opportunities (ID124); fear of loss of reputation, and
fear of Workcover (ID126, ID161). ID91 highlighted their fear by
reporting “I do not feel safe disclosing injuries to my supervisors
while still not on a permanent contract”. And ID69 wrote “Our CEO
made it clear that we were all replaceable”. Table 5 provides further
details of barriers.
1 (3.1)
1 (3.1)
1 (3.1)
1 (3.1)
Respondents gave more than reason for not changing practice.
reporting workplace pain and injury (n = 29/69; 42%) were hospital policies, electronic reporting systems and organisational and
colleagues’ expectations. Being unable to complete a shift (ID71,
ID105, ID116), needing time off work (ID29, ID78, ID125), or inability to fully perform duties during a shift (ID139, ID141, ID155,
ID62, ID167), enabled reporting. In addition, experiencing pain
(ID63, ID66, ID105) and/or visible difficulties e.g., due to limping
(ID63) while performing duties also encouraged reporting. A workplace culture of trust, respect, and open communication enhanced
reporting verbally and via email (n = 14/69; 20.3%). Requiring medical assistance or hospital admission at the time (ID22, ID42, ID61
ID129), or soon after the injury (ID47, ID138) were enablers to
reporting. Furthermore, the need for self-protection was a motivator for reporting workplace pain/injury to ensure a documented
record in case of ongoing issues requiring future treatment or
time off work (n = 7/69; 10.1%). Table 4 provides further details
of enablers.
Barriers to reporting the occurrence of pain/injury
In contrast, many participants did not report that they had experienced workplace pain/injury (58/127; 45.7%). The most frequent
barrier to reporting was perceptions of pain/injury being minor or
insignificant (ID4, ID10, ID25, ID30, ID52, ID81, ID82), not sustained
(ID10, ID25, ID74, ID114), transient (ID20, ID122), not impacting on
activities of daily living (ID28) or working ability (ID26, ID89, ID93),
or that it was self-manageable (ID77, ID168, ID170). ID94 did not
consider their injury was “worth the effort” of reporting at the time
because they found the mandatory incident reporting system to be
“really time consuming”. Participants also reported being too busy
(ID30, ID38) to report the injury, and felt “guilty troubling” their
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Table 5
Barriers to reporting pain/injury.
Table 6
Components of moral distress: Sample response.
Barriers to reporting
Respondent n = 58 (%) a
Perceived as a minor/insignificant injury
Unclear cause of injury
Lack of support
Fear: being transferred out of ED; being allocated to
other areas of ED; retrenchment, job loss; becoming
a liability; causing trouble; losing job opportunities;
loss of reputation, Workcover stress
Accepted as part of the job
Did not impact daily living or ability to work
Self-manageable
Too busy/too time consuming to report
Feel weak reporting
Exacerbation of pre-existing back pain (scoliosis)
Not very much organisation could do
19 (32.8)
10 (17.2)
9 (15.5)
8 (13.8)
a
Components of
moral distress
Participant responses
Pressure to act
wrongly
More staff to help each other; helps stick to safer
practices. When less people, corners cut, can lead to
injury (ID40).
Too busy to change things, it makes it too slow (ID33).
Didn’t think it would be taken seriously (ID5).
Unheard or
devalued
professional
insights
8 (13.8)
4 (6.9)
3 (5.2)
3 (5.2)
2 (3.4)
1 (1.7)
1 (1.7)
Violations of
ethical
professional
practice
Respondents gave more than one example of change to practice.
Identification of moral distress
In the secondary analysis, data were re-examined using the key
components of moral distress as a framework. This enabled identification of areas where nurses may have been conflicted between
changing practice and providing care to patients, while also trying to care for self, and change their manual handling practices.
Table 6 reports a sample of participant responses and possible areas
of moral distress. It’s important to note that individual nurses differ
in whether or not a situation is morally distressing to them.
Repetitive
situations
Discussion
It is well known that musculoskeletal pain or injury is a common occurrence in emergency nurses [2,8]. However, there is a
paucity of research identifying practice changes as a result of manual handling injury. Findings of this study reveal that the majority
of respondents did attempt to make changes to their practice as a
result of pain/injury. The most frequent change was focussing more
on own wellbeing by modifying the way in which they worked.
As suggested by Crane et al. [19], workplace stress and resulting
workplace injury may have activated nurses resilience and ability to maintain personal and professional well-being to cope with
stress and adversity at work. However, some respondents did not
change their practice as a result of injury.
System cause
Patient cause
Don’t want to cause any trouble (ID83).
You feel weak reporting and expecting change (ID49).
Too busy and I felt guilty troubling my manager (ID30).
Told to just get on with it (ID135).
Manager not receptive to feedback, reports/concerns
(ID3).
We protect the patients but who protects us. . .(ID60).
They won’t do anything; have bigger concerns than
individual nurse’s complaints of pain. I’m replaceable
and cheap. The flooring isn’t. (ID90).
Workplace was not supportive of injured workers;
known to move them to different areas, with a view to
retrenchment. Concerned I would lose my job (ID39).
Did not wish to become a liability. CEO made it clear
we were all replaceable (ID69).
Only started when at a new hospital with 12 h shifts
and very hard floors (ID90).
We have seen 30 patients in 8 h with no relief for
breaks (ID48).
In ED it’s difficult to think about ergonomics and
correct, healthy musculoskeletal movements, given
the high volume, high pressure, highly stimulating
environment. There is a significant amount of manual
lifting (ID49).
Have a ridiculous level of work to cope with and
completely inadequate resources to deal with the
heaviness and volume of work (ID64).
Old equipment doesn’t meet patients’ needs, are ‘too
expensive’ to replace, yet are terrible for patients with
limited mobility (ID76).
Do not feel safe disclosing injuries to supervisors while
still not on permanent contact (ID91).
Most injuries from the unexpected patient collapse
and the nurse trying to protect patient (ID55).
Patients can be unpredictable especially elderly and
mentally ill. It’s just a matter of looking out for yourself
and your colleagues (ID7).
Patients get bigger (ID67).
Failure to change practice following workplace injury: what have
we been missing?
Using the key components of moral distress theory [18], we
examined participants responses and identified areas of possible moral distress. Where practice change was considered not
possible due to the high pressure, high volume of the ED and
lack of equipment and staff, nurses were placed in a position
where they may have felt pressured to ‘act wrongly’ in relation
to safe manual handling practices. Further, when nurses are conflicted between reporting what they perceive as an insignificant
injury, with feelings of guilt in “troubling” their manager, they may
have experienced being unheard or devalued. With unpredictable
patients and lack of managerial and organisational support, patient
and system level factors beyond their control, impacted on nurses’
ability to change their practice to decrease injury [14]. Not only
are emergency nurses working in an unpredictable environment,
but change itself is unpredictable and uncertain and can result in
fear; a primary emotion [10]. Fear of repercussions was also a frequent reason for not reporting pain/injury. A cultural expectation
that musculoskeletal pain is part of nursing work, where injured
workers are not supported, may be seen as violations of ethical
professional practice to protect workers.
Furthermore, in analysing respondents reports, there was a
suggestion that managers behaviours may have been the result
of moral distress as they were conflicted between supporting
their staff, and providing staff numbers to deliver care. Managers
behaviours such not being receptive to feedback and concerns, or
lack of action on reports, or “making it clear that staff are replaceable” indicate there may have been increased distress levels. Thus,
moral distress can occur in managers as well as staff and can result
in reduced performance with poor planning, normalising understaffing, inadequate training, working with inadequate resources
and rushing [9].
As highlighted by Blom and Viljoen [10], “Only when leadership is able to mitigate the fear response in individuals [and
themselves], can meaning and successful change become possible”.
As highlighted by Hiler et al. [20], sustaining a healthy workplace includes “skilled communication, true collaboration, effective
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Australasian Emergency Care xxx (xxxx) xxx–xxx
decision-making, appropriate staffing, meaningful recognition, and
authentic leadership”(p.60) .
Conflict of interest
None of the authors have a conflict of interest.
Limitations
Acknowledgements
A limitation of this study was the inclusion of Australian CENA
members only, consequently, the voices of registered and enrolled
nurses who were not members of CENA were not included. The
sample was also a voluntary, self-selecting sample. Whilst the
findings of this study may not be able to be generalised to all
nurses, there is still the ability to examine the relationship between
pain/injury and response [21]. Also, while the data was interpreted
through the lens of moral distress theory, nurses were not specifically asked if they found a situation morally distressing.
The authors acknowledge the participation of the emergency
nurses who participated in this study. We also acknowledge the
Board of Directors and Research Committee of the College of Emergency Nursing Australasia (CENA) for their support to access the
CENA membership for completing the survey.
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Implications for practice
Nurses need to find the courage to report all pain/injury sustained at work. Managers need to take all reports seriously,
implementing actions to decrease injury. Moral distress is serious
and impacts on managers and nurse’s performance, decisionmaking ability, capacity to follow policies and procedures, and
make changes to practice; all impacting their wellbeing in the
workplace [22]. Nurse managers need to be aware of morally distressing situations that may occur and the effects on nurses, and act
to reduce these. EDs should conduct regular reviews of the workplace to identify potential stress/moral distress factors that may
be eliminated or reduced by preventive interventions [9]. Managers can use screening tools such as the Measure of Moral Distress
for Healthcare Professionals (MD-HP) [18] to screen for the effects
of moral distress and intervene as necessary. Education programs
need to include: the identification of moral distress; predisposing
factors; identification in staff; and strategies for decreasing moral
distress and increasing wellbeing. Further research is required to
identify any moral distress in the ED, with a view to developing
educational programs and interventions to decrease its impact.
Research needs to focus on strategies that can be used in real time,
on-the-job, as the morally distressing episode occurs to lessen the
known crescendo effect on staff wellbeing [22].
Conclusion
A workplace culture of trust, respect and open communication
decreases stress and moral distress, enables safer workplace manual handling practices and reporting of pain/injury. Moral distress
is an invisible workplace challenge that needs to be met for staff
wellbeing.
Funding
An internal academic grant was provided by Monash University
to conduct of the survey.
Provenance
This publication does not concern any commercial product,
either directly or indirectly.
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