beattie2021

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Contents lists available at ScienceDirect
Australasian Emergency Care
j o ur na l ho me page: 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 Beattiea, Kelli Innesa, Kelly-Ann Bowlesb, Cylie Williamsc, Julia Morpheta,∗
aMonash
University Nursing and Midwifery, Wellington Road, Clayton, Victoria, 3800, Australia
bDepartment
of Paramedicine, Monash University, Peninsula Campus, 47-49 Moorooduc Hwy, Frankston Victoria, 3199, Australia
cMonash
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 emergen-
cies,
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 con-
flicted
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 debili-
tating.
•Predisposing
factors include organisational, cultural, patient-
related,
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 under-
standing
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 emer-
gency
staff wellbeing.
Introduction
Workplace injury and musculoskeletal disorders, particu-
larly
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 lift-
ing/transferring
injuries may be prevented by using mechanical
lifting
equipment. Yet mechanical devices are unable to pre-
vent
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 activi-
ties
[3].
Recommendations
by Jones [4] include the passing of legisla-
tion
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 fac-
tors
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 exam-
ple,
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 life-
threatening
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.
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. con-
fined
working spaces); organisational factors (e.g. lack of equipment,
inadequate
staffing levels, and work-time pressures); patient-
related
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 knowl-
edge/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 mak-
ing,
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 prac-
tice
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 prac-
tices
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 inter-
nal
constraints, which can result when nurses’ belief systems are
not
considered, resulting in internal conflict. Consequently, when
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 communica-
tion,
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 open-
ended
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.
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 demo-
graphics
and whether or not participants had experienced
musculoskeletal
pain or injury at work. Open-ended questions
sought
information about: whether or not participants had expe-
rienced
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 qualita-
tive
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 prac-
tice,
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.
Responses n = 175
n
(%) or Mean
(SD)
Gender n (%)
Male
32
(18.3)
Female
142 (81.1)
Prefer
not to answer 1 (0.6)
Age
group n (%)
Under
25 6 (3.4)
25−29 22
(12.6)
30−34 28
(16.0)
35−39
22 (12.6)
40−44
20 (11.4)
45−49
26 (14.9)
50−54
16 (9.1)
55−59 23
(13.1)
60−64
10 (5.7)
65−69
2 (1.1)
Principal
place of practice n (%)
Victoria
64 (36.6)
Queensland
40 (22.9)
New
South
Wales
23
(13.1)
South
Australia 21 (12.0)
Western
Australia 17 (9.7)
Tasmania
6 (3.4)
Northern
Territory 2 (1.1)
Australian
Capital Territory 2 (1.1)
Location
of practice n = 174 (%)
Metropolitan
110
(63.2)
Regional
41 (23.6)
Rural
21 (12.1)
Remote
2 (1.1)
Role
in emergency department n (%)
Nurse
Unit
Manager 10 (5.7)
Associate
Nurse Unit Manager 9 (5.1)
Nurse
Practitioner 10 (5.7)
Clinical
Nurse Specialist 37 (21.1)
Registered
Nurse/Clinical Nurse 92 (52.6)
Enrolled
Nurse 4 (2.3)
Nurse
Educator/Clinical Support Nurse 12 (6.9)
Clinical
Nurse
Consultant
1
(0.6)
Time
spent in emergency service areas Mean % of Time (SD)
Admin/Research/Management/Education
17.37 (28.58)
Triage
17.70 (18.34)
Resuscitation
Cubicles 20.28 (19.48)
General
Cubicles 28.47
(29.96)
Fast
Track 9.24 (16.04)
Waiting
Room 3.34
(6.03)
Procedures
Rooms 3.50 (7.78)
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 profes-
sional
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
The
majority of participants who answered this question
reported
experiencing work-related musculoskeletal pain/injury
Table 2
Ways
in which respondents changed their practice.
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
55
(59.1)
Used
lifting equipment 11 (11.8)
Enlisted
colleague assistance 11 (11.8)
Decreased
unnecessary manual loads, reduced bed
movement
8 (8.6)
Refuse
risky tasks to avoid long term injury 4 (4.3)
Unable
to physically assist patients as before 3 (3.2)
Decreased
working hours, including double shifts,
overtime,
time spent in clinical nursing
3
(3.2)
Changed/thinking
of changing working role e.g.,
education,
research, academia
3
(3.2)
Increase
patients’ independence 3 (3.2)
Ergonomic
assessment/support e.g., sit-stand desk
when
in office
2
(2.2)
Extensive
occupational health, safety/No lift
education;
educating
staff on smart practices
2
(2.2)
Regular
stretching/exercise at work 2 (2.2)
Only
participate in resuscitation when no other option 2 (2.2)
Let
the patient ‘fall’ (instead of catching them) rather
than
risk self-injury
1
(1.1)
Enlist
family members’
assistance 1
(1.1)
Hospital
terminated respondent 1 (1.1)
Keep
to
myself as I do not want to draw attention to
myself
1
(1.1)
More
cautious around mental health patients 1 (1.1)
With
minimal adjustable
computer screens,
changed
multifocal
glasses to avoid neck hyperextension
1
(1.1)
Loss
of
weight 1 (1.1)
“Orthotic
shoes” 1 (1.1)
Have
not been able to return to work yet due to injury 1 (1.1)
aRespondents
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 num-
ber
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 partici-
pants
made comments that did not relate to the question of change
(14/139;
10.1%).
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 occur-
rence
of pain or injury. Of those, the most frequent enablers to
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Table
3
Reasons
pain/injury did not lead to practice change.
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
7
(21.9)
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)
6
(18.8)
Patient
factors: obesity; unexpectedly grabbing
nurses;
assault; refusing care/direction during lift
(no
other practice change identified)
4
(12.5)
Equipment
not
available or
faulty 3
(9.4)
Pain
medication (no other practice change identified) 2 (6.3)
Lack
of support: Told to take Panadol and rest; told to
just
get on with it (no other practice change
identified)
2
(6.3)
Acceptance
that nursing work is heavy/difficult;
general
wear/tear of the work which often heals
with
rest (no practice change identified)
2
(6.3)
Accidental
injury e.g., unexpected and seemingly
innocuous
tasks
2
(6.3)
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
2
(6.3)
Short
duration of pain (no practice change identified) 1 (3.1)
Musculoskeletal
things tend to work themselves out
over
time
(no practice
change identified)
1
(3.1)
Pre-existing
genetic disorder (no practice change
identified)
1 (3.1)
Had
surgery to repair injury (no practice change
identified)
1 (3.1)
aRespondents
gave more than reason for not changing practice.
reporting workplace
pain
and injury (n = 29/69; 42%) were hos-
pital
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 inabil-
ity
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 work-
place
culture of trust, respect, and open communication enhanced
reporting
verbally and via email (n = 14/69; 20.3%). Requiring med-
ical
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 moti-
vator
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 expe-
rienced
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
Table 4
Enablers
to reporting pain/injury.
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
29
(42.0)
Unable
to complete shift or work due to pain and/or
physical
limitations
15
(21.7)
Open
policy and departmental culture of trust, respect,
open
communication
14
(20.3)
Self-protection
to ensure a
record in case of ongoing
issues
requiring future treatment or time off work
7
(10.1)
Required
medical assistance at the time or soon after
injury
6 (8.7)
Witnessed
by colleagues 4 (5.8)
Manager
needed to be aware of why nurse was off
work
2 (2.9)
Didn’t
want to make it worse by working more 1 (1.4)
aRespondents
gave more than one example of change to practice.
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 bar-
rier
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 big-
ger
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 report-
ing
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 pre-
vented
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.
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Table
5
Barriers
to reporting pain/injury.
Barriers to reporting Respondent n = 58 (%) a
Perceived
as a minor/insignificant injury 19 (32.8)
Unclear
cause
of injury 10 (17.2)
Lack
of support 9 (15.5)
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
8
(13.8)
Accepted
as part of the job 8 (13.8)
Did
not
impact daily living or
ability to work 4
(6.9)
Self-manageable
3 (5.2)
Too
busy/too time consuming to report 3 (5.2)
Feel
weak reporting 2 (3.4)
Exacerbation
of pre-existing back pain (scoliosis) 1 (1.7)
Not
very much organisation could do 1 (1.7)
aRespondents
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 identi-
fication
of areas where nurses may have been conflicted between
changing
practice and providing care to patients, while also try-
ing
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.
Discussion
It is well known that musculoskeletal pain or injury is a com-
mon
occurrence
in emergency nurses [2,8]. However, there is a
paucity
of research identifying practice changes as a result of man-
ual
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 abil-
ity
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.
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 possi-
ble
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 con-
flicted
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 fre-
quent
reason for not reporting pain/injury. A cultural expectation
that
musculoskeletal pain is part of nursing work, where injured
Table 6
Components
of moral distress: Sample response.
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).
Unheard
or
devalued
professional
insights
Didn’t
think it would be taken seriously (ID5).
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).
Violations
of
ethical
professional
practice
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).
Repetitive
situations
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).
System
cause 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).
Patient
cause 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).
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 replace-
able”
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 under-
staffing,
inadequate training, working with inadequate resources
and
rushing [9].
As
highlighted by Blom and Viljoen [10], “Only when lead-
ership
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 work-
place
includes “skilled communication, true collaboration, effective
5