The past 18 months represents the most stressful time in most nurses’ careers. Nurses working in long term care have confronted COVID-19 with determination, courage, and compassion. Now, nurses are encountering another more personal challenge … fatigue, burnout, and moral distress. By prioritizing self-care and integrating workplace wellness strategies nurses can proactively protect their personal well-being.


Prior to the pandemic crisis nursing in long term care was already a stressful job with high levels of clinical and leadership responsibilities that required the balancing of effective and compassionate resident care with sector limitations. The COVID-19 pandemic has compounded these issues and the prolonged physical and mental strain has resulted in many nurses experiencing fatigue, potentially leading to burnout and moral distress, and impacting the sustainability of the nursing workforce.

Nurses recognize they must now prioritize their personal well-being. Taking care of themselves protects their own mental and physical health and improves their job satisfaction, workplace engagement, and performance.

Given the significant importance of nurses’ contribution to quality and safety, both for the people who work in, and the residents that live in, long term care, it is essential that all stakeholders truly understand and support nurses as they seek to protect their well-being in the face of burnout and moral distress.

Burnout

Even the most resilient nurse could experience feelings of being overwhelmed and not coping well as the pandemic progressed. The communication overload was enough to make anyone feel frustrated and anxious. These feelings, plus the grief associated with the loss of life and the heightened fear that if not already, it could happen here, or the risk of exposing family members, left many feeling emotionally or physically drained. And now as we move into the 4th wave nurses must brace themselves once again and draw on their inner strength to lead their team through this recurring pandemic. As a result of these difficult conditions, nurses are at a high risk for burnout (Sriharan et al. 2021). Burnout is in response to chronic workplace stressors, which of course the pandemic crisis has now become. Over and above feeling completely exhausted (emotionally and physically), the nurse may have a sense that they are no longer effective, experience little to no job satisfaction, have headaches and irritability, with increasing cynicism and detachment. When dealing with these symptoms the nurse may initially begin to miss work deadlines, procrastinate, be late for work, complain of feeling persistent tiredness or have physical illness. As the symptoms intensify there is increased absenteeism escalating to sick leave and ultimately the nurse quitting their job and leaving a profession they had once loved and were committed to. We need to support, not stigmatize nurses, if they do experience burnout. It is not a sign of being an ineffective nurse or of not being able to cope. Instead, we all share responsibility in preventing burnout and to work on personal and professional solutions.

Moral Distress

Doing the right thing for both the resident and the staff ensures that nurses maintain their professional integrity and ethics. During the pandemic difficult and complex decisions were made that were often outside of nurses’ control. In fact, the nurse may have felt a different action was the “right” thing to do in the best interest of the residents. Often external constraints made it nearly impossible to take what the nurse felt was the right course of action. A common example was isolating residents even though the nurse felt it was causing increased anxiety, agitation, and confusion for the majority of the residents. Not being able to act accordingly resulted in nurses feeling powerless, guilty, and experiencing moral distress. Other causes of moral distress may be working with inadequate resources (supplies or staff shortages), being pushed to function outside their usual scope of practice, lack of collaborative decision-making and juggling the need for efficiency with the needs of residents. All of these conditions and actions contribute to a decline in quality care and can be a source of moral distress (Pijl-Zieber et al. 2008).

Moral distress results in negative emotions such as anxiety, anger, resentment, and frustration as well as physical symptoms such as insomnia, bouts of crying and headaches. Moral distress is closely aligned with burnout and both impact quality care, staffing shortages and lack of job satisfaction (Sriharan et al. 2021). It becomes a vicious cycle where nurses feel stressed and overwhelmed, experience burnout, leave their jobs, resulting in staff shortages which then fosters conditions for nurses to experience moral distress, which then accelerates further staff turnover. Again, proactive strategies are required to limit conditions that contribute to the moral distress experienced by nurses, and to support nurses as they grow to understand the meaning of moral distress and determine preventative strategies.

Personal Protection Strategies

My Plan, My Way

Woman sitting pensively on the corner of a dock looking out at water
Photo by Keenan Constance from Pexels

We have all read or heard the messages about the importance of self-care. The abundance of advice can seem overwhelming and result in feelings of guilt and anxiety. How can I possibility fit self-care into my life when I have so many other higher priority commitments and responsibilities? If by the end of the day you are feeling exhausted, it can be difficult to find the energy and motivation to focus on self-care activities when all you really want to do is watch a mindless TV show.

But wait a minute, is this really a problem? We know that we look at the resident from a holistic perspective, considering their physical, emotional, social, mental, and spiritual needs. Isn’t this the same philosophy we should apply to self-care? We understand that each of us is a unique “whole” person and recognize the interdependence between our biological, social, psychological, and spiritual selves. Therefore, isn’t it reasonable to suggest that the focus of self-care should be on you, and as such only you can determine what approaches will work best to replenish and revitalize your body, mind, and spirit.

To shift your thinking away from the litany of recommended self-care activities that you feel obliged to try, reflect on things you do that relax or energize you. For example, getting together with a friend. Does this leave you feeling calm and happy or drained and upset? What about taking a walk? Do you return feeling positive and optimistic or negative and tired? Monitor your feelings and do the things that make you feel good and limit the things that make you feel bad! So go ahead, take control. Protect your personal well-being by creating a self-care plan, based on your terms and needs. And, if at the end of viewing a mindless TV show you reflect and think that was relaxing and enjoyable, add it to your self-care plan. If you feel frustrated and irritated, it would be a good idea to remove it from your plan. After all, it’s your plan, your way!

Attitudes That Impede Self-Care

All or Nothing

A hindrance to self-care is the attitude that either you fully commit to self-care, or there is no point to doing anything. Realistic self-care is a step-by-step process. You try one achievable activity, monitor how it makes you feel, and if it works, add it to your self-care plan. Success is realized when you make small changes over time, as you continue to grow your personal self-care plan.

Some have said that self-care seems selfish, even self-indulgent. This is simply not true. Being selfish focuses on “me” and doing only for oneself and not giving to others. Conversely, self-care benefits you and everyone else. It ensures that you don’t deplete all your personal energy, enabling you to effectively take care of others.

Silo Thinking

Another self-care attitude negatively impacting success is when self-care is considered so personal that it cannot be integrated into other aspects of one’s life. However, self-care plans work best when integrated with your personal and professional life. For example, if exercise through walking provides relief and a sense of accomplishment, wearing a step counter and monitoring steps at work and away from work overcomes one silo in your life.

Put It Behind You

It is easy to criticize yourself and hard to practice self-forgiveness. When you hear your internal voice chastising you for slippage from your self-care plan, as difficult as it can be, let it go.  By practicing self-forgiveness, you reduce your anxiety and stress, boost your positivity, and set the stage to reflect and learn from your experience. You are doing the best you can right now. Remember to apply this same principle to others as they too are doing the best they can. “If you are more accepting of others, then you inevitably become more gentle with yourself” (Brene Brown, 2017).

Workplace Protection Strategies

Given the urgency of nurse shortages in LTC it is imperative that organizations look to strengthen well-being protection strategies to retain current employed nurses and recruit others. By integrating employee well-being into the values of the Home, it will hold everyone accountable to advocate and support workplace well-being strategies.

Communicate and then Repeat and Repeat again

Group of employees having a discussion at a table.

During this COVID-19 crisis communication remains a key success strategy. Between frequent meetings, team huddles, emails, and printed messages, effective communication is fundamental in sharing new and updated information. Communication needs to be timely and transparent, and leaders need to listen and acknowledge concerns. It is important to keep these communication techniques open, post-pandemic, to avoid information gaps and to support nurses in their leadership and clinical practice. On the other hand, poor communication practices will serve to increase frustration and stress.

Engage and Empower

During the pandemic nurses have demonstrated their critical thinking skills and determined innovative solutions that not only impacted the nursing department, but the organizational level as well. Managers need to continue to harness this potential, so nurses feel recognized and empowered.

Continuing to engage nurses in decision-making and seeking their input and feedback also fosters this sense of empowerment, builds healthy work relationships, and creates a positive work environment.

Working Together

Well-being involves a broad range of feelings, attitudes, and both internal and external experiences and conditions. It is subjective and includes physical and mental dimensions. Strategies are not a “one size fits all” making it more challenging for workplaces to support nurses’ well-being. Managers and nurses should work together to determine wellness initiatives that encourage active participation. This collaborative approach will ensure that the voices of nurses are heard, and that what is important to them is reflected in the program. Utilize available tools to assess employee wellness, or the organization can create their own assessment tool.

Well-Being Support

Nurses should know their well-being is vital to the success of their Home and be encouraged to share when and why they are feeling stressed. Their managers should reinforce that feeling stressed is not a sign of weakness, but is in fact normal, and invite the person to a private or group meeting or have an informal conversation to discuss their feelings and conditions contributing to their stress. However, managers should not wait for the nurse to report feelings of anxiety and stress, but instead check-in regularly and be alert to signs of burnout and moral distress.

Managers should also make sure that there is a safe place for nurses to gather and reflect on the pandemic experience. Reflection allows nurses to hear others’ perspectives, share emotions, and to find a sense of meaning from the pandemic experience. This process is an important step in restoring confidence and re-vitalizing commitment to the Home.

Summary

Nurses working in long term care have demonstrated extreme resilience throughout the COVID-19 pandemic. They have been able to adapt quickly and successfully navigate through this complex and rapidly changing work environment. There has been a substantial amount of professional growth and a deep sense of accomplishment.  They have been steadfast in providing compassion and support to colleagues, staff, residents, and families.

Now is the time for nurses to pause and reflect on their personal well-being. They should consider how the pandemic has impacted their mental and physical health and commit to self-care actions that will protect them from burnout and moral distress. Long Term Care organizations should also prioritize initiatives that support the well-being of their nurses to ensure they have the energy and positive approach to guide their teams and residents through upcoming uncertainties and towards the new reality of long-term care.

References

Blake N (2021) Building a new, better normal after COVID-19. Nursing Management; 52:6,20-23.

Brown D (2017) Brene Brown on the 1 question you need to ask about people you truly dislike. Inc Newsletter [online}; Available at: https://www.inc.com/damon-brown/brene-brown-on-the-one-question-you-need-to-ask-about-people-you-despise.html. Accessed September 2021.

McLean C, Kamkar K (2020) Helping health care workers cope with COVID-19 related trauma. Anxiety Canada [online]; Available at: https://www.anxietycanada.com/articles/helping-health-care-workers-cope-with-covid-19-related-trauma/. Accessed August 2021.

Moore C (2020) Nurse leadership during a crisis: ideas to support you and team. Nursing Times; 116:12, 34-37.

Pijl-Zeiber E et al (2008) Moral distress: an emerging problem for nurses in long-term care. Quality in Aging; 9:2, 39-48.

Prestia A S (2020) The moral obligation of Nurse Leaders: COVID-19. Nurse Leader [online]; Available at: https://pubmed.ncbi.nlm.nih.gov/32313516/. Accessed August 2021.

Sriharan A et al (2021) COVID-19 related occupational burnout and moral distress among nurses: a rapid scoping review. Nursing Leadership; 34:1, 8-19.

Su A J (2017) 6 ways to weave self-care into your workday. Harvard Business Review[online]; Available at: https://hbr.org/2017/06/6-ways-to-weave-self-care-into-your-workday. Accessed August 2021.

Westring A F (2021) There’s no “right” way to do self-care. Harvard Business Review[online]; Available at: https://hbr.org/2021/04/theres-no-right-way-to-do-self-care. Accessed August 2021.

Darlene Legree

Darlene has over 35 years of diverse experience in long term care, from direct care provider, registered nurse, to management and staff education positions. With additional education in Nursing Informatics, MDS and Adult Education, and receiving her Gerontology Certification from the CNA, Darlene provides training and consulting in clinical, documentation, leadership and organizational practices. Darlene sits on the executive of Gerontological Nursing Association of Ontario – Central East Chapter.