The Face of Moral Distress and Self-Stewardship Among Oncology Nurses
Since the onset of COVID-19, the United States, Brazil, India, and Russia have maintained a status of having the highest incidence of confirmed cases.
Since the onset of COVID-19, the United States, Brazil, India, and Russia have maintained a status of having the highest incidence of confirmed cases.1 According to the World Health Organization, as of January 2022, there have been over 64 million confirmed cases in the United States.2 Health care workers have been severely affected by this illness and there has been a consequent increase in pressure on the nursing workforce and health care system.1 Anxiety, depression, fear, burnout, and posttraumatic stress disorder have played a role in increasing that pressure.3 Other contributing factors include the fear of contracting COVID-19, social isolation, and exposure in the workplace.3,4
Among all populations, patients with cancer are recognized as a vulnerable group susceptible to the COVID-19 virus because of their prolonged weakened immune system. Their long-term treatment trajectory also increases their risk because of frequent visits to a health care facility and possible exposure to a patient who has the virus. Compared with other populations, these patients are also at significant risk for transfers to the intensive care unit, intubation, and death.5
To date, patients with cancer have also demonstrated the highest complications associated with COVID-19.5,6 These complications manifest as physical and psychological stressors that were identified at the outset of the pandemic. Patients have expressed fears of contracting the illness, ongoing management of their treatment, and end-of-life care that limits the physical presence of their loved ones. Additionally, mental health disturbances can lead to continued worry about the trajectory of their illness, increased physiological pain, and stress related to COVID-19.7
Despite the challenges brought about by the pandemic, patients with cancer deserve staff who are not only competent but prepared to stand by them through diagnosis, treatment, and outcomes.8 Nurses who are resilient have demonstrated a higher level of engagement, care, and dependability. This engagement leads to higher patient satisfaction as well as improved outcomes. Moreover, self-care and organizational strategies are 2 significant evidence-based interventions that have proved to reduce psychological distress, especially during health care crises.
Self-Care Strategies to Reduce Psychological Distress
Health care workers will soon have to make sense of this crisis.3 They will need assistance to reshape their lives and practice self-care to reduce the risk of burnout. When health care providers are not emotionally well, it can be extremely challenging for them to heal others.
Self-care builds moral resilience and enables nurses to respond positively to stressors. Resilience allows “one to maintain perspective, keep a situation in context, and understand that some conditions are out of one’s control.”4 Nurses can build this skill through activation of the parasympathetic nervous system, which reduces their response to stress and exercises mindfulness. Strategies such as breathing exercises or guided meditation through the help of mobile apps can be useful in assisting nurses to find meaning in their work.
Self-stewardship is also an important strategy for maintaining resilience. It is defined as the “skill of tending to and nurturing one’s well-being,”4 an important skill during this current pandemic given its ability to help one cultivate an accurate perspective of stressors. It helps nurses to understand that they have done nothing wrong during this public health crisis. Self-stewardship can be cultivated through psychological interventions, professional forums, and even safe spaces that allow individuals to express their frustrations.
Organizational Strategies to Reduce Psychological Distress
Leaders within the health care system who want to reduce moral distress and burnout among their staff must provide evidence-based interventions. For example, 9 strategies were implemented at the Mayo Clinic to promote engagement and reduce caregiver burnout:9
- Allowing staff to have sincere discussions with leaders to solve burnout and promote overall well-being.
- Seeking to understand what motivates staff and provide meaning in their work.
- Developing targeted interventions that foster improvements in each department.
- Developing community among colleagues by sharing ideas such as debriefing, pausing to remember patients who have died, and Schwartz rounds.
- Using rewards and incentives to show respect and encouragement for staff.
- Aligning values to foster a healthy workplace culture.
- Promoting work-life balance among staff to produce the best work.
- Providing resources to promote resilience and selfcare such as meditation.
- Facilitating and funding research that other organizations also can use to reduce burnout and promote staff well-being.
This pandemic has lasted longer than anyone could have anticipated. As we move forward, it is time for health care workers and administrators to work together to implement solutions and provide relief. It is time to begin to heal.
- Labrague LJ, De Los Santos JAA. COVID-19 anxiety among front-line nurses: predictive role of organisational support, personal resilience and social support. J Nurs Manag. 2020;28(7):1653-1661. doi:10.1111/jonm.13121
- Situation Reports January 2020. World Health Organization. January 2020. Accessed January 17, 2022. https://bit.ly/3IgBK6h
- Shah M, Roggenkamp M, Ferrer L, Burger V, Brassil KJ. Mental health and COVID-19: the psychological implications of a pandemic for nurses. Clin J Oncol Nurs. 2021;25(1):69-75. doi:10.118/21.CJON.69-75
- Hossain F, Clatty A. Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nurs Ethics. 2021;28(1):23-32. doi:10.1177/0960733020961825
- Liu C, Zhao Y, Okwan-Duodu D, Basho R, Cui X. COVID-19 in cancer patients: risk, clinical features, and management. Cancer Biol Med. 2020;17(3):519-527. doi:10.20892/j.issn.209-3941.2020.0289
- Robilotti EV, Babady NE, Mead PA, et al. Determinants of COVID-19 disease severity in patients with cancer. Nat Med. 2020;26(8):1218-1223. doi:10.1101/2020.05.04.20086322
- Wang Y, Duan Z, Ma Z, et al. Epidemiology of mental health problems among patients with cancer during COVID-19 pandemic. Transl Psychiatry. 2020;10(1):263. doi:10.1038/s41398-020-00950-y
- Blackburn LM, Thompson K, Frankenfield R, Harding A, Lindsey A. The THRIVE program: building oncology nurse resilience through self-care strategies. Oncol Nurs Forum. 2020;47(1):E25-E34. doi:10.1188/20.ONF.E25-34
- Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004