Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

A reader responds to our recent blog post on the Heavy Burden of Moral Distress. We hope you find this real-life example an encouragement that correctional nurses are speaking up when they have concerns about patient health issues in the criminal justice system.

The topic of moral distress among nurses is an elephant in the conference room of many healthcare organizations but at the core of conversations amongst nurses in the medication room.    A few typical statements made during these informal, ethically charged and expressive gatherings include; “It doesn’t’ do any good to tell anyone, they won’t do anything.” “It’s all about the bottom line.” “They don’t care how much more work they give nurses.” “Nurses who complain too much get fired.” “I need a job to so I can take care of my family.” “This is just the way it is, get used to it.”  Statements like these are made with such frequency today that moral distress could and should be viewed as an epidemic in nursing practice.  The following is a glimpse into the challenges some correctional nurses faced and how their quest and obligation as nurses to do the right thing put them on a path leading directly into the dark, lonely void of moral distress.

My Story

While working at a correctional facility, three nurses expressed their ongoing concerns to supervisors and administration about the well-being of inmates who were:

  • Not getting their prescribed medications for extended periods. This includes medications for chronic conditions, seizures and other serious illnesses,
  • Providers prescribing incompatible medications and refusing to change the order(s),
  • Providers documenting physicals on inmates they had not seen,
  • Stat and other critical orders not getting noted for days,
  • On-call providers not returning calls and,
  • Inmates with serious, potentially life-threatening conditions, being transferred without regard to maintaining some continuity of care.

A few nurses called the allegedly anonymous organization  “ Hot Line,” (nurses are encouraged to use these for reporting purposes) and voiced their concerns but to no avail.  Having exhausted all efforts to report their concerns internally they reached out to their local nursing organizations.  While these organizations provide invaluable services and support in many areas they were unable to provide immediate direction or tangible backing for these situations. They, like the nurses, were uncertain who they should and could turn to for support.

The onset of moral distress began when the first link in the organization’s chain of command broke because of  failed communications and after dismissing the nurses concerns with indifference.  The distress peaked when the nurses were terminated for doing the right thing. Terminated for doing what nurses are required to do, what we have vowed to do – complying with the Nursing Code of Ethics.

Nurses have taken an oath and are required to practice in accordance with the Nursing Code of Ethics which provides:

  1. A succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.
  2. It is the profession’s nonnegotiable ethical standard.
  3. It is an expression of nursing’s own understanding of its commitment to society.

The sections applicable to the events being discussed are 3.4 and 3.5 as noted below:

Nursing Code of Ethics 3.4 “Standards and Review Mechanisms” 

Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review.

Nursing Code of Ethics 3.5, “Acting on Questionable Practice”

When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns.

Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.

Obligated to Speak

Nurses are obligated to bring difficult issues forward for discussion and review. We are duty-bound to report unsafe practices and or circumstances and must do so regardless of personal risk.  However, at the same time there is a responsibility to provide nurses with support and assistance when they do speak out. This is the crossroads where the path of moral distress becomes the loneliest and sometimes most frightening. It is alsothe time when a nurse needs support and encouragement the most. Unfortunately it is at this intersection that most nurses feel alone, abandoned, and with nowhere to turn.  This often becomes a turning point for nurses believing they must choose between speaking out or getting terminated; consequently many nurses make a silent and painfully emotional promise to never speak out again.  This forces nurses to overlook practices that not only put their patients at risk but their nursing license as well.  At this juncture moral distress has become an emotional pathogen.  Were it not for the support and encouragement of our patients and the public, many nurses would leave the profession.

Public Esteem

The public’s long-standing esteem for nurses is well documented in public opinion polls. Nurses rate high with the public in trended national survey questions about trusted professions, prestigious occupations, and “honesty and ethical standards.”  It is disheartening that organizations do not always see their nurses through the public’s eyes.  It is regrettable that even nurses don’t see themselves through the public’s eyes.  If nurses would stand together in our communities of practice perhaps we could begin a dialogue with our local nursing associations and employers to establish the support system illustrated in the Nursing Code of Ethics. Together we could address the circumstances and symptoms associated with moral distress at the onset and transform them into opportunities for change before nurses are forced to make that dreaded silent promise to keep quiet. Speaking out is included in the nonnegotiable ethical standards.

Would you be willing to speak out in a similar situation? Join the conversation with a comment.

8 thoughts on “Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

  1. My initial response is – that would never happen in my organization. Then my next thought Get Real! I am going to use this to start a conversation here as well. I expect lots of enthusiastic responses!


    • So true, Barb! I was thinking something similar. How great that you will use this to launch some dialog in your organization. Good will come of it!


  2. Speaking from my personal experience, I was Morally Distressed into such poor health and depression, I was like the proverbial frog in the pot of water. I hand it to jail nurses, because hands down it is one of the most difficult jobs on the planet. You almost have to not care about people to survive, or have exceptional ability to put it aside. I could not. It was very difficult watching people in Solitary confinement, and those with complicated medical conditions, Solitary, for lengthy periods of time for the mentally ill. I literally watched people getting sicker from extended time in Solitary, up to years. It was extremely difficult to motivate people, and custody DID NOT want to hear about these concerns. No One was tracking the length of or the number of times with the use of solitary for medical or disciplinary purposes. Mental Health did not want to hear about these concerns, which flabbergasted me. Advocating became a daily passion, and I tried to use my influence to create changes that would be positive. I watched it fall apart due to administrative bureaucracy, lack of vision, laziness, “not my problem” attitudes, active labeling of people as ‘the walking wounded’, ‘garbage’, never going to change, and not worth anyones time or money. Complete unwillingness to even attempt to make a change. The majority of staff were institutionalized. Unfortunately, I was actively undermined by my own staff nurses (usually those in the field for a long time), most had no interest in what they perceived as “more work”, or “feel good” work. I was even once told that nurses do not educate inmates about medicines, or chronic diseases. The ones with the ability to see the bigger picture, or who cared, like myself, are at risk. The worst thing you can be labeled is “an inmate lover”. Most people do what they do to CYA, or CYA of your buddy. I once was asked if I had ‘slept with an inmate’ because I was asking for something slightly out of the way to happen for them. (get release medications) Then there were the full out jaded, just plain mean. All of these attitudes, postures, demeanors, are symptoms of moral distress in part, (or a much bigger problem) It can only be remedied by excellent visionary leadership in the custody division, and the people who support the larger infrastructure of an actual community oriented health care model. Support for nurses and nursing, public health awareness, disease prevention, addiction and treatment, re-entry and recidivism reduction. It will take a lot of will to make the culture changes this country needs to change the delivery of care in these institutions. So obviously, I had to leave, and not of my choice, because I loved the work I was doing. The burnout, the opposition, the back stabbing, proved too much for me, my health was suffering, and I wish this topic and discussions like it had been available as a place to help me identify and seek support sooner for what was going on for me. Thank you for this.


  3. Your post unfortunately provides a very accurate description of what goes on behind bars. Thank you for doing everything you could and I hope you are feeling better. The nursing world needs more nurses like you. Take care.


  4. Thanks Elaine, I do appreciate your affirmation and concern, I think it is very hard to talk about, even after writing this, I wondered if I was doing the right thing or if there will be some backlash. I am doing great now, I have learned so much about myself, and systems change, and leaders vs managers. Fortunately i was lucky, and able to find great help, and am in a job that I enjoy very much.


  5. Thank you for everything that you have written re: Moral distress. You have nailed my situation and my feelings on the head. I feel that Corporations and Supervisors need to take more responsibility in inmate health. It is very easy for them to “blame” the nurses that are working with the inmates daily.
    I have been a Correctional Nurse for over 12 years, and see the continual decline in inmate care. It is sad. Corporations are a business and treat humans as a business. I see supervisors, that are only concerned about their self-advancement and will terminate great nurses “with cause”, but are not required to disclose to that nurse the reason for termination. What are they trying to hide?
    I wish more nurses would speak out, but I understand they feel intimidated and scared to speak out, in fear that they will also be terminated. I am sad that I have lost many good nursing friends, because if the supervisors knew they were still in contact with me, they would also be terminated.
    I would like to challenge all nurses to speak out and fight for nurses rights!


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