Unequal burden of hardship

Mental health experts warn that the feelings of guilt some nurses have reported could lead to mental health issues, self-harm or in some cases, even suicide.

Conversations with nurses, who wished to remain anonymous because they are worried that speaking out could threaten their jobs, revealed that guilt is impinging on every aspect of their working lives.

One critical care nurse, a senior sister in a London hospital, says she feels guilty when showing positive emotions at work because the prevailing culture is one of negativity.

‘When I was a junior nurse, a healthcare assistant told me to stop smiling because it was winding people up,’ she says. ‘I was made to feel I was letting everyone down by not fitting into the NHS culture of being miserable. I’m still careful not to be too positive. If I am, I feel I’ve done something wrong.’

A band seven cancer nurse, also in London, says he has stopped buying his morning drink because he is worried more junior staff cannot afford to go to the local coffee shop.

‘I know some of the junior nursing staff ask kitchen staff if there’s out-of-date food they can take home because they can’t afford to eat regularly,’ he says. ‘I feel bad when I’m swanning around the ward with a £3 coffee in my hand.’

bold>Constant feelings of guilt are affecting my life – what can I do?

RCN professional lead for mental health Stephen Jones says:

• » Talk Guilt is isolating, so speak to colleagues and mentors. RCN members can have free counselling

• » Accept A patient may need things you cannot provide. For example, they may require a nurse of a different gender. Accept that you are part of a team and are not capable of helping everyone

• » Reflect This can help reframe events that cause guilty feelings. When done individually or in a group, reflection can also highlight where practical changes need to be made

• » Challenge Feeling guilty can indicate wider changes need to be made in your department. Union reps can offer advice on how to challenge, and can offer support

Picture credit: Tim George

Risk of self-harm

Laura Hyde Foundation founder and trustee chair Liam Barnes started the charity to ensure medical and emergency workers had mental health support, to honour the memory of his cousin Laura, an emergency department nurse who died by suicide seven years ago.

He says guilt is a good word to use, as most nurses can relate to it, rather than terms he says pathologise, such as moral injury and moral distress.

‘Alarm bells should be ringing when nurses say they feel guilt regularly,’ he says. ‘Because when you are in this mindset of feeling guilty every day, you might start doing other things. You can be depressed or anxious, but in my view, it’s guilt that makes you self-harm.

‘It’s guilt that makes you feel you deserve to be harmed, that you are the guilty one. And where does it stop? From there, it becomes more extreme unless there are interventions.’

Not everything is your fault

Some nurses say that, for them, guilt – defined by the Cambridge English Dictionary as ‘a feeling of worry or unhappiness that you have done something wrong, such as causing harm to another person’ – even extends to sitting down for a break if there are too few chairs to go around.

A band five oncology nurse says her hospital’s lack of basic resources such as chairs, means she feels guilty sitting during long shifts.

‘We have to give the chairs to patients’ families,’ she says. ‘I was handing over, and the day nurse got hold of a chair for me and told me to sit down. I felt bad, because everyone else was standing, and I was the one with the chair.’

Some research has warned that guilt is considered pathological when an individual falsely believes they have caused another person’s problems, or thinks they have the means to relieve another’s suffering when they do not.

EF Training was set up in 2010 to deliver emotional health workshops to NHS staff and has worked with 85 NHS employers. Its founder, Jayne Ellis, was a diabetes specialist nurse who worked in the NHS for more than 30 years.

‘I was working with a trust in Manchester last week,’ she says. ‘I opened with my usual question: “What is it that makes you say yes, when your manager asks you to take on another shift?”.

‘It always sends chills through me when the entire room says “guilt”. Then they look at each other, and don’t know how to react, because they didn’t expect everyone else to say that same word.’

Ms Ellis says conversations with nurses have led her to believe many will have had motivation for entering nursing that now makes them more susceptible to guilt.

‘Broadly speaking, I think nurses come from three groups,’ she says. ‘Often they were raised in families that value public service, or they have a personal connection – for example, an oncology nurse whose mother died of cancer – or they have a personal mission that started young.

‘You’ll hear stories like “I started caring for injured snails in the back garden as a toddler, then friends, then I became a nurse.”’

Negativity at work may be internalised by individuals, which has a knock-on effect on their performance

Picture credit: iStock

Social conditioning and PTSD

Ms Ellis says this makes nurses more vulnerable to feelings of guilt when they cannot cope, because they feel their loved ones are being let down.

‘The health service is a very tough environment now,’ she says. ‘So, when the nurse from a public service family inevitably says they cannot cope, their family says, “But why?” They think they are letting their family down.

‘The nurse with the personal connection feels they are letting their mother down by not caring for oncology patients like they want to. The personal mission nurses often feel they have lost their life goal, they label themselves as naïve for having become a nurse and feel guilt for making the wrong decision.’

Frontline-19 founder Claire Goodwin-Fee is a psychotherapist who started the free psychological support service for NHS staff in 2020.

‘Commonly, we hear from nurses that their seniors will yell at them, patronise them, embarrass them in front of patients, dismiss concerns and tell them to shut up and get on with it,’ she says.

‘Transfer that template to your personal life, and that’s an emotionally abusive relationship, so it’s no wonder they are feeling guilt. They are internalising what’s happening to them, and then believe the abuse is their fault. Then they can’t care properly for patients, because they feel so distressed all the time. They’re guilty over that too.’

Ms Goodwin-Fee points to guilt as symptomatic of post-traumatic stress disorder (PTSD).

‘Some – but not all– nurse PTSD cases are related to working through COVID,’ she says. ‘We will often find that the PTSD is traced back to 15 or 16 years ago and the way the person was treated, what was expected of them, and the things they saw long before COVID.

‘Sometimes nurses will tell us their negative feelings are down to working through COVID when they’re not. That’s because there is a guilt about accessing psychological support, but not fitting the hero stereotype.’

Being a female-dominated profession means there are disproportionate levels of guilt and feelings of unworthiness in the profession, and other factors intersect too, says Ms Goodwin-Fee.

‘Being a woman means you’ll feel guilty whatever you do,’ she says. ‘For example, society sees your choice as wrong whether you’re a working mother, stay-at-home mum, or not a mother. That female social conditioning will affect nursing culture. But it is more complex than that. Race, class and immigration status affect how nurses are treated, and then feel, too.’

Senior nurses’ experience

Dementia UK chief executive Hilda Hayo, a nurse for 43 years, left her role as an NHS trust director of nursing in 2013 and says feelings of professional guilt affect nurses at all levels.

‘Guilt existed for me as director of nursing,’ she says. ‘It exists for many senior nurses. The higher up people go, they will believe they can’t leave the NHS because it’s all they’ve ever known. So, in senior positions you will find some people feel trapped and guilty for not having left sooner. They also feel guilt about conforming to something that really doesn’t fit their values anymore.’

She thinks professional guilt in nurses is best tackled by system-level change. For example, when patient care is missed, she says, nurses may blame themselves. Yet, the cause is often to do with organisational issues, such as understaffing.

‘You need managers who will treat the workforce like they want to be treated,’ she says. ‘Various NHS trusts have tried to do that a few times, but it hasn’t worked. There has been a focus on bringing in managers who make sure targets on paper are met, and meanwhile nurses are saying they feel guilty over sitting on a chair.’

Changing NHS culture

EF Training’s Ms Ellis agrees health service culture needs to change and singles out the How Are You Feeling? toolkit, provided by NHS Employers. It asks health service staff to take a quiz that assesses their emotional well-being and advises on how to improve this.

‘A nurse told me she felt distraught after using this tool,’ says Ms Ellis. ‘It is set up to make nurses feel guilty.’

How Are You Feeling? asks nurses to pick a smiley, sad or angry emoji to reflect their mood. Selecting the angry face prompts a response to the effect that colleagues may see the respondent as ‘prone to mistakes, defensive, and inconsistent’ and patients may see them as ‘too busy to help, short-tempered, and rude’.

Pressure from above can be difficult to bear for those on the front line

Picture credit: iStock

How are you feeling?

Anyone who selects the sad face is told colleagues may view them as ‘lazy, unhelpful, and like they are carrying you’, and patients may perceive them as ‘uncaring, cold and unreliable’.

‘They ask nurses, how are you feeling?’ says Ms Ellis. ‘When we say ‘sad’, they tell you “Okay well, everyone thinks you’re lazy and cold too”. If you want an example of why we feel guilt that affects mental well-being, here it is, in black and white. It exemplifies a whole culture that needs to change.’

NHS Employers director of development and employment Caroline Waterfield says the toolkit was developed in 2015 with input from NHS staff focus groups.

She says: ‘This is a popular and well-liked resource. We would never want users to have a negative experience when using it, or for its content to exacerbate negative feelings.

‘Our resources are regularly reviewed. We encourage feedback as it is invaluable in supporting the effectiveness of our products. This product is currently being reviewed and we will take these users’ comments on board.’