The Normalization of Risk, Silence Culture, and Moral injury In Nursing | Opinion

This is an opinion article contributed by a nurse under the pen name Larkin Mercer, an RN with nearly two decades of experience, with a primary focus in the OR and holding a CNOR certification. Drawing from years in rural healthcare, her work explores advocacy, moral injury, and the unseen pressures nurses navigate every day.

As you are driving down the highway, you pass a black-and-white sign Speed Limit 55 MPH. Initially, you set your cruise control to 55 and hold steady. Your thoughts begin to wander to your long to-do list and the limited amount of time you have to accomplish it all. You bump up your speed by a couple miles an hour. A few miles go by, and since nothing bad happened at 57 MPH you increase again to 60 MPH.

This is how easily the normalization of risk creeps into our busy lives.

As nurses, whether we are new graduates or experienced clinicians starting somewhere new, we all begin the same way: reviewing policies and procedures. They are printed in black and white much like the speed limit sign. There is no grey area. No room for interpretation.

For example, policies clearly define when breaks and lunches are to be taken. But what is written and what is practiced are two very different things.

We justify it in our minds. If we skip lunch today and finish our charting, maybe we can leave on time and make it to our child’s concert tonight. The next time, we skip lunch to take a new admission because staffing is short and our supervisor is pleading for help. We don’t want to let them down.

When these exceptions become routine and no immediate harm occurs, the line moves.

The normalization of risk occurs when repeated exposure to unsafe, emotionally harmful, or unsustainable conditions causes people to gradually accept them as routine.

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In healthcare, workarounds are often created with good intentions – to keep patients moving, to help a team get through the shift, or to compensate for time and resource limitations. But over time, what begins as a temporary adaptation can slowly become an accepted standard.

In the operating room, it may look like rushing turnovers to maintain throughput. Elsewhere, it may look like routinely working short-staffed, charting after hours, or relying on informal processes because “there isn’t time” to follow the intended one.

Healthcare workers are not intentionally lowering our standards or purposefully violating policy. More often, they are adapting in order to survive within the demanding system.

But adaptation can easily become acceptance.

Sometimes the most normalized risks are the ones no one can chart. They can only be felt.

When healthcare workers advocate for change and repeatedly see little or no response, many begin to experience moral injury. We know the situation is not right because our education, policies and professional standards taught us otherwise. Yet we have to continue operating on the other side of the line because of the demands from the system require it.

Over time, this can create guilt, grief, emotional exhaustion, hypervigilance and numbness. These experiences are often mislabeled simply as burnout, but they are not the same thing.

What eventually changes once the normalization of risk has developed is the culture itself.

Some people continue to speak up and voice concerns, but they are often met with statements like “This is the how we’ve always done it,” or they become labeled as difficult. This is how silence culture develops.

It creates an environment where people fear speaking up, fear disrupting hierarchy, and fear becoming “the problem.”

Silence in healthcare is often complex. It is rarely apathy. More often, it is exhaustion, fear, or learned helplessness.

The most dangerous part of normalization is that eventually it stops feeling abnormal.

So, who ultimately pays the price for the normalization of risk?

Everyone.

Patient safety is on the line every time that line moves. Nurses are harder to retain, and those who stay often sacrifice their emotional well-being in the process. Trust erodes. Team culture deteriorates under the constant pressure to “do more with less” while receiving little reciprocity in return.

No single moment creates these cultures. They develop gradually through accumulated compromises.

True resilience in healthcare will never come from asking people to endure increasingly unsustainable conditions.

It comes from psychological safety. From leadership visibility. From empowering advocacy. From listening to frontline staff regarding and protecting them from retaliation when concerns are raised. It comes from building systems that support sustainable care practices rather than relying on endless adaptation from the people inside them.

Resilience should not require silence.

Advocacy should not require sacrifice.

Healthcare workers often do not recognize normalization when they are living inside it. The first step toward changing culture is recognizing what we have slowly stopped noticing.

Patient safety depends on cultures where concerns remain visible long before harm becomes unavoidable.

🤔 Nurses, do you have thoughts on this?  Tell us in the comments.