Clinicians in Distress

Late in the summer of 2020, Dr. Rita Gallardo saw Mrs. Alvarez (both names are changed) in her oncology clinic. Mrs. Alvarez was tired, bruised, and aching, and a lab test pointed to a rare blood cancer, one Rita had seen only once before. The prospect of treating it made her uneasy. Her instinct, because all the doctors in her system were similarly unfamiliar with this rare blood cancer, was to send Mrs. Alvarez to a more specialized center, which happened to be part of another health system.

Rita knew the perfect person to see her patient: her mentor from her oncology fellowship, an expert in rare blood cancers who had treated hundreds of similar cases and worked at an academic center just 75 miles away. He was also a gentle, kind man who would take the time to make sure Mrs. Alvarez understood what he was doing and why.

But Rita also knew her health system expected employed doctors to refer patients to doctors within their own system to prevent patient revenue “leakage” to competitors. She knew administrators were tracking her referrals, and her supervisor hinted at serious consequences if she failed to meet those expectations. But Rita made the referral anyway and waited for repercussions.

Just a few weeks later, her supervisor admonished her for making more outside referrals than was the norm. It is illegal to threaten or reward physicians for their referral habits, so organizations use a variety of other tactics to steer referrals where they want them to go, such as strongly worded reminders to physicians that internal referrals improve continuity of care, communication, tracking to ensure follow-up, and patient satisfaction. Rita didn’t buy any of those rationales, but she heard her supervisor’s indirect message clearly: her job was on the line if her patients’ needs, rather than those of her hospital, remained her priority.

For the second time in five years, Rita, a US Army veteran who had deployed to Iraq and cared for combat-shattered young service members, recognized her experience of moral injury. Looking for a healthier practice that prioritized patients, she left a job whose organizational values did not align with her professional obligations to her patients. She prioritized the promise she made to her patients, at significant personal cost.¹

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In 2017, my husband suffered a critical illness. He is also a physician, and during the course of his short stay at our local hospital, the doctors caring for him—his colleagues—were distant and impassive in the face of his extremis. They delayed his transfer, despite my urgent requests, until his next option for treatment was extracorporeal membrane oxygenation, a therapy not offered at the small facility. They were caring people and not reckless physicians, so their stonewalling and what felt like brinkmanship with my husband’s life seemed out of character. But their inaction stuck with me because of how unsettling and inexplicable it was, given what I knew of them, and of medicine. If asked what was wrong, they might have said they were burned out, because there was no other language for their experience at the time. But to me, their struggle seemed different. It seemed like their hands were tied, as though without accurate language, they were resigned to a situation they couldn’t articulate and therefore could not solve.

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Recently, when I was a patient, my physician shrugged off a long-delayed diagnosis as the cost of working with a poorly designed electronic medical record (EMR). He found it too hard to locate notes from outside clinicians, and after offering feedback on the EMR that was ignored for months, he stopped looking for the notes. He also didn’t respond to questions sent through the patient portal, relegating that to other staff; they deferred the answers until my weeks-later follow-up appointment. My physician knew what needed to happen, and he had asked for it repeatedly. His choices were to leave or strike out on his own—but other hospitals in the area were just as bad, and he knew that reestablishing a practice elsewhere would take much longer than the few years left before he retired. So he stayed, frustrated but without viable alternatives, knowing his patients would do better with simpler care coordination. The upshot was delayed communication, a delayed diagnosis, and, ultimately, a compromised outcome. All because a physician’s tool, selected by a committee of nonclinicians, was built to optimize revenue cycles instead of patient care.

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And, finally, as a psychiatrist, I struggled to find a business model that allowed me to practice in a way that was best for patients. Teaching hospitals stressed productivity and medication management. In private practice, I could choose the best combination of therapies for patients, but insurance reimbursement was abysmal, and a cash pay practice limited patient access. Psychiatrists might be able to build successful practices using that model in more affluent regions, but not in the rural farming community where my husband found work—and where my patients lived. I concluded that, tough and resourceful as I was in all other regards, somehow this doctoring thing just was not working out. It felt like the medicine I imagined I would practice when I went to medical school was no longer possible because the oath that had been a cornerstone of that work no longer meant what it once did.

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Each of these examples, different though they may appear, reflects the range of intensities, awareness, and duration of clinician distress. Countless earnest efforts to address clinician distress over more than three decades have fallen short. More than half of US clinicians reported feeling burned out in 2022.² Robust data tie clinician distress inversely to patient outcomes.³ Administrators and other healthcare leaders, too, are feeling more distressed.⁴ It is hard to know if healthcare is good for anyone today.

During my husband’s illness, I was working for the US Army overseeing research progress at academic centers across the country that had received grants from the US Department of Defense. I regularly met and spoke with physicians at those institutions, and many of them seemed to find their clinical work ever more challenging. So I started asking them, informally, whether they felt shut down and unable to act, as my husband’s physicians had seemed to be. Physicians, nurses, occupational and physical therapists, social workers, and, in confidential conversations, administrators all admitted they were struggling to do their jobs, constrained by healthcare’s bureaucracy and unable to do what they knew was best for those they served. But the ubiquitous “burnout” label didn’t quite fit. They knew, going into healthcare, that they were signing up for long hours and sometimes impossibly hard, tragic work. What they didn’t know was that healthcare systems might work against them in accomplishing their mission of excellent care. None of us had language for that situation—so I started looking.

When I heard about moral injury and learned that drone pilots experienced the condition, even though they had never physically been in combat, I was sure the concept could expand to healthcare. Admittedly, there are some fundamental differences in the contexts of war and healthcare. Military moral injury usually arises from the misdirected deployment of specialized skills, like lethal force, a momentary overstep of the military’s contract with society to provide protection. That situation is not a wholesale departure from the military’s mission. Moral injury in healthcare, though, stems from a fundamental conflict between the profession’s societal contract of healing and the pursuit of revenue-focused business values.⁵

Moral injury was first defined by a psychiatrist working with combat veterans from the Vietnam War. Originally conceived as “betrayal by a legitimate authority in a high-stakes situation,”⁶ it was later expanded to connote a transgression of deeply held moral beliefs⁷—for example, the oaths we take in healthcare to prioritize patient needs. These two elements are often viewed as the external and internal sources of moral injury, respectively, but it may be more helpful to view them as having a stimulus and response relationship: a betrayal, to which one acquiesces, resulting in transgression of moral beliefs. It is the relational rupture of betrayal, and the inescapable experience of transgression, that clinicians find unbearable.

What Distinguishes Moral Injury from Other Conditions?

Accurately applying a psychological construct in a new context requires strict adherence to how the experience is defined and methodical and constant parsing of the new condition from other conditions. This can be especially difficult with moral injury because several conditions share similar symptoms and may occur together. Moreover, at times the conditions influence each other—as when, for example, administrators repeatedly ignore nurses’ complaints about the burden of short staffing causing their burnout. Repeated often enough, the nurses no longer excuse this inaction as ignorance but see it as betrayal, heightening their risk of moral injury. Posttraumatic stress disorder, empathy-based stress conditions (compassion fatigue, secondary traumatic stress, and vicarious traumatization), and burnout are most easily confused with moral injury, and each warrants a brief discussion.

As with moral injury, the identification of posttraumatic stress disorder (PTSD) arose from work with military combat veterans. The current psychiatric Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines PTSD as a reactive condition arising after a real or perceived threat of death or serious injury.⁸ The basis of PTSD is a threat to one’s mortality, while moral injury stems from a threat to one’s moral foundations. Both conditions may arise from traumatic experiences, and responses may be similar, including shame, guilt, depressed mood, and mistrust. But studies are beginning to show that distinct brain regions process the experiences, suggesting different neurobiological processes.⁹

Empathy-based stress conditions such as compassion fatigue, secondary traumatic stress, and vicarious traumatization are also easily conflated with moral injury. Compassion fatigue is “a state of exhaustion and dysfunction biologically, psychologically, and socially as a result of prolonged exposure to compassion stress.”¹⁰ Someone experiencing compassion fatigue might once have been described vernacularly as “crusty,” “hardened,” or “jaded.” My physician’s shrug about the consequences to me of a labyrinthine EMR might easily be construed as compassion fatigue, if he truly was unbothered by the constraints on his care. But while there are some health workers for whom this may be the case, most feel the obligation of their oath deeply. If the inaction of my husband’s physicians cloaked their anger and shame at not being able to deliver better care, then they were likely suffering moral injury as well as, or instead of, compassion fatigue.

Secondary traumatic stress represents the “natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other [or client/patient]. It is the stress resulting from helping or wanting to help a traumatized or suffering person.”¹¹ Nurses working in the emergency room who exhibit the hypervigilance, flashbacks, rumination, and low mood associated with PTSD despite never having been exposed to life-threatening violence themselves may be suffering secondary traumatic stress. But, like PTSD, the condition is distinguished from moral injury because there is no sense of moral transgression.

Vicarious traumatization is a pervasive, longer-lasting shift in a caregiver’s inner experience that results from disrupted beliefs about the world after empathetically engaging with others’ traumatic experiences.¹² For example, emergency room staff may struggle to see the world as just or fundamentally good after caring for too many victims of gun violence or child abuse. Moral injury, on the other hand, leads those experiencing it to question not whether the world is still a good place but whether they are still good people. As Rita Gallardo said, if she had followed her employer’s directives and put profits ahead of patients’ best interests, she would not have been able to think of herself as the excellent physician she took an oath to be, which is the hallmark of moral injury. Questioning both one’s worldview and oneself would suggest co-occurrence of vicarious traumatization and moral injury.

Finally, burnout and moral injury are also discrete experiences and independent drivers of clinician distress. Like moral injury, burnout is not classified as a psychiatric disorder in the DSM-5. But in 2019, the World Health Organization included burnout in the 11th revision of its International Classification of Diseases as a “syndrome” that results from “chronic workplace stress that has not been successfully managed.”¹³ In other words, burnout corresponds to the demand-resource mismatches or operational challenges of mandatory overtime, overbooked clinics, and administrative burden. Moral injury may arise from these same situations when there is an added component of betrayal leading to relational ruptures such as broken trust, values conflicts, and unresolved miscommunications. Although they are independent experiences, early data¹⁴ suggest that burnout and moral injury occur concurrently¹⁵ often enough that when one is present, the other should be queried.

This is cause for concern because burnout is shockingly common. In a recent survey, two in three clinicians reported at least one symptom of burnout in 2021. Twenty-five percent of clinicians were considering switching careers; of those, fully 89 percent said burnout was the driving factor, followed by not having the resources they needed to operate at full potential and a lack of effective processes and workflows, supplies, and equipment. Moreover, 59 percent of clinicians considering leaving said their teams were not adequately staffed.¹⁶

Unfortunately, much of the rhetoric about distress in the last few years has encouraged managers to intensify mental health support for workers rather than addressing the systemic problems that the healthcare workers say are their big concerns. Pathologizing an appropriate response (e.g., frustration, anger, or withdrawal) to a toxic situation (betrayal) harms individuals and weakens systems. Fragilizing the healthcare workforce—although we know that physicians are more resilient than the average employed population¹⁷ and suspect other seasoned clinicians are as well—by calling their distress a mental health issue rather than a toxic work environment is yet more destructive. While mental health care and supportive well-being programs* should be viewed as baseline conditions for the difficult work of healthcare, the crisis of moral injury won’t be solved in a therapist’s office. It depends on reshaping healthcare systems and the environments they create—something no healthcare system has yet undertaken in earnest.

A Longstanding Problem Made Worse by the Pandemic

Many who are not on the frontlines of healthcare might view the pandemic as having incited health worker distress. But on February 24, 2020, weeks before New York City shut down, I testified before the New York City Council’s Health and Hospitals Committee about safety in the city’s emergency rooms—which were (and remain) overcrowded, understaffed, and under-resourced—and the pressing need to address moral injury. Indeed, this issue existed well before COVID-19, but the pandemic brought the challenges into stark relief.

Health workers had long warned that staff, supplies, and space pared to the bone were potentially catastrophic in a crisis because there was no slack in the system to accommodate a massive surge. With COVID-19, what they had long feared came true. At the same time, many people in the United States take for granted that we can get healthcare whenever we need it, wherever we are, and that there are limitless resources available for our healing. That requires a constant supply of healthcare workers selfless enough to do exquisitely hard work driven by the personal satisfaction they derive. Administrators have depended on health workers’ deep commitment to healing, too, relying on health workers’ reluctance to walk away from their careers and abandon their patients to an unknown fate.¹⁸

But the healthcare workforce was changed by their experiences of working through the pandemic.¹⁹ One of the main options for mitigation—speaking up publicly or whistleblowing—was widely barred during the pandemic, ostensibly to allay patients’ fears about hospitals being unsafe. Health workers were fired for speaking up,²⁰ and others who stayed silent for fear of retaliation faced an increased risk of moral injury. Many described to me an experience called mortality salience, or becoming aware of the inevitability of their own death, which led to a sudden reordering of their priorities.²¹ Clinicians experiencing mortality salience have reconsidered whether their obligation to their profession is imperative.

Now, administrators are left with the novel situation of a workforce they can no longer take for granted. In fact, after nearly one in three health workers left their jobs (voluntarily or not) during the first year of the pandemic,²² a recent survey forecasts a continuing exodus.²³ One nurse told a reporter:

In many hospitals, people felt like, you’re throwing us to the wolves, and you’re not helping us and providing us the necessary resources that we need—the personal protective equipment, that sort of stuff. And it still hasn’t changed three years in. Our nursing turnover is huge. They’re like, I don’t want to do this anymore…. I’m leaving the bedside, and going to work in an ambulatory clinic, or I’m going to completely leave nursing as a profession at all, because this is just not what it was like to be a nurse before.²⁴

A 2022 survey found that the top reasons nurses were leaving their jobs were hospital management and chronic understaffing; COVID-19 was a distant third.²⁵ Although workforce data in early May 2023 showed nurses returning to staff hospital positions from travel nursing jobs,²⁶ the trend bears watching. As the AFT’s Healthcare Staffing Shortage Task Force report describes, there’s no shortage of qualified individuals to do these jobs; there’s a shortage of licensees willing to tolerate the conditions in healthcare workplaces.²⁷ If nurses find empty promises of workplace changes, they may turn on their heels and walk out again.

One in three nonclinical staff—including housekeeping, food service, administrative, and laboratory staff; receptionists; schedulers; lab or x-ray technicians; finance and information technology support personnel; and researchers without a clinical role—and one in five physicians also plan to leave in the next two years.²⁸ This exodus is the manifestation of the relational rupture of moral injury, the fundamental breach of the psychological contract between the healthcare industry and the workforce that serves patients. Moral people, especially idealistic young people, are enticed to join a moral profession and a moral organization to do moral good. They expect and trust that the organization is committed to what is best for patients and will be good to the workforce, honoring and aligning with their obligation to serve their patients. Breaking that implied psychological contract is costly:

As clinicians and their families do the reckoning of what’s important in the wake of COVID-19, it is hard to imagine they will value employers who put the wellbeing of the organization ahead of the wellbeing of its workforce. It is unlikely that those who waded into the breach without sufficient protection, as their pay was cut, their protests gagged, their employment threatened, and their friends fell ill, will plan long, loyal careers with the organizations that treated them this way.²⁹

The healthcare workforce is speaking out and voting with its feet in a way it has never done.³⁰ Stemming that tide demands a change in organizational cultures to morally centered, just institutions.

Preventing Moral Injury

How does an institution become morally centered? Interventions to repair relationships with the healthcare workforce and reduce the risk of moral injury are a start. These interventions come from empowered clinicians, courageous leaders, and policy action.

For the individual who has experienced moral injury, addressing the “betrayal by a legitimate authority” puts them in the difficult position of having to call out the missteps of those in power. It takes rare courage to do that. For most, the stakes are too high, so they stay quiet. But clinicians can empower themselves by joining with their colleagues and speaking with a collective voice. Formalized bodies for speaking collectively include medical staff, professional societies, and unions, which typically have the strongest protections for worker voices and the most leverage at the workplace.^†

Clinicians are essential for decision-making with clinical implications. Organizations that are serious about mitigating the risk of moral injury will formalize opportunities for clinicians to engage. For example, any organization can implement GROSS (Getting Rid of Stupid Stuff) initiatives, which ask clinicians to identify administrative tasks that add no value to patient care and should be eliminated. The idea started at Hawaii Pacific Health in 2017, when leaders asked clinicians to identify elements of the EMR that were “poorly designed, unnecessary, or just plain stupid.” They received nearly 200 nominations for items that included noting the condition of an umbilical cord in an adolescent; printing discharge papers and then scanning them back into the EMR to capture the patient’s signature, which hospital lawyers deemed irrelevant; and alerts to document repeated head-to-toe nursing assessments during a single shift on some units.³¹ The Cleveland Clinic undertook a similar effort in 2018 and eliminated distracting alerts, unnecessary popups, and inaccurate trend reports.³² Other organizations have expanded the initiative to eliminate requirements based on overinterpretation or misinterpretation of regulations, like tuberculosis mask fitting and training requirements for outpatient physicians. One organization pushed back on state regulations requesting staff to repackage information already available through other reporting.³³ Yet another organization worked with the state to reduce an hourslong training for signatories of a single form down to just minutes.³⁴

While adjustments to existing platforms can make modest improvements to workflow or burden, real transformation would occur if health systems pressured vendors to develop truly intuitive user interfaces (think about the ease of operating an iPhone, for example), built with robust clinician input. An intuitive user interface could dramatically cut down on the outsized burden of documentation, improve communication between clinicians, and lead to better care for patients from clinicians freed up to be more attentive and informed.

Ideally, those in positions of power (hospital CEOs, legislators, regulators, or insurers, most commonly) will accept responsibility and accountability for relational repair. They hold the most influence over the healthcare environment and therefore are most likely to betray the healthcare workforce, whether inadvertently by making underinformed operational decisions or intentionally by focusing on profits more than patients. They must commit to identifying and reducing those risks.

A few such leaders have been early adopters of a moral injury perspective, asking for guidance in caring for their workforces. One example is the late Dr. Leon Haley, who became the CEO of University of Florida Health Jacksonville in 2018—and with whom I collaborated briefly until his untimely death in 2021. Dr. Haley walked through the emergency department every day and spent time on inpatient floors weekly. He coaxed feedback from everyone from environmental services to department chairs, apologizing when he needed to and thanking them for their candor. Armed with that information, he secured millions of dollars from the city to upgrade his hospital’s physical condition. He approved a wellness office without hesitation, despite a significant cost. He was present, curious, concerned, and connected to his workforce while also communicating openly, especially during the most difficult stretches of the COVID-19 pandemic, about the challenges they faced. He moved effortlessly between those meaningful interactions with individuals to using what he learned from them to advocate for change.³⁵ Because of these connections, he knew his workforce was strained in the pandemic and the usual burnout mitigation strategies were not working. Always open to new approaches, Dr. Haley followed the suggestion of his wellness officer to consider reframing their burnout mitigation through a moral injury lens. Though our collaboration was cut short by Dr. Haley’s death, his leadership style was well matched for this work, and most of the initiatives he started continue. Ed Tufaro, the interim CEO of a large physician-owned practice, described such leadership, including his own, succinctly: “If I do my job well, I’m taking care of the people who take care of the patients.”³⁶

Those in management roles between the frontline and the C-suite—the connectors—are ideally placed to facilitate the necessary and notoriously difficult free flow of bidirectional information. William Bird, the former senior vice president for Penn State Health Medical Group, established dyad partnerships—pairing each clinician leader with an administrative partner—to minimize clinician distractions from patient care. My husband’s radiology practice joined Penn State Health in 2019, so I have seen up close their system and its impact on his partners. When scheduling or prior authorization challenges arise at a radiology site, for example, the practice manager for outpatient imaging investigates the health system friction points and works with the necessary central offices to smooth them. The radiologists can continue their clinical care uninterrupted while patient issues are solved in the background. Four and a half years later, my husband and his partners still love their jobs. When they experience frustrating days, having a well-informed management partner working on their behalf so they can stay focused on their patients and their mission of excellent care goes a long way.

For organized workforces, labor-management partnerships (LMPs)^‡ can be an effective way to raise worker concerns that fall outside the scope of typical collective bargaining.³⁷ LMPs can simultaneously improve working conditions and patient outcomes by creating an environment of mutual respect and problem-solving between management and frontline workers.

Organized workers can also launch campaigns to cultivate community support. After all, patients do not want profits to be valued more highly than patient care and workforce well-being. One example is in rural Willimantic, Connecticut, where Hartford HealthCare decided to end labor and delivery services at Windham Community Memorial Hospital in 2020, claiming declining births and retention issues. AFT Connecticut members from education and public employee locals joined nurses and health professionals in building a coalition of concerned community members and local organizations in the fight to resume these essential services. Together, they collected signatures, organized demonstrations, sponsored ad campaigns, and provided public testimony on how the closure harmed patients, workers, and the community. After a lengthy investigation, the Connecticut Office of Health Strategy ordered Hartford HealthCare to reopen labor and delivery services and pay more than $151,000 in fines. The health system appealed the decision.³⁸ According to AFT Connecticut Vice President John Brady, “Our members continue to organize with the coalition because we have an ethical responsibility, as a union of caregivers, educators, and public servants, and as members of our communities, to advocate for access to affordable, quality healthcare—not only in Windham, but across the state wherever such care is threatened. We do that through partnerships with various community coalitions and allies.”³⁹

While none (that I am aware of) have done so yet, organizations truly committed to building a just, courageous, and continuously improving workplace could initiate monthly administrative morbidity and mortality rounds. Attended by all levels of administration and clinicians, these meetings would parse the role of nonclinical decisions (including resource allocation and staffing) in suboptimal patient outcomes. The intention is not to lay blame but to improve all aspects of the system that impact patient experiences. Such action would restore a sense of shared values and responsibility between clinicians and administrators.

Finally, legislation at state or national levels is necessary. Through policy actions, legislators exert legitimate authority over clinicians. When they enact policies that protect clinicians, they mitigate the risk of moral injury (and of related distressing conditions discussed earlier). But only coalitions of healthcare workers from various sectors will move such policy actions forward.

Recently, unions and professional societies have called for worker protections against violence and in support of safe staffing ratios. “Our nurses and health industry workers care every day for the sick, the elderly and the mentally ill, yet they often feel unsafe or unprotected themselves from the assaults that occur in hospitals and other healthcare-related settings,” said AFT President Randi Weingarten in May 2022,⁴⁰ when the Workplace Violence Prevention for Health Care and Social Service Workers Act was reintroduced in the Senate.⁴¹ The legislation would require employers to implement prevention plans to protect healthcare and social service employees from incidents of workplace violence. The AFT also launched the nationwide Code Red campaign in February 2023 to address the healthcare staffing crisis; while the campaign is ongoing, at the time this article was finalized for publication in September 2023, affiliates in Connecticut, Oregon, and Washington had already secured additional staffing protections in state law, among other significant victories.^§ Similarly supported by diverse health worker unions, Rep. Jan Schakowsky and Sen. Sherrod Brown reintroduced the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act⁴² on March 30, 2023. The bill would set minimum nurse-to-patient staffing requirements, study best practices for nurse staffing, and protect nurse whistleblowers speaking up for the safety of their patients.

In addition, dozens of federal agencies impose requirements on healthcare organizations. Harmonizing and consolidating those requirements began at the Centers for Medicare and Medicaid Services (CMS) in 2017, when Seema Verma was appointed director. By the time she left in 2021, the overall number of measures in the Medicare fee-for-service programs was reduced by 15 percent, from 534 to 460, saving an estimated 3.3 million hours of reporting effort, as well as $128 million for the agency.⁴³ Chiquita Brooks-LaSure, the next CMS director, promised to continue the effort under the moniker Meaningful Measures 2.0.⁴⁴

Another positive step would be for healthcare organizations, including nonprofit organizations, to be included in the Federal Trade Commission’s proposed ban on noncompete clauses so that healthcare workers are free to leave unhealthy workplaces. And financially exploitative health system practices like failing to fully disclose the availability of charity programs to patients with financial need⁴⁵ and harming indebted patients by cutting off their care,⁴⁶ suing them,⁴⁷ or offering them credit cards from which hospitals benefit⁴⁸ must end. Likewise, we must ensure that the Consumer Financial Protection Bureau, the federal consumer watchdog, closely monitors how healthcare financial products and insurance are evolving. Simplifying benefits, patient financial liabilities, and negotiated rates would make it easier for clinicians to heal their patients without inadvertently inflicting financial wounds.

As we emerge from three years of the COVID-19 pandemic with scores of lessons learned (but relatively few acted on), it is time to reframe our understanding of workforce discontent. The transactional or operational challenges of burnout are still relevant, and the distress of PTSD and empathy-based stress must be alleviated, but expanding the framework to include the relational ruptures of moral injury clarifies the sources of harm to healthcare workers and better frames solutions. Frontline worker voices are crucial to reestablishing healthy healthcare workplaces through improving EMRs, addressing patient care safety and quality, standing up to violence, and insisting on transformative, compassionate leaders at the helm of courageous, continuously improving, and morally centered organizations. But it is risky for workers to speak up alone. So, what will we promise each other as we build solutions together?

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Wendy Dean, MD, is a psychiatrist, author, and cofounder of Moral Injury of Healthcare, which addresses clinician distress and its impact on patient care. She has overseen research funding for the US Department of Defense and supported military medical research at the Henry M. Jackson Foundation for the Advancement of Military Medicine.

*Focusing on “reducing the stigma” of moral injury is also misplaced because it makes “stigma” a societal problem and effectively lets health systems off the hook for creating harmful conditions. (return to article)

^†Healthcare unions, including unions for advanced practitioners, are growing as clinicians seek to address the working conditions that lead to moral injury. Read one physician’s story, “Do No Harm: Organizing as a Physician,” in the Spring 2023 issue of AFT Health Care. (return to article)

^‡To learn about LMPs, see “Improving Working Conditions in Turbulent Times” in the Spring 2022 issue of AFT Health Care. (return to article)

^§For more on Code Red victories, see the package of articles that begins here. (return to article)

Endnotes

1. W. Dean, If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First (Hanover, NH: Steerforth Press, 2023).

2. L. Kane, “‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023,” Medscape, January 27, 2023, medscape.com/slideshow/2023-lifestyle-burnout-6016058?faf=1.

3. L. Hall et al., “Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review,” PLoS ONE 11, no. 7 (2016): e0159015; J. Halbesleben and C. Rathbert, “Linking Physician Burnout and Patient Outcomes: Exploring the Dyadic Relationship Between Physicians and Patients,” Health Care Management Review 33, no. 1 (January 2008): 29–39; and M. Panagioti et al., “Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-Analysis,” JAMA Internal Medicine 178, no. 10 (2018): 1317–31.

4. C. Green, “Stress and Burnout a Growing Concern for Healthcare Leaders,” Medical Group Management Association, September 7, 2022, mgma.com/mgma-stats/stress-and-burnout-a-growing-concern-for-healthcare-leaders.

5. D. Chokshi and A. Beckman, “A New Category of ‘Never Events’—Ending Harmful Hospital Policies,” JAMA Health Forum 3, no. 10 (2022): e224703.

6. J. Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character (New York: Simon and Schuster, 1995).

7. B. Litz et al., “Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy,” Clinical Psychological Review 29, no. 8 (December 2009): 695–706.

8. Center for Substance Abuse Treatment, Trauma-Informed Care in Behavioral Health Services, Treatment Improvement Protocol (TIP) Series, No. 57 (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014), ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16.

9. H. Barnes, R. Hurley, and K. Taber, “Moral Injury and PTSD: Often Co-Occurring Yet Mechanistically Different,” Journal of Neuropsychiatry and Clinical Neurosciences 31, no. 2 (April 23, 2019): A4–103.

10. C. Figley, Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatized (New York: Brunner/Mazel, 1995), 253.

11. C. Figley, “Compassion Fatigue: Toward a New Understanding of the Costs of Caring,” in Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers, and Educators, ed. B. Stamm (Baltimore: Sidran Press, 1995), 3–28. Italics in original.

12. L. Pearlman and K. Saakvitne, Trauma and the Therapist: Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors (New York: W. W. Norton, 1995).

13. International Classification of Diseases, “ICD-11 for Mortality and Morbidity Statistics: QD85 Burnout,” World Health Organization, January 2023, icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281.

14. D. Morris, “What Role Does Moral Injury Play in Accounting for Occupational Distress in Mental Healthcare Workers?,” paper presented at the 10th Anniversary of the Crisis, Disaster and Trauma Section of the British Psychological Society Conference, London, April 21, 2023, researchgate.net/publication/370252007_what_role_does_moral_injury_play_in_accounting_for_occupational_distress_in_mental_healthcare_workers; and Barnes, Hurley, and Taber, “Moral Injury and PTSD.”

15. D. Morris, “Moral Injury and Healthcare, Oct 2022: The Evidence,” paper presented at the Erikson Institute Fall Conference on Moral Injury, Stockbridge, MA, October 14-15, 2022, researchgate.net/publication/364589229_moral_injury_and_healthcare_oct_2022_the_evidence; and D. Morris, E. Webb, and P. Devlin, “Moral Injury in Secure Mental Healthcare Part II: Experiences of Potentially Morally Injurious Events and Their Relationship to Wellbeing in Health Professionals in Secure Services,” Journal of Forensic Psychiatry & Psychology 33, no. 5 (August 9, 2022): 726–44.

16. E. Ney, M. Brookshire, and J. Weisbrod, “A Treatment for America’s Healthcare Worker Burnout,” Bain & Company, October 11, 2022.

17. C. West et al., “Resilience and Burnout Among Physicians and the General US Working Population,” JAMA Network Open 3, no. 7 (2020): e209385.

18. D. Ofri, “The Business of Health Care Depends on Exploiting Doctors and Nurses,” New York Times, June 8, 2019.

19. J. Billings et al., “Experiences of Frontline Healthcare Workers and Their Views About Support During COVID-19 and Previous Pandemics: A Systematic Review and Qualitative Meta-Synthesis,” BMC Health Services Research 21 (2021): 923.

20. N. Scheiber and B. Rosenthal, “Nurses and Doctors Speaking Out on Safety Now Risk Their Job,” New York Times, April 27, 2020.

21. K. Vail et al., “When Death Is Good for Life: Considering the Positive Trajectories of Terror Management,” Personality and Social Psychology Review 16, no. 4 (2012): 303–29.

22. G. Galvin, “Nearly 1 in 5 Health Care Workers Have Quit Their Jobs During the Pandemic,” Morning Consult Pro, October 4, 2021, pro.morningconsult.com/articles/health-care-workers-series-part-2-workforce.

23. J. Kelly, “New Survey Shows That Up to 47% of U.S. Healthcare Workers Plan to Leave Their Positions by 2025,” Forbes, April 19, 2022, forbes.com/sites/jackkelly/2022/04/19/new-survey-shows-that-up-to-47-of-us-healthcare-workers-plan-to-leave-their-positions-by-2025/?sh=4f009e93395b.

24. D. Thompson, “The ‘Great Resignation’ Is Taking a Toll on U.S. Health Care,” U.S. News & World Report, December 1, 2022, usnews.com/news/health-news/articles/2022-12-01/the-great-resignation-is-taking-a-toll-on-u-s-health-care.

25. Minnesota Nurses Association, Why We Left: 2022 Nursing Workforce Report (Saint Paul, MN: March 31, 2022), documentcloud.org/documents/21564976-2022_03_31_mna_workforce_why-we-left?responsive=1&title=1.

26. M. Evans, “Nurses Flock Back to Hospitals After Leaving in the Pandemic,” Wall Street Journal, May 1, 2023, wsj.com/articles/nurses-flock-back-to-hospitals-after-leaving-in-the-pandemic-4f94b591.

27. AFT Healthcare Staffing Shortage Task Force, Healthcare Staffing Shortage Task Force Report (Washington, DC: AFT, November 2022), aft.org/sites/default/files/media/documents/2022/hc_StaffingTaskforceReport_Nov2022.pdf.

28. L. Rotenstein et al., “The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19,” Journal of General Internal Medicine 38 (2023): 1920–27.

29. W. Dean, “Orienteering in the Moral Landscape,” paper presented at Generation C: A Hybrid Symposium Publication, Providence, RI, June 15–22, 2021, generationc.xyz/wendy-dean.

30. S. Brophy et al., Heroes on Strike: Trends in Global Health Worker Protests During COVID-19 (Washington, DC: Accountability Research Center, April 2022), accountabilityresearch.org/wp-content/uploads/2022/04/ARC-Accountability-Note_Health-Worker-Protests_WEB.pdf; and H. Mensik, “The Largest Healthcare Worker Strikes Waged—and Avoided—in 2022,” Healthcare Dive, January 17, 2023, healthcaredive.com/news/the-largest-healthcare-worker-strikes-waged-and-avoided-in-2022/638796.

31. M. Ashton, “Getting Rid of Stupid Stuff,” New England Journal of Medicine 379, no. 19 (November 8, 2018): 1789–91.

32. A. Merlino and A. Weathers, “Success Story: Getting Rid of Stupid Stuff at the Cleveland Clinic,” AMA Steps Forward, July 9, 2020, edhub.ama-assn.org/steps-forward/module/2768110.

33. Personal communication from Jim Beckner, August 2020.

34. W. Dean and S. Talbot, “Shut Up and Listen,” Moral Matters (podcast), Season 2, Episode 9, July 8, 2021.

35. Dean, If I Betray These Words.

36. W. Dean and S. Talbot, “Never Lead with Finances,” Moral Matters (podcast), Season 1, Episode 8, January 7, 2021.

37. Kaiser Permanente and the Partnership Unions, “Labor Management Partnership,” lmpartnership.org.

38. A. Coles, “A Victory for Union-Led Community Coalition to Save Maternity Services,” AFT, July 8, 2022, aft.org/news/victory-union-led-community-coalition-save-maternity-services; and M. Caron, “Multiple Connecticut Hospitals Seek to Shutter Labor and Delivery Centers,” Fox61, November 15, 2022, fox61.com/article/news/local/pregnant-women-face-a-crisis-of-maternal-care/520-fe868891-d8e4-4a8a-8f23-48a1bab6fb66.

39. Brady, J., email message to editors, July 19, 2023.

40. Office of US Senator Tammy Baldwin, “Senator Baldwin Introduces Bill to Protect Healthcare Professionals from Workplace Violence,” press release, May 11, 2022, baldwin.senate.gov/news/press-releases/senator-baldwin-introduces-bill-to-protect-healthcare-professionals-from-workplace-violence-during-national-nurses-week.

41. Workplace Violence Prevention for Health Care and Social Service Workers Act, HR 1195, 117th Congress, 2021–22, congress.gov/bill/117th-congress/house-bill/1195/text.

42. Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023, S 1113, 118th Congress, 2023–24, congress.gov/bill/118th-congress/senate-bill/1113/text.

43. Centers for Medicare and Medicaid Services, “2021 CMS Quality Conference: Healthcare Innovation During a Time of Disruption; CMS Quality Measurement Action Plan,” US Department of Health and Human Services, March 2021, cms.gov/files/document/2021-cms-quality-conference-cms-quality-measurement-action-plan-march-2021.pdf.

44. Centers for Medicare and Medicaid Services, “Meaningful Measures 2.0: Moving from Measure Reduction to Modernization,” US Department of Health and Human Services, cms.gov/medicare/meaningful-measures-framework/meaningful-measures-20-moving-measure-reduction-modernization.

45. A. Mathews, T. McGinty, and M. Evans, “Big Hospitals Provide Skimpy Charity Care—Despite Billions in Tax Breaks,” Wall Street Journal, July 25, 2022, wsj.com/articles/nonprofit-hospitals-vs-for-profit-charity-care-spending-11657936777.

46. S. Kliff and J. Silver-Greenberg, “This Nonprofit Health System Cuts Off Patients with Medical Debt,” New York Times, June 1, 2023, nytimes.com/2023/06/01/business/allina-health-hospital-debt.html.

47. N. Levey, “Investigation: Many U.S. Hospitals Sue Patients for Debts or Threaten Their Credit,” NPR Shots Health News, December 21, 2022, npr.org/sections/health-shots/2022/12/21/1144491711/investigation-many-u-s-hospitals-sue-patients-for-debts-or-threaten-their-credit.

48. N. Levey, “Biden Administration Issues New Warning About Medical Credit Cards,” KFF Health News, May 4, 2023, kffhealthnews.org/news/article/medical-debt-credit-cards-biden-administration-warning-high-interest-rates.

[illustrations: Carole Hénaff]