“The system is flawed. It’s grinding us. It’s grinding good docs and providers out of existence.”
Keith Corl, M.D, Assistant Professor of Medicine, Brown University
Author’s note: This is not a post about technology. I’m deeply concerned about the current state of our healthcare workforce, and recent newsfeed articles only point out that the situation is getting worse. And it’s not just about burnout, which is covered extensively in the press, in research publications, and at conferences around the world. It’s broader than that. I’ve borrowed the term “triple-demic” to characterize the current situation to include moral injury and physical threats to healthcare workers as the key issues demanding immediate action.
Roughly 2.9% of healthcare workers quit their jobs in November 2022, equating to about 600,000 resignations, according to new data from the Bureau of Labor Statistics. That’s the second-highest quit rate in recent healthcare history, only behind the 3.1% rate in November 2021. Burnout from caring for Covid-19 patients, rigorous work schedules, and stagnant or low wages continue to push many hospital nurses, technicians, nursing home staff, and others to switch to other healthcare settings — or leave the profession entirely. Three major factors contribute to these resignations: burnout, moral injury, and physical threats. Burnout has received most of the attention throughout the pandemic. But the other two factors also need to be addressed to fix the problem. Some thoughts on each follow.
Burnout
Burned-out healthcare professionals are more likely to leave practice, which reduces patients’ access to and continuity of care. Burnout can also threaten patient safety and care quality when depersonalization leads to poor patient interactions and when burned-out caregivers suffer from impaired attention, memory, and executive function. A survey conducted by an AHRQ-funded project, the MEMO—Minimizing Error, Maximizing Outcome—Study (AHRQ grant HS11955), found that more than half of primary care physicians report feeling stressed because of time pressures and other work conditions. Some of those work conditions are shown in the graphic below:
“The nation’s health care delivery systems are overwhelmed, and nurses are tired and frustrated as this persistent pandemic rages on with no end in sight. Nurses alone cannot solve this longstanding issue and it is not our burden to carry.”
Ernest Grant, PhD, RN, FAAN, President of the ANA
Moral Injury (MI)
Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical, and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care. Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.
That idea resonates with clinicians across the country. The response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, and endless clicking on electronic health records.
“We have come to believe that burnout is the end stage of moral injury, when clinicians are physically and emotionally exhausted with battling a broken system in their efforts to provide good care; when they feel ineffective because too often they have met with immovable barriers to good care; and when they depersonalize patients because emotional investment is intolerable when patient suffering is inevitable as a result of system dysfunction.”
The Moral Injury Institute
Healthcare workers suffer an injury at the hands of each other: the medication error ignored at the nurse’s station, the doctor who orders unnecessary procedures, and the technician who is forced to carry out morally questionable orders. This regular violation of ethics, winking at incompetence, and hypocritical prosecution of employees ‘outside the clique’ drags down an organization’s culture. Healthcare workers are so blind to the effects of moral injury that they call their cognitive dissonance ‘professional detachment’ and label the effects they suffer ‘burnout and fatigue’ rather than guilt and anger. The impact on the healthcare worker of human trauma should not be downplayed: the opportunities to address trauma and suffering bring providers into the system. It is when the system itself inflicts suffering that the healthcare worker experiences MI.
A less discussed aspect of moral injury is shaming in the healthcare profession. The best discussion of the issue is this recent video from Dr. Zubin Damania. He interviews Dr. Emily Silverman, a UCSF hospital physician and host of the popular podcast The Nocturnists. They dive into shame and emotional repression in doctors, healthcare professionals, and beyond. It is a lengthy discussion but well worth the investment of your time. (And read the comments thread too. Interesting observations from healthcare professionals worldwide on the shaming issues they’ve faced.)
If you want to learn more about the topic, here are some additional resources to explore:
- The Nocturnist Shame Series
- More on Dr. Silverman
- The Shame Space – An international network of professionals who use creative storytelling and research to advance shame awareness, shame resilience, and shame-sensitive practice in healthcare, with the overarching goal of creating more connected, authentic, and safe healthcare systems for all. The Shame Space was formed in 2022 by scholars studying shame at the University of Exeter, Duke University, and Duke-NUS Medical School.
Physical Threats
The seriousness of this issue was reinforced last week in an article written by Michael Dowling, President & CEO, Northwell Health, in Beckers Healthcare titled: The unthinkable priority now facing hospitals.
In his opinion piece, Dowling highlights this “additional and disturbing priority — one that, I would argue, we never imagined. We now must protect our hospital patients and employees from the growing threat of intimidation and violence. There has been a dramatic spike in staff assaults, with many leading to serious injury and some leading to death.” (How have we gone from nightly 7 pm balcony applause and cheering for healthcare workers during the pandemic to physical assaults in their workplace?)
“People are proud of their bitterness now.”
Peggy Noonan, Wall Street Journal, 2019
The number of injuries from violent attacks against medical professionals was already on the rise pre-pandemic, increasing 86 percent from 2011 to 2018, according to the Bureau of Labor Statistics. In a spring 2022 survey by National Nurses United, nearly half of the hospital nurses (48 percent) reported rising workplace violence, more than double the 21.9 percent who responded as such a year prior.
Dowling has already taken action to address the problem. At Northwell, they call this new priority “The Safe Place Initiative.” It includes the following actions, investments, and measures:
- An investment in educating visitors, patients, and team members on proper behavior and how to promote dignity, respect, and understanding. Thousands of pieces of informational signage and posters are prominently displayed, emphasizing that harassment and verbal or physical assault will not be tolerated. Signs are also on display that reminds all visitors that this healing place — the hospital and ambulatory facility are weapon-free zones.
- A comprehensive investment in training employees on what to do in a potential active shooter situation, on how to de-escalate a potentially violent situation, and on how to “stop the bleed” in the case of such a circumstance. Over 50,000 of our employees have already received this training.
- The enhancement of security in all locations by increasing the presence of security personnel, as well as increasing video surveillance and alarm systems.
- The installation of weapon detection technology at the entrance of our facilities.
- Education for staff on how to recognize signs of domestic and partner violence and enhanced support offerings to team members impacted by such violence.
“Now is the time to champion kindness, respect and compassion. Times like this call for even greater generosity of spirit, the “better angels” of our nature. Positive leadership unites, promotes mutual trust, builds confidence and is optimistic.”
Michael Dowling, President & CEO, Northwell Health
I have tremendous respect for the work that Mr. Dowling is doing at Northwell. Action, not just words. Leadership, not just platitudes. We need more of this.
I’m not sure that I have good answers to these critical issues. I suspect that there is not one solution that will fit every situation. But my hope in writing this post is to raise awareness of the seriousness of these issues, put a different frame around the various elements, and drive a deeper conversation around how we can solve these challenges before we lose more dedicated professionals because of frustration, exhaustion, and intimidation. These good people deserve nothing less.
