Nurses in the U.S. Are Suffering "Moral Injury"

Minnesota emergency room nurse Cliff Willmeng remembers, during the early days of the pandemic, treating a patient at United Hospital who asked how the nurses were doing. The man was a Vietnam veteran, and Willmeng recalls that he said, ​“This is your war.”

“I kind of laughed, like what do you mean by that?” said Willmeng, who recalled he didn’t grasp at the time how horrible the pandemic would become. ​“He said, ​‘We dealt with this in Vietnam. You don’t know it yet but none of you are ever going to be the same again.’”

More than two years later, Willmeng, like countless other nurses and frontline workers nationwide, knows all too well how true those words turned out to be. 

“The combination of the lethality of the virus and the seemingly total abandonment of collaboration from the management I was under produced anxiety and fear in me I had never felt, never,” said Willmeng, who had worked in emergency rooms and a trauma intensive care unit in Colorado and Chicago. ​“I was watching nurses sign their advance directives right there at the nursing station, preparing to be intubated and die. It was terrifying.”

In recent years, academics and frontline workers have used the terms ​“moral injury” and ​“moral distress” to describe the debilitating combination of anxiety, fear, guilt, shame, anger and betrayal that results when workers like nurses are thrust into life-or-death situations without the resources and support structures to carry out the mission they’ve committed to. 

The term ​“moral injury” was coined by former U.S. Department of Veteran Affairs psychiatrist Jon­athan Shay based on his work with Vietnam veterans, as explained in a December 2020 white paper by the National Nurses United (NNU) union. Moral injury involves the ​“deleteri­ous long-term, emotional, psychological, behavioral, spiritual, and/​or social effects” of ​“perpetrating or failing to prevent acts that trans­gress deeply held moral beliefs and expectations in a high-stakes environment,” the paper notes. 

Nurses describe deep parallels between the experiences of veterans who are thrust into horrifying conflicts, left to fend for themselves and forced to make painful choices by corrupt or absent leadership — then blamed or punished for their actions.

Academic studies explain that moral injury is closely related to post-traumatic stress disorder, and can be a significant factor in veterans, emergency workers and others developing PTSD, as a number of studies have shown. It is not listed in the Diagnostic and Statical Manual related to mental illness, and moral injury is not considered to be a mental illness or to directly cause mental illness. This is in part because there is some ambiguity in defining exactly what moral injury entails, as it involves philosophical, social and ethical, as well as psychological, questions, which an article the British Journal of Psychiatry and other journals have explained. 

That journal notes that relatively few studies have been done on moral injury, yet it is recognized by many as a serious issue that goes beyond the ethical dilemmas that most people face. With many ethical dilemmas, the journal notes, people have the power to make a choice. ​“In moral injury, individuals commonly feel at the mercy of events, constrained by an overarching strategy or hierarchical rules that govern their actions. For some, it may erode their sense of meaning and place in the world,” says the 2020 journal article, by Edgar Jones. 

In military situations, an individual can experience moral injury when they are forced to harm civilians or take unjustified military actions, and the emotional and mental impacts are worsened in situations like the Vietnam War, where veterans face blame and hostility from the general public, or situations like the Iraq War, where the general public is largely unaware of what the veterans have been through, studies note. Nurses report a dynamic that has some parallels: They don’t have the resources to serve their patients well, but hospital administrators blame them for failings or don’t acknowledge the extreme conditions they are working under. And where patients often treat them with hostility or even violence. 

During the pandemic, experiences causing moral injury ranged from having to choose which patients got ventilators, to not being able to check in on Covid-19 patients regularly in order to minimize risk of transmission.

Elizabeth Lalasz, a registered nurse and NNU steward at Chicago’s public hospital, explains that the burn-out, depression, stress and anxiety that nurses face has typically been framed as an individual experience, rather than a systemic injustice caused by a broken healthcare system driven by the bottom line.

In 2021, the United States ranked last among high-wealth countries in the quality of its healthcare system, despite spending the highest amount of these countries on healthcare. Countries with much better healthcare systems provide universal coverage so that finances don’t prevent people from accessing healthcare, and money was not wasted on administrative burdens or siphoned off to insurance companies and massive profit for private healthcare companies. 

Lalasz noted that the pandemic just exacerbated and laid bare longstanding problems with the healthcare system, including lack of access for poor people, and private — and cash-strapped public — healthcare systems trying to save money or maximize profit by not investing adequately in staffing and resources. 

“We do this with the intention of trying to help and save lives,” said Lalasz, who worked three stints in Covid-19 wards and contracted the disease herself, missing 18 days of work. ​“If you’re not able to have what you need to be able to do that, it’s systemic. All these things existed prior to the Covid-19 pandemic, but that really brought it to a head.”

She said nurses like herself who contracted Covid-19 felt management was ​“minimizing” their experiences and their concerns, and ​“gaslighting” them into thinking they just had to toughen up. 

“There needs to be an acknowledgement that there is a systemic problem with the way the healthcare system is run in this country,” Lalasz said. ​“This was something that happened called a worldwide pandemic. It’s not my fault that it happened — it’s capitalism’s fault.” 

During the pandemic, healthcare workers faced guilt and anxiety about bringing Covid-19 home to their families, on top of the trauma of being unable to adequately care for patients and fearing for their own lives. Meanwhile, workers had to fight and fundraise just to get the basic PPE that could help protect them and their patients and communities — a recipe for moral injury. 

“We had managers telling us it wasn’t an airborne disease,” Willmeng remembers. ​“We’re doing the math on it: If I get it, maybe I’ll be ok, maybe I’ll die. Either way, I could also give it to my patients or my wife or my son or my next door neighbor or that nice woman at the grocery store.” 

As the pandemic has evolved and become slightly less of an acute crisis, the behavior of healthcare institution management has accelerated a nursing shortage that has become its own crisis. Hundreds of thousands of healthcare workers have retired or otherwise left the profession during the pandemic. Meanwhile, thousands of nurses have left staff jobs — often unionized — to work as gig-worker ​“travel nurses” earning much higher hourly pay but without collective bargaining rights or job security. 

A recent report by McKinsey & Company estimates the United States could face a nursing shortage of 200,000 to 450,000 available nurses — 10% to 20% fewer than needed — by 2025. A November 2021 industry study found that 90% of nurses surveyed are considering leaving the profession, citing burnout, staff shortages and unmanageable workloads as key reasons. 

The nursing shortage makes conditions more stressful and dangerous for those who stay in the profession, creating an intense negative feedback loop rife with the potential for continued moral injury. 

This cycle is also exacerbated when nurses leave unionized staff jobs to become traveling nurses with much higher pay but no job security, collective organizing rights or sense of permanency with their patients and community. In keeping with the cycle of blame and guilt typical of moral injury, traveling nurses have been criticized for taking high pay and abandoning their staff posts, when the underlying problem is hospitals’ failure to create physically and morally sustainable staff jobs. 

“There’s not a shortage of nurses,” said Lalasz. ​“There’s a shortage of nurses who want to work under these conditions.” She argued that the system takes advantage of the workforce made up largely of women, disproportionately women of color, assuming they will be willing to do the work without adequate protection or compensation. ​“It’s like, ​‘You’re caring, you’ll do this.’ We’re done with that. That’s why people have gone [into] traveling [jobs]. The working conditions are so bad, the staffing is so horrendous, you’re not respecting us, so we’re done.” 

Especially at a ​“safety net” hospital like Chicago’s John H. Stroger, Jr. Hospital of Cook County where Lalasz works, Lalasz notes, it’s important to have staff nurses who understand the needs and deep vulnerability of their patients — like the people incarcerated in the county jail whom she treated early in the pandemic. 

Ironically, the shift to travel nursing undermines the very organized labor system that is more necessary than ever in a time of crisis. Organizers stress that they want to identify and explain the concept of moral injury so that healthcare workers channel their trauma into organizing rather than turning inward or dropping out. The NNU white paper cites trauma experts saying that:

Those who expe­rience moral injury as a perpetrator of an immoral act or from failing to prevent an immoral act typically respond with internalizing emotions such as guilt and shame, whereas those who experience moral injury as a witness who was unable to prevent an immoral act typically respond with externalizing emotions such as anger and resentment. It is crucial that those involved ascribe the blame to the responsible actor(s) and not inappropriately take responsibility for failing to prevent a transgression, if that was not in their power. Anger and resentment are more likely to lead to the collective action necessary to redress transgressions by authoritative leaders or institutions while emotions such as shame and guilt may lead to withdrawal.

Willmeng is disappointed that healthcare unions didn’t do more to assert their rights and demand changes from the industry during the height of the pandemic. As NNU and other healthcare unions have reiterated, higher levels of unionization and a meaningful role for healthcare workers in making decisions about resource allocation and strategy would go a long way to providing better healthcare for patients and making the profession tolerable for workers. Ultimately, NNU and countless individual healthcare workers and leaders say that universal healthcare would vastly improve patient care, allowing access for people regardless of income and eliminating the profit motive that causes private hospitals and insurance companies to ration care and skimp on resources. A recent study published in the journal Proceedings of the National Academy of Sciences found that universal healthcare would have meant 338,000 fewer people dying of Covid-19. 

Willmeng feels that now unions are better marshaling their forces, with Minnesota nurses threatening a statewide strike as multiple contracts for 15,000 nurses are in negotiations. In early June, nurses picketed at 11 Twin Cities-area hospitals, highlighting stratospheric executive pay even as nurses struggle with debilitating understaffing and Republican legislators killed a bill that would involve nurses in staffing plans and provide loan forgiveness for hospital nurses. 

“U.S. capitalism is calling you essential, and you parlay that into what? We failed to rise to a major historical event — we’re trying to put the pieces back together again now,” said Willmeng, who started his current emergency room job hours after the union contract expired. He was fired by a different hospital during the pandemic for wearing hospital-issued scrubs, rather than his own, since he didn’t want the extra contagion risk of bringing scrubs home. He was later reinstated and settled a wrongful termination lawsuit. 

In late June, Chicago hosted the Labor Notes international convention of union members and activists, a gathering of progressive rank-and-file union members and leaders and labor activists from the United States and other countries. Much attention was focused on the need for mental healthcare for frontline workers. 

Elizabeth White, a therapist in Kaiser Permanente’s California system that serves many public union members, described the difficulty of getting crucial mental health appointments for her clients — and the toll that takes on therapists themselves. 

​“You’re basically always playing a game of Twister, twisting things to try to make it work for people,” she said. ​“We want to do the right thing for our patients, and the employers take our good intentions and exploit that. That’s the moral injustice.” 

During one Labor Notes session, nurses and other healthcare workers packed a large ballroom to speak out about their experiences, frequently mentioning moral injury and sharing their tactics for survival and organizing. 

“Nurses who have been through the meat grinder of Covid are now having their benefits taken away, feeling like no one cares if we live or die,” said registered nurse and Michigan Nurses Association former interim president Anne Jackson, after the session. ​“We’re not able to give the care we used to give, and we’re ashamed, and yet hospitals are making record profits.”

Marty Harrison is a staff registered nurse at Temple University’s hospital in Philadelphia, serving among the country’s poorest zip codes, where patients typically have multiple underlying conditions and complex problems. 

“I feel like I’ve done something evil because I didn’t have the capacity to take care of this person,” she said. ​“That went from being due to the pandemic to being due to the staffing crisis. The employer doesn’t appreciate the degree to which doing a good job is essential to us. No matter how much money I make, I’m not happy if I can’t take care of my patients. We can’t communicate that to them, because they don’t feel that way about their jobs.” 

She and others said that the hemorrhaging of staff nurses has obliterated the mentoring and organizing networks that used to exist for young nurses. ​“They’re not letting new nurses even know what quality care would be,” she said.

New nurses often leave the field or move to traveling jobs quickly, she and others said, overwhelmed by the lack of support and depth of dysfunction. While healthcare workers at Labor Notes said they understand that reaction, they hope their colleagues will turn their feelings of moral injury and distress into organizing. 

“What I do is fight back,” said Harrison. ​“For me that’s an essential mechanism.”