What Causes Moral Injury

From Dangerous Conditions for Patients to Disregard for Providers, These Union Leaders Have Many Examples to Share

AFT Health Care

To truly understand moral injury—and the urgency of developing a more supportive healthcare system—we must listen to the professionals who are being harmed, shift after shift. One year into the pandemic, the leaders of the Health Professionals and Allied Employees (HPAE), an AFT affiliate in New Jersey, generously gave us their time to share their members’ experiences.


Editors: Moral injury has come to the forefront in the last year because of COVID-19, but healthcare providers have long faced systemic barriers to providing the care they know all patients deserve and to being treated respectfully themselves. Will you share some pre-pandemic examples of situations that led, or could lead, to moral injury?

Barbara Rosen, HPAE Vice President: In the last decade or more, there’s been a rise of for-profit hospitals, and of a profit-driven mentality among many nonprofit hospitals; their mission has turned to caring more about money than patients. This has put a strain on the staff, leading to moral injury.

Some of our hospitals are better than others, but there’s been a widespread decline in working conditions. We’ve witnessed crumbling infrastructure, obsolete technology, broken equipment, and filthy environments. A nurse in one of our worst hospitals said conditions are so bad that it seems like it’s “being run by slumlords.” Patient acuities are up, and staffing is down. That in itself is a moral injury because those with the authority blame the bedside nurses instead of supporting them.

Too many of our members have impossible workloads. They’re not able to deliver the level of care and compassion that they entered the profession for. Healthcare workers are probably the most compassionate people on the planet. The employers tell them, “Well, you know, we cut [costs, staff] because our motto is to work smarter and not harder,” but the staff sees this as “It’s work to the death, with less and less and less.”

Debbie White, HPAE President: As a bedside nurse, I have been a mentor and a preceptor for a long time. It was only two years ago that I became the president of HPAE, which is a full-time job, and had to leave bedside nursing. When nursing students are learning, they are so idealistic and energetic; they cannot wait to become nurses. Then they graduate and orientation is suddenly cut short because administrators say, “We need you on the floor working as staff right now.” They are thrust into an environment where they see even the most experienced nurses unable to keep up with the workload, and they become more and more conflicted. They feel alone as the reality of the workplace begins to manifest.

I have witnessed many a new nurse break down in tears as they realize that they are working in an untenable environment. When these new nurses go to management and say, “I can’t keep up,” they are told, “It’s your time-management skills,” or “Maybe this job is not for you,” or “Maybe you really just need to work on your stress level,” thus effectively blaming the nurse rather than the environment. Many new nurses will eventually leave bedside nursing, saying “This is not what I signed up for.”

Alexis Rean-Walker, HPAE Secretary-Treasurer: When I think of what moral injury refers to, it is an injury to a person. When I think of morals, I think of your conscience, your values, how you perceive yourself. It is an injury to an individual’s moral conscience and values resulting from a transgression of a perceived moral code of conduct.

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So, think of me as any particular employee. If I work for your company, you have expectations. You expect me to come to work. You expect me to be there on time. You expect me to do my job well to the best of my ability. I also have expectations. I expect to be provided with the tools to do my work from a moral standpoint. So, if I come to work and my employer does not supply me with what I need, I am injured morally. When my employer doesn’t supply me with enough colleagues to distribute the workload or PPE for my protection—the gowns, masks, face shields, and gloves I need—that is both insult and injury to me. My employer is not standing by the employment contract; both sides have an expectation, but one side is letting the other side down. This results in psychological harm to one’s belief system.

Debbie: Consider one nurse I worked with; I’ll call him Mike. Every patient review of Mike was exemplary. Mike took the time to listen to his patients, and his patients reported that their concerns were addressed. Mike routinely stayed late to chart because he devoted so much time to his patients’ emotional and teaching needs, as well as their physical needs. Mike was famous for picking up those subtle cues that say a patient isn’t doing well and should be in a higher level of care.

But routinely, management would say, “You have terrible time management. You’re creating incidental overtime. You need to get out on time.” Mike would come in day after day and say, “Deb, I just can’t keep up with this. I can’t take care of the patients and do what management tells me to do.” That is moral injury.

As the most experienced nurse on my unit, I was frequently assigned the role of charge nurse. Often, I would come to work in the morning and find insufficient staff assigned to our unit. Staff would rely on me to advocate for the unit, and because I was the president of the local, my concerns might be addressed. But I would hear from coworkers that their concerns were often ignored. One young nurse said to me, “Who is going to listen to me—a first-year nurse who says ‘I can’t keep up’? Especially when every other unit is saying the same thing.”

Another example centers on the inability to provide patient teaching. For instance, with a newly diagnosed diabetic, teaching a patient to self-inject insulin is critical. Without careful instruction, a patient will have a much more difficult time overcoming the fear inspired from hearing the doctor say, “From now on, you must give yourself a needle a couple of times a day.” Helping a patient overcome that fear is time-consuming but key prior to discharge.

As an experienced nurse, I would try to make teaching a priority, but the rest of my assignment might suffer as a result. It is just one of the many ways that short staffing affects patients. Patients suffer, and so do the nurses trying their best to provide care.

Barbara: We represented staff at a hospital that was privatized. There was a long-term care unit in that hospital that would be staffed with one nurse for 60 residents and about four certified nursing assistants. The workload was not safe, but if anything went wrong, the blame would sit squarely on the shoulders of the nurse. In hospital medical-surgical units, it’s not unusual for one nurse to be assigned to eight patients, including patients on oxygen and intravenous fluid and receiving blood transfusions. Nurses are leaving their shifts feeling they haven’t delivered 100 percent, leading to moral injury.

Debbie: In one hospital, a unit had a serious problem with falls because of short staffing. A fall is considered by hospitals to be a sentinel event, requiring a root cause analysis. On this unit, staffing was such an issue that the manager put a calendar on the wall recording the numbers of days without a fall, thinking this would somehow be a deterrent. Unfortunately, there is no substitute for having proper staff, and the unit could not get through a week, or sometimes even a day, without a patient fall. Why? Because there weren’t enough staff to be as vigilant as was necessary to prevent falls from happening. There weren’t even enough staff to answer call bells in a timely manner. Finally, since there were so many X marks on that calendar, the manager tore it down.

Barbara: Nursing homes received COVID-19 patients to increase capacity during the surge. What happened next could easily have been predicted. Understaffing and lack of rigorous infection control programs were problems before the pandemic. Now add the lack of effective PPE, and the result is huge outbreaks and an unprecedented number of fatalities.

Debbie: The heart of the problem is victimization of staff who work under incredibly stressful, difficult conditions because they become a cog in a wheel, a line item in a budget. Staffing should be an asset, not a budget line that can be cut down to its lowest number in order to save a healthcare corporation money and reap more profit.

Among the for-profit hospitals in New Jersey, we’ve seen some troubling issues. The State Commission of Investigation released a report showing one of our employers had siphoned off over $100 million in profit into a shell management company, where it went directly into the pockets of the owners. None of these profits went into upgrades or even maintenance of the hospital.

This resulted in technology that didn’t work, outdated and broken equipment, rodent infestations, bare-bones staffing, layoffs, and crumbling infrastructure. One nurse told us that she saw a mouse standing on one of the IV pumps. That is what it feels like to work for a for-profit company that puts profits over patients.

For-profit hospitals in our state were not subject to the same transparency laws of nonprofit hospitals. Fortunately, HPAE has remedied this by endorsing state legislation that now requires the same financial transparency as nonprofits.

Barbara: At another hospital, in lieu of solving the staffing problem, they dreamt up a nurse intern program, and they attracted new graduates as well as nurses who had been out of the profession for a while, with the notion that they were going to train them and get them back into the profession.

These interns were not paid at first. When issues arose regarding workers’ comp, they then started receiving minimum wage. There was no education program for these nurses at all. They gave them a simple orientation and put them to work as nurses on the unit. HPAE filed complaints with the labor board and won. But they didn’t get hired at the end of the program. Management just said “Your work is done” when they had to pay RN wages.

Editors: Of all the causes of moral injury, the longest standing in the United States is racism. As union leaders, have you been called upon to defend your members’ rights to equality and dignity?

Alexis: Far too often. The most recent was just a few days ago.* I got a call regarding an incident involving two members; I believe they are in two different unions, but they are on the same level and work in the same department. They are two African American women who go to work striving for excellence. Upon hiring, they both had bachelor’s degrees, and while working one also earned two master’s degrees. Despite working and repeatedly bidding on jobs or promotions, they have not advanced. The member who earned the master’s degrees is now making a formal complaint against the employer.

Now, this particular employer has recently hired a new president who is working on changing the environment, but sometimes it is too little, too late. One potentially important change is that this employer is allowing two members to start a program within the institution that will hopefully help stop the inequities. Having higher qualifications than your counterpart who receives the promotion is heartbreaking, and this needs to change.

Let me add a COVID-19 example. There is a member, also an African American woman, who recently retired from a particular hospital. One of her siblings got COVID-19 and was admitted to the hospital where her sister had worked. She was not doing well, so the hospital was going to put her on a Do Not Resuscitate (DNR) list without contacting the family.

Thank God the retired member had friends—her former coworkers—at the hospital who called her. And she called that hospital and told them, “I’m telling you now, you better put my sister on the CPR list, because you’re going to resuscitate her if anything happens to her.” Her sister came home a couple days later, and she’s safe and sound, recovered from COVID-19. But the fact that they were going to choose her, without alerting the family, without telling anyone why she had been selected, it leaves me wondering what their criteria are for that DNR list.

Editors: Let’s talk about COVID-19 more specifically. How did the pandemic—and the handling of the pandemic—compound moral injury?

Debbie: There are a couple of incidents of moral injury that stand out in my mind during COVID-19. The most important to share is that of Alfredo Pabatao. Alfredo, a transport worker, was advised by his employer that masking—during COVID-19—would scare patients. He was told, “Remove your mask and carry it in your pocket. If you need to put it on, you can, but don’t wear it too much because we don’t want to scare the patients.” He followed the direction from the employer, and Alfredo Pabatao is now listed on our memorial page. He contracted COVID-19, and he was the first of our members to die from this awful disease. His employer left him exposed and at risk of contracting a deadly virus. That is extreme moral injury. For Alfredo and his family, it is unspeakable. But even for his colleagues, the moral injury is severe.

Another recent example occurred in mid-November through early February of this year. Our members found counterfeit masks within the facilities of New Jersey’s largest employer. Nurses noted the masks didn’t fit well, didn’t provide a seal around the face, and didn’t have the typical markings of a 3M respirator. Our members, frontline healthcare workers, are caring for a very high number of COVID-19 patients, and they knew that a respirator that didn’t provide a seal around the face was not safe PPE.

The employees were frantic because they couldn’t get their employer to respond and provide genuine respirators. The employer’s response was that they “would look into the matter.” Meanwhile, these counterfeits remained on units for months.

Alexis mentioned this bigger picture with moral injury, in which the employer does not live up to its end of the deal. In this instance, the employer didn’t provide a safe and healthy work environment. Our members flooded the Department of Health with calls, and a formal complaint was also filed. The department investigated, and the employer was cited. We also filed an Occupational Safety and Health Administration (OSHA) complaint, and we’re awaiting the final outcome.

In the meantime, the employer transferred these counterfeit respirators to their other facilities, and eventually we began to hear about outbreaks at those same facilities—100 employees infected in one facility, and 50 employees infected at another.

Editors: How does something like this affect morale and trust? What does it feel like to work under these circumstances?

Debbie: Terrifying, absolutely terrifying. And disheartening. The word disposable came up throughout the pandemic. Healthcare workers said they felt disposable: “It feels like my employer doesn’t care about me as a person. I am a cog in a wheel.”

After the terror came outrage. Our members were angry: “How dare you treat me this way?” Unfortunately, we are also seeing many nurses, especially those close to retirement, just leave the profession.

Barbara: We have one hospital that had 420 RNs before the pandemic. Now there are only 300. Nurses have been leaving in droves because they either have been sickened with COVID-19 or are just sick of the working conditions.

Debbie: Let’s talk about the mental health of healthcare workers as a result of the pandemic. Driving into the parking lot of a hospital and seeing refrigerator trucks that were used to contain the bodies of those who died during the first surge was absolutely horrifying for our healthcare workers. There was an enormous death toll. This wasn’t necessarily a failure on the part of the employer, it was just an awful truth of the pandemic itself. But adding in all the stressors that currently exist in the workplace to those created by COVID-19—the increased workload; the incredible numbers of very sick, unstable, and dying patients; and the constant, nagging fear of exposure—and you have a recipe for PTSD. Some members are now starting to experience the anxiety and depression that comes with PTSD—which, of course, is a hallmark of moral injury.

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Alexis: And what about the nurses at the bedside of patients who are dying from COVID-19? It’s like standing in the gap for family members, doing what they can’t do. Holding patients’ hands when they take their last breath. That is a major, major stressor to go through in your everyday work environment.

Editors: Let’s turn from digging into the challenges, which are many, and talk about interventions. How can we alleviate current suffering and prevent moral injury in the future?

Barbara: There are two ways of looking at that. You can work on the symptoms that you’re experiencing, and you can get down and work on the root cause of it. We like to look at the etiology: that’s where the union’s work comes in.

On the federal level, a lot of the issues arose from the Trump administration’s mishandling of COVID-19, such as the Centers for Disease Control and Prevention having wishy-washy guidance, OSHA refusing to implement an emergency temporary standard for COVID-19, and the former president’s hesitancy to use the Defense Production Act to produce PPE that would have saved lives.

On the state level, we have been working to promote hospital transparency in an attempt to keep money at the bedside instead of in the pockets of profiteers. We succeeded in getting a law passed, CHAPA (the Community Health Care Assets Protection Act), which deals with the conversion to for-profit hospitals. We’ve been working on a staffing law for at least 15 years; just imagine how much better prepared for COVID-19 we would have been if it had passed. It has been noteworthy that with the lack of any cohesive pandemic plans, we need a seat at the table going forward. New Jersey does not track healthcare worker or hospital outbreaks, unlike nursing home outbreaks. This information is imperative for analysis and remediation of problem areas. This year, we were successful in getting a law passed that requires the reporting of worker and hospital outbreaks. These legislative fights are not easy because we’re up against the hospital association and these big hospital systems, both of which are big political donors.

On the local level, we work for contract language to protect the work environment, create safety committees, and get a seat at the table on a host of patient safety and workforce issues.

Working on all three levels is necessary to deal with the underlying causes—what’s causing moral injury in healthcare workplaces.

Alexis: For our members who are suffering, I suggest a self-care, self-love approach. Taking time out for yourself—by meditating, walking, exercising, reading a book, or possibly doing therapy. But really, the issue is systemic; the employer has to live up to its end of the agreement—including the spirit of the agreement. I think the increase in staffing would make the biggest difference.

Barbara: Advocating for quality healthcare is in a whole different arena than what it was when I started nursing 46 years ago.

Alexis: When it comes to racism, the key is to remove barriers. If we tried harder to remove structural, institutional, and systematic racism, that would help. Not judging a person by their appearance or discriminating against people based on their names or geographical area. These are changes organizations could make quickly to help relieve stresses. Having stress from your work environment added on top of your personal stress of your day-to-day life—trying to live and survive in a racist society—makes a difference. Attacking things at multiple levels would make a difference.

Debbie: One thing we did immediately with COVID-19 was to try to educate as many members as possible. We created an information hub and conducted town halls, sending as much out to our members as we could. Because when it came down to it, members would have to advocate for themselves in the moment. We wanted to give them the tools, resources, and knowledge to do that.

We have also remained present in the media. We were one of the loudest voices in the state in terms of worker safety. Many of our workers spoke to the press as well. We advocated for all of our healthcare workers in the state, and even the nonunionized heard us.

Elections matter. Trump turned the pandemic into a political statement. A simple protective measure like wearing a mask became a statement for the Democratic Party. Thus, one of our biggest victories was making sure Joe Biden was elected, and we were pretty successful in our phone banking efforts for both that campaign and the Georgia US Senate runoffs.

We also feel like we need to keep up the pressure on OSHA for an emergency temporary standard, and we’ve supported state legislation that allows that any essential worker who contracts COVID-19 is presumed to have been exposed in the workplace and is entitled to workers’ compensation benefits. This takes the burden of proof from the employee and places it on the employer. We’ve educated our members all over the state regarding that law and what they should do if they contract COVID-19.

We also now have a state law that requires employers to track and report the numbers of infected and sickened workers. I can tell you that there was so much opposition to this law that we had a five-month delay. The Senate version passed in July, but it took a herculean effort to get it passed in the Assembly, where it finally passed at the end of December. Still, it wasn’t signed into law until the end of January. How convenient to start tracking the data as the second surge is dying down and after so many workers have been vaccinated.

Something else HPAE has been able to do at the local level is to negotiate memorandums of agreement for things like pandemic planning committees, hazard pay, and limits on floating to areas outside the expertise of some of our nurses.

We’re currently working on the mental health issues created by the pandemic. We are looking into what kind of a mental health program can be facilitated in our state. Police officers who endure stressful situations are directed immediately to occupational health, where they can get treatment for posttraumatic stress disorder. Developing a similar program for our healthcare workers is one of our initiatives.

Barbara: When your profession gives you lemons, get up and make lemonade. Take care of yourself and work with the union. There is power in numbers to make the changes you want to see. And I think that’s everything in a nutshell.

*This incident occurred shortly before our initial interview in February 2021. (return to article)

The outcome was still pending as of March 12, 2021, when this interview was finalized to go to press. (return to article)

[Photo Credits: Patrick T. Fallon / AFP via Getty Images, Go Nakamura / Bloomberg via Getty Images, Irfan Khan / Los Angeles Times via Getty Images]


AFT Health Care, Spring 2021