I remember the first robotic surgical procedure I participated in after the Covid 19 lockdown began in March of 2020. I read articles and followed Facebook groups of doctors practicing in high volume areas, primarily New York. Many of the procedures followed were gleaned directly from their advice and experience. They were the front line. One hospital in particular, Elmhurst in the Bronx, was considered “the epicenter of the epicenter”. This hospital, which is in the Mount Sinai system, has resident physicians who are primarily foreign medical graduates caring for a very diverse community.
At the end of May 2023, these resident physicians, as part of the Committee of Interns and Residents/Service Employees International Union, went on strike.
Among the many articles about the strike, in which the residents cited a lack of pay parity with other residents in the Mount Sinai health care system, but also a lack of support and recognition for the tremendous amount of work and emotional effort required during one of the darkest periods in the history of the world’s health care systems.
The resident physicians, in negotiations with Mount Sinai, repeatedly made demands for workforce support, which included pay commensurate with other residents in the Mount Sinai hospital system. In a statement released to the residents by the hospital administration, a chart with the proposed salary increases includes this statement ; “there was very little response to our generous package proposal” (1).
Ultimately, after a three-day strike, residents from specialties in Internal Medicine, Psychiatry and Pediatrics went back to work with a negotiated salary much closer to that of their other peers in New York.
In a statement from the Committee of Interns and Residents, Dr. Sarah Hafuth said “This fight was always about power, and Elmhurst residents are truly building that together”. (2)
In a sense, the Mount Sinai H + H system was bringing a knife to a gunfight.
The experience of those of us in healthcare during the pandemic was the product of an already stressed and dysfunctional system pressed to an untenable extreme. Having worked in hospitals since my first job almost forty years ago, I honestly have never witnessed the helplessness, fear, frustration and anger that was so palpable during the pandemic. We struggled collectively to put a word to the cloud that surrounded and suffocated us. It does have a name.
Moral Injury.
Moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs. Examples of events that may lead to moral injury include:
- Having to make decisions that affect the survival of others or where all options will lead to a negative outcome
- Doing something that goes against your beliefs (referred to as an act of commission)
- Failing to do something in line with your beliefs (referred to as an act of omission)
- Witnessing or learning about such an act
- Experiencing betrayal by trusted others
Watson et al, “Moral Injury in Health Care Workers” PTSD:National Center for PTSD
A strike is a conflict in which the parties have engaged in collective bargaining, but have been unable to effect resolution through negotiation. It is the final common pathway for a party unwilling or unable to accept the proposed solution. In conflict management, one of the most common reasons for the inability of the involved parties to reach a solution is that one or both parties are unaware of the reason or reasons for the conflict
In reading the Mount Sinai H + H statement, there is no mention of the moral injury, either by name or by the unbelievable situations in which the student doctors found themselves. The offer includes increased pay for a Chief Resident, six week paid leave of absence, expanding medical education benefits, and “creating language” for hazard pay (not guaranteeing hazard pay itself). These are interest based solutions. Interest based solutions are quantifiable. It is easy, on some level, to argue about the number of apples you are going to give me. It’s just a number. And while we might disagree on the number, for the person offering the apples, there is much less effort involved in figuring out how many apples are required to make me go away and leave you alone.
But let’s say the apples represent far more to me than just a number. I remember when there were no apples. I remember that even if there were apples available, I didn’t have ladders to get apples for the people who needed them. When people who were my responsibility didn’t get apples, they suffered greatly. At times, I had to decide who got apples and who didn’t. Those memories don’t go away. My worldview of apples changes. Until this is addressed, there will be no resolution to the conflict.
“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.”
Alexis Rean-Walker, Nurse, HPAE (4)
Dr. Suzanne Shale describes moral injury related to the Covid 19 pandemic (6). She describes the circumstances that lead to moral injury related to the pandemic, experienced by patients and family within the health care system as well as providers. In her words, “moral injury requires moral repair”. She lists seven ways institutions can begin to address moral repair.
- Acknowledge the injured party is a moral equal.
In a statement from the CIR, it is stated that the Elmhurst strike was about “power”. This is consistent with moral injury. Interest based conflict would have been easily resolved just by increasing reimbursement of the striking physicians to a level commensurate with their peers. To truly resolve the conflict, the hospital should offer residents a voice to directly contribute to hospital policy and management. For example, inviting house staff to have regular, valued input with hospital administration with documented effort at adoption would be a sign of equality.
- Acknowledge the authority of shared norms.
The guiding principle of placing patient care as the primary
of any health care system is the very definition of a shared norm.
Violation of that norm was clearly exhibited both during and after the pandemic. It persists as evidenced by the lack of provision of staff and infrastructure to meet the standard of care.
It is not possible to say that you place patient care and safety as a first priority while having one nurse care for eight patients (or more) on the floor. Keeping a resident on shift longer than twenty-four hours because there are no attending physicians available increases the risk of error on the part of the well-meaning but exhausted doctor. When healthcare workers strike in the name of better patient care, this is sincere. They have seen, with their own eyes, the struggle to provide the best care they can with the most meager resources available. However, when hospital administrators state repeatedly that money is the primary issue, one suspects that money is the primary issue FOR THEM. Because both parties have different norms and motivations, conflict persists.
- Acknowledging injury.
There must be a context and an opportunity to speak of the
harms of that occurred and give them voice and legitimacy. Administrators responsible for keeping hospitals open during the pandemic have no doubt experienced stress and harm also. Stories shared on social media and within groups, while producing resonance, are not the same as having the profound trauma recognized by those perceived to be in leadership. “Lip service” given to this, which may occur by making short references to the injury, may almost work in the opposite way. The recognition of the injury becomes a bullet point instead of a significant part of what is required to heal.
This should be a formal process, whether by in-person meetings, town halls, or shared written documentation. To speak of the injury creates a real and living acknowledgement, and takes a public and definite step toward repair.
- Acknowledging responsibility.
Dr. Shale states in her article that acknowledging responsibility is not the same as assigning blame. It is a person or institution recognizing that a part was played by them in the occurrence of moral injury. Because of this, it is paramount to accept a role in the process of reconciliation.
The pandemic was not the fault of the health care system at large, or the administrators and non-clinical staff. They were working in impossible situations. The already fragile infrastructure of the American hospital system was stressed to its maximum and beyond during the height of COVID. As thousands of health care providers, including nurses, doctors, and staff stopped working after COVID, the numbers of personnel available to meet the needs of patients surging back into the system for outpatient care and preventive medicine were not available.
Those continuing to work found themselves overloaded, and those in the non-clinical hierarchy did not take active accountability for this.
Financial reward does not meet the need or repair the deep emotional trauma of being taken for granted. If the assumption is that there will always be someone available to work a shift, do a procedure, or write a prescription, there will never be the acknowledgement of the systemic failure which continues to affect the work life of those in health care, and indirectly the life of the patient.
- Acknowledging that remedy is due.
This may be the most challenging of all. To admit that moral injury occurred, by definition, means that it must be repaired. This is also why moral injury must be defined and recognized as a separate entity from burnout.
Burnout by definition is localized to the individual; “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration” (7). If we define the experience of the striking individual as being “burned out”, it is simple (and easier) to assign solutions which address the individual in ways suited to this definition. I heard one operating room employee say that when they reported how significantly short-staffed and exhausted they were, hospital administration listened, then bought them pizza the next day. Nothing else was done. Now, when there are staffing issues to the point that employees are not given breaks to eat, they simply say there is no point in saying anything. “They will just say ‘sorry’ and buy pizza”.
Moral injury is a systemic issue. It occurs when the individual encounters that the system which was supposed to keep their interests first and share their values and norms has betrayed them. Because it is systemic in nature, efforts directed to the individual such as time off, wellness programs, and other more easily quantifiable measures are much less likely to resolve concerns or provide remedy. It is also much more difficult to heal systemic issues.
The failure to offer remedy may also serve as a “second harm’. Once the moral injury has occurred, for the system to fail to acknowledge that remedy is due may actually compound the moral injury itself. If hospitals try to ignore systemic solutions which legitimately would provide healing to providers and better care to patients, either because those solutions seem too difficult or because it may be easier to address them as purely financial, moral injury will persist and work stoppage will be much more common.
- Acknowledging righteous anger, or other negative feelings.
Witnessing the healthcare environment of the pandemic is something I will never forget. The fear of going to work every day and not knowing if you would bring COVID home to children and family. My husband is a pulmonologist and we decided early into the COVID outbreak that we would not sleep in separate rooms, If one of us got COVID, we likely both would. I remember every day waking up and worrying if I lost my sense of smell, and keeping a jar of garlic in the fridge just so I could make sure I could sniff it. As a physician in solo practice, I didn’t know what would happen if I contracted COVID and was unable to care for patients or pay my employees.
As many negative feelings as I have, I cannot fathom the inerasable memories of my friends and colleagues. Those who watched countless people die, helpless to save them. To simply put these feelings away and get back to work is not tenable. Those providing patient care in hospital systems need TIME. The ability for administration to provide understanding and space only can occur when providers are viewed as individuals who have been morally injured, and not resources within the hospital infrastructure.
Indeed, to see people as being morally injured and create the space to recover is a litmus test. If this occurs, it is a sign that the system is moving away from seeing people as individuals and not as necessary cogs in a machine.
- Acknowledging that, in injuring each other, we should experience sorrow and regret.
There is no price tag on sorrow. More than anything, this expresses why money alone will not stop resident strikes. The lack of genuine remorse for what these residents at Elmhurst have been through is palpably absent in the written statement released by Mount Sinai. If anything, painting these house officers as being driven by money alone ignores the very soul of moral injury that they have experienced. I would hope there would be a moment of meeting, a time in which hands could be held and those in administration could cry with the residents and say “I am so sorry you had to have this experience so early in your career”.
This kind of love and support is the very thing required to begin the healing process.
Until the disease causing the strikes is correctly diagnosed, it will persist. It must be called by its name. Moral Injury. Until this occurs, the strikes will continue.
I hope that recognition on the part of those in leadership in the healthcare system will occur quickly.
1.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://icahn.mssm.edu/files/ISMMS/Assets/Education/Residencies%20Fellowships/Bargaining-Update-5-19-23.pdf
2. https://www.cnn.com/2023/05/24/us/new-york-city-hospital-residents-end-strike/index.html
3
4.
Ulrich, C. M. and C. Grady. 2019. Moral Distress and Moral Strength Among Clinicians in Health Care Systems: A Call for Research. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201909c
6.
Shale SMoral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage itBMJ Leader 2020;4:224-227.
7.
