How Doctors and Nurses Can Team Up to Fight Moral Injury in Healthcare

Wendy K. Dean, MD; Simon G. Talbot, MD


November 20, 2019

Since we first reframed physician distress as moral injury in 2018, we have heard from scores of physicians—but also from nonphysicians in healthcare for whom that language resonates as well. Nurses, advanced practitioners, first responders, respiratory therapists, and physical therapists all have told us that they feel it too.

In fact, at a recent national meeting of perioperative nurses, more than 80% of audience respondents who reported feeling distressed endorsed the term "moral injury," rather than "burnout," in an informal poll. No segment of healthcare has a corner on distress. We are all suffering.

Why is it so hard, then, to build an advocacy community to fight moral injury across the various healthcare professional groups?

Too often, rather than viewing each other as providing complementary care, different healthcare professionals become factionalized and retreat into protective silos, lobbing thinly veiled hostilities from the safety of that position.

But when we are more interested in making sure other professionals are wrong than in understanding how their positions have merit, we lose focus on the bigger picture: making healthcare better for patients and sustainable for clinicians. Self-righteousness doesn't help us achieve any positive goals.

When resources contract, it is human nature to withdraw into a known protective space, defend territory, or generally become less willing to look at the needs of a larger group. But this dynamic works to the detriment of patients. Good care benefits from multiple sectors of medicine working in concert. And better teamwork leads to higher job satisfaction.

Doctors' and nurses' different perspectives give them unique ways to evaluate how well a team is working. This is partly the result of how different healthcare professionals are trained to think and to communicate.

Physicians think good teamwork is having someone who anticipates their needs and follows directions; nurses think good teamwork is having their input heard and considered.

As Sexton and colleagues wrote when describing interactions in a hospital setting, "Nurses are trained to communicate more holistically, using the 'story' of the patient, and physicians are trained to communicate succinctly using 'headlines.'" As a result, physicians think good teamwork is having someone who anticipates their needs and follows directions; nurses think good teamwork is having their input heard and considered. Knowing this, we can approach cooperation in a way that reduces misunderstandings.

Both physicians and nurses have engaged in behavior that is hostile toward the other. One nurse author writes, "Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors." The tone drives a wedge between nurses and other professionals.

Nurses, physicians, and hospital administrators are equally to blame for the current antagonism among clinicians. In the past, a physician's ultimate responsibility for a patient's outcome came with the authority to determine a treatment plan, and to guide its execution. It conferred the role of team leader. Unfortunately, some physicians used that role to dictate rather than collaborate, and they denigrated the contributions of other team members.

A Shift in Healthcare Leadership

As team-based care has gained more attention, though, the assumption of physician as team leader has shifted. Leadership is more distributed, if responsibility is not, and consensus—among nurses, doctors, the patient, family, and other professionals—is expected. Some physicians have struggled with that shift. Some resent losing authority without appreciably offloading responsibility. Some feel too rushed and oversubscribed to generate consensus. And a few lash out in response.

Resources of time and money are shrinking in healthcare, which leaves everyone feeling threatened. We are continually asked to do more with less. We worry about patient safety and having the time to provide a compassionate, human experience of care. We worry about the ability to access necessary treatment. And we worry about whether we will have a job, sustain our income, and be able to repay our school loans.


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