A nurse on chronic understaffing and moral injury: ‘You were supposed to take care of me’ | Opinion

May 20, 2022 6:00 am

Nurses affiliated with the group National Nurses United read the names of registered nurses who died during the coronavirus pandemic while demonstrating in Black Lives Matter Plaza in Washington. The group placed a pair of shoes for every RN who has died during the pandemic. 2021 Photo by Win McNamee/Getty Images.

After two years on the frontline of the COVID-19 pandemic, 15,000 nurses in the Twin Cities and Twin Ports are now bargaining for new contracts with hospital executives at major health care systems in Minnesota. We believe both nurses and hospital executives should share the goal of a contract that recognizes nurses’ sacrifices and addresses the nurse retention crisis in our hospitals. We want a contract that respects the value of nurses and encourages us to tell our friends and family that nursing is a worthwhile profession, and that hospital executives truly value their employees in Minnesota. 

Do health care executives share those goals? 

As much tragedy and turmoil as the COVID-19 pandemic has caused, it has also highlighted longstanding issues in our economy, workplace and our health care system. It has given us the opportunity to question where priorities and values lie. It has forced us to look at current practices and ask whether they are what we want going forward. It has given us an opportunity to change. I hope that opportunity will not be wasted. 

COVID-19 affected us all, but perhaps no one as much as the nurse. Every day, we are forced to make choices about which tasks need to get done to protect the health and safety of our patients. Often, we must make these decisions in a few seconds or less. Hundreds of these decisions — every day that we work. This can turn into consecutive days when a patient care need goes unmet because there is an endless list of tasks that need to be completed. And now we are expected to accomplish these tasks with fewer people. This delayed care for our patients might include hygiene needs, wound care, or quality and comprehensive discharges. Often, we must choose between our patients’ needs and our own needs to use the bathroom or take a lunch break. 

We all know the consequences of these lapses in care. No nurse wants to be forced to make the decision to forgo patient care because their ever-growing list of tasks seems endless. This is the reality of working chronically understaffed. This is every day working the floor. We are functioning in a pressure cooker where we are expected to ensure safety and quality without the appropriate resources. We are forced to choose which patient care needs must get done and which can wait. 

What nurses are experiencing is not “burnout” from working hard. Nursing has always been a difficult profession. What nurses are experiencing is the definition of moral injury. According to the U.S. Department of Veteran’s Affairs, “moral injury can occur when someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs,” including situations “where all options will lead to a negative outcome.” Such moral injury leads to “moral distress such as guilt, shame, and anger,” and potentially to Post-Traumatic Stress Disorder (PTSD).

During the pandemic, I experienced moral injury while working on a COVID medical-surgical unit. The ICU was full, so as many patients as possible were transferred to other units to free up beds for more critical patients. As a result, nurses had to quickly learn how to provide complex care to more critical patients who required oxygen delivery devices. I will never forget one day when I was scrambling on an understaffed shift. Eventually, I was finally able to get to one of my more stable patients. Though they did not suffer any adverse effects, they expressed distress at feeling neglected, and said eight words that absolutely shattered me to the core: “You were supposed to take care of me.” 

I can confidently say that most hospital executives we are negotiating with have never had the experience of crying into a half face respirator. It is hot, messy, and uncomfortable, and it adds to the ever-present fear that my PPE might become compromised, potentially exposing myself and my loved ones to COVID. Until that day, I had never cried during my nursing career. During my seven years as a nurse I have been physically assaulted twice, verbally assaulted countless times, and I regularly need to sacrifice my basic needs to meet the increasingly unrealistic demands of hospital management. 

Despite all that, this is what broke me.

Nurses had assumed that once COVID numbers leveled off, the practice of rationing care would end. But today, we are still working under the “lean” staffing choices of our hospital executives. I don’t know how anyone can hear these stories and not feel a sense of tragedy and outrage. Certainly, an individual reading this without feeling a sense of compassion should not be making executive decisions in health care. But cases like this happen for every nurse in every hospital, every day. 

On top of these tragic stories, chronic understaffing by hospital management has a measurable impact on hazardous events like falls, pressure injuries and infections. This is the cost of running health care like a business. These patients are your siblings, parents and grandparents. 

These are the consequences of forcing nurses to work in an environment which goes against their moral beliefs. It is truly grotesque.

Continued staffing cuts by hospital executives shave down the number of staff we have to accomplish the same tasks, for nurses and other health care workers. Patient assignments for nursing assistants have gone up, as have the number of patients assigned to any one nurse, regardless of the level of care needed. The current staff-to-patient ratios set by hospital managers leave health care workers scrambling to provide the safe, appropriate care our patients need. 

How do you prevent hospital-acquired infections and injuries, and these tragic patient stories? How do you ensure that on every shift, patients get the care they need? Nurses. 

The answer is more nurses and more nursing assistants.

Nurses and patients do not need more “process improvement” recommendations from executives, handed down while staff levels are slashed. Without the staff to accomplish these recommendations, they won’t get done, and they don’t address the issue of having to do more work with fewer people. 

Actions speak louder than words, and it is past time for our hospital executives to make real, lasting improvements to the situation in our hospitals. Nurses can see the impacts of short staffing on patient outcomes, as more nurses are pushed out. Those who were willing to sacrifice their mental and physical health are burnt out and left. Those of us who remain continue to suffer moral injury every day as we are forced to ration care because our managers will not provide adequate staff. We are slogging through every day, just hoping to make it to the end of that twelve-hour shift without making a choice that results in patient harm. 

Hospital executives have been gradually diminishing staffing levels and autonomy for years. We have also seen a lot of leadership turnover, as managers are pressured to run their units “as lean as possible” in order to achieve 100 percent productivity and to stay within budget. The managers who left know this practice is unsustainable. This is an issue at every hospital in Minnesota, part of a national trend by hospital executives, exacerbated by the pandemic.  

I have personally witnessed the consequences for patients and employees when executives run our health care system like a business. It contributes to the growing health disparities within communities of color. It forces employees to work in an inherently dysfunctional and inequitable environment, to sacrifice their own mental, physical and spiritual wellbeing for the sake of the bottom line. It results in patients paying four times the actual cost of their medical care, sending millions into medical debt. 

Nurses and patients know this is unsustainable. My question to Minnesota hospital executives is this: What are you doing to mitigate the effects of moral injury on your employees? What are you doing to protect patients? What are you doing to prepare for the next pandemic? What have you really done to improve the unconscionable staffing crisis and retention crisis that you helped create? How can you look your nurses in the eye after the past two years and say, “We’ve done enough”? 

While we suffered the moral distress, the uncertainty, and the risk to our health and our families, hospitals responded by giving us pizza and ice cream and calling us “heroes” — when what we needed was adequate staffing, PPE, hazard pay and bonuses, and paid COVID leave. We’re treated like children. Would any hospital CEO accept this as an alternative to their million-dollar raises?

The “Great Resignation” represents a shift in power from corporations to workers. Workers are unwilling to put up with jobs that reward them to the bare fiscal minimum for the sake of company profits. We have the power now. Workers are flocking to jobs that value them and don’t force them to go above and beyond with little-to-no compensation or recognition. 

Workers are seeking companies that allow work life balance and treat their employees with respect and appreciation outside of empty phrases like “hero.” Companies that blindly choose to stay the course of exploiting their employees to improve profit margins are going to find it harder and harder to recruit and retain quality employees. 

Health care is in a crisis. We are rapidly losing nurses unwilling to work in this dysfunctional environment. They are leaving with years of experience and the ability to train and mentor new nurses. If hospital managers continue to treat nurses like an expendable resource, the crisis will only get worse. 

Every single one of us will need the services only a hospital can provide at some point in our lives. Hospital executives need to ask themselves what they are doing to ensure that when the time comes, your nurse will have the resources needed to appropriately care for you or your loved one. 

What nurses are asking for will go a long way to improve nurse recruitment and retention, as well as patient safety and satisfaction. 

Along with fair compensation for our sacrifices during the pandemic and for the rising cost of living, nurses are seeking solutions to chronic understaffing and its impact on patient care; to better prepare for the next pandemic, for the sake of workers and patients; and to prioritize diversity, equity and inclusion within our health care organizations. 

Nurses are fighting to ensure Minnesota hospitals can provide safe and quality care. Every nurse in the state is watching. They are waiting to see if there will be substantial changes and improvements, or more of the same empty promises.  

Nurses and other health care workers are the people who make hospitals work. We are responsible for the small things that leave an impression on patients — not hospital executives or organizations. Decisions are being made by people too far removed from the bedside, and the outcomes of these decisions are only examined as numbers and percentages, such as the number of critical events, number of exits and hires. Behind the numbers are human beings — patients and nurses — who are victims of our dysfunctional health care system.  

Now, it is up to Minnesota hospital executives to decide what role they want to play as nurses seek respect, retention, and the ability to provide quality patient care. Hospital CEOs can make our hospitals into employers that value what workers bring to the table, or they can continue to ignore the issues driving nurses from the bedside.

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Alison Marcanti
Alison Marcanti

Alison Marcanti is a registered nurse who has worked at United Hospital in St. Paul for seven years. She is on her Minnesota Nurses Association negotiating team with Allina Health System.