November 3, 2021

Episode 64: A deep dive into moral injury

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Description

Our guest for this episode is Dr. Patricia Pittman, a Professor of Health Policy and Management and the Director of the Health Workforce Research Center at George Washington. Dr. Pittman is part of a team of researchers working on the Moral Injury Project, the aim of which is to inform the healthcare industry and the broader public about the challenges facing nurses and about the importance of system-level changes to address these problems. 


Dr. Pittman and her team have been collecting stories of moral injury from nurses across a variety of levels and settings in order to identify the constraints that are weakening the social conscience of the profession. Today she talks with Dam about what she’s learned from this project, why she thinks the causes of moral injury need to be addressed at the policy level, and how nurses can get involved. 


Links to recommended reading: 


Podcast

Transcript

Dan:
Polly, welcome to the show.

Polly:
Thanks so much for having me, Dan.

Dan:
Yeah. So, I would love to hear your background at a high level and what got you interested into all of the craziness that's around healthcare workforce.

Polly:
So, I am Master's in public health and a doctor of medical anthropology. I actually trained in Argentina where I was living for the first portion of my adult life, doing a lot of human rights work. And I transitioned into health policy/public health when I had my three little girls down there and had a number of issues as a patient that I objected to, and decided I better take a closer look at the quality of healthcare if I was going to make a contribution to the place I live. So, that led me into health policy and public health. I worked for the Pan American Health Organization for a while. I came back to DC, which is actually my hometown, in 1998, so a while ago, and eventually transitioned back into what we affectionately call domestic health policy stuff. And I've been working on the issue of nursing and nursing policy for maybe a dozen years or so.

Polly:
I first got interested in nursing around the time of the early 2000 nursing shortage when there were a lot of international nurses being brought to the United States. And the first point of reflection was that this could be problematic for source countries that were losing their nurses. But I quickly began to learn that the international nurse recruitment industry here in the United States had some issues and got really interested in the business model and some of the implications of the business model from the point of view of the international nurses rights. In particular, I became rather deeply concerned with the contract breach fees that they use, which are very, very high and lock these international nurses into low paying jobs. And then I worked on the first IOM Report on the Future of Nursing with Sue Hassmiller and colleagues as the coordinator of research, and that gave me a much broader perspective, of course, on what was happening in nursing, and have continued to have a special place in my heart for nurses and the challenges that nurses face in the healthcare system.

Polly:
And it's expanded to now include all things health workforce. I direct something called the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University, which is a partnership of seven schools at GW. The School of Public Health hosts the Institute, but it also includes the School of Nursing and Medicine and Business and Law, et cetera, et cetera. So, we do a lot of projects in research, in education and in what we call action, which includes raising issues such as how important it is to orient health professions education to social mission, and trying to create measurements and data for these issues that we think are important in terms of improving what we call health workforce equity, which is essentially the contributions of the workforce, or not, to health equity. So, all the policies and programs that allow or don't allow the health workforce to do a good job of addressing health equity is what we focus on.

Dan:
Wow, what an awesome background and just so much to unpack there as well. The Future of Nursing Report has also had a lot of focus on workforce, and it seems like we're always in this perpetual shortage. So, do you think this is the new normal, that we're just never going to have enough nurses, or are there some steps we can take to shore up the supply and demand?

Polly:
So, nursing leaders have taught me that it's not a continuous phenomenon. It's a cyclical phenomenon, and it has everything to do with what else is happening in the economy. So, we often talk when we think about the nurse labor market about the countercyclical nature of nurse shortages, and what happens is that, in periods of economic boom and low unemployment, nurses that are unhappy in their jobs retire early or reduce the number of hours that they're working or leave the profession entirely if they're able to find better work. And in periods of economic recession, like the last one, we just saw this happen, it was textbook, nurses come flooding back into the workplace because they and their families need that income. And so luckily there've always been enough nurse jobs so that during recessions nurses have played a really important role in communities in sustaining income.

Polly:
But what's underlying that cyclical nature is some structural problems in nursing work, particularly in the hospital and possibly also in nursing homes, but particularly in the hospital, which is where a little over half of nurses still work. These are jobs, as you know, as everyone knows, that are really difficult jobs. And there are a lot of problems that are leading to, let's call it job satisfaction in the most polite terms. People are often calling it burnout now. And increasing we're interested in one type of burnout, which is moral injury. And these are problems that lead nurses to not want to work in those settings. Pretty basic labor economics.

Dan:
I've definitely seen those trends over my career as well. And it is. It does follow those economic cycles. And you can see the average age of the nurse increase in times and decrease in times. But it seems like there's also some interesting pieces that are happening now. One is the pandemic and a prolonged perception of poor working environment, which is leading to what we'll talk about as well, which is moral injury. But there also seems to be a mismatch of supply and demand understanding across the country as well, that we don't really know where all of the nurses are or how to even recruit them or pull them into places where they're needed.

Dan:
And the ways we've done that in the past have been through staffing agencies or state-led organizations, but we're still in this opaque nature of we don't even know how many ICU nurses are in any given state in any given time and able and willing to work, let alone trying to get them in the door to different facilities. Do you think those are confounding factors that are solvable or is that just something that just makes it a really, really complex problem that we need to really put more energy into?

Polly:
So, I think they're two distinct issues that you're raising and they're both really, really important. And one is the lack of data about where nurses are working and what they're doing. We rely in the United States on something called a National Sample Survey of RNs, which traditionally is administered every four years. It's a pretty good sample survey. In this last round, the Census Bureau managed it and it's sponsored by HRSA. But it's a sample survey, so it's not all nurses. And it's just essentially trying to understand what percent of the nurse workforce is doing X, Y, Z, or looks like X, Y, Z. But when you have a pandemic or any other kind of natural or manmade disaster, you need real-time data about who is in your community and could be mobilized. And when you're trying to do preparedness work, you need to be able to make projections that are geographically specific.

Polly:
And we don't have that data in the United States. As everyone knows, the physicians have something called the AMA Masterfile. They have something called a Provider Identification Number, an ID that they use for billing, but except for advanced practice nurses, most RNs are not billing and so they have no need to have that number. So, we can't find them in the government database of NPIs and our professional associations don't have a Masterfile. And so there's a lot of work being done in this space. And the National Council of State Boards of Nursing is doing some really interesting work trying to create a unique nurse identifier that might one day get us to being able to identify how many nurses there are in a given place and what they're doing. However, it's mostly focused on the re-credentialing process and as a mechanism to help employers do that in a more automated way, and possibly also including it in the HR so that they can do assessments of individual productivity and group productivity around different models of care.

Polly:
It's not really designed to be understanding workforce. So, we hope that it will evolve into that, but for now we don't have it. And I personally have been very interested in trying to encourage nurses to get NPIs because RNs can get them. And if we had a larger number of nurses with NPIs, we would be able to track them through the national system. But that's an alternative route. They're not mutually exclusive. And both, I think, would be important. But you're absolutely right. We have, more than any other health profession, we have this big black box when it comes to understanding what nurses are doing. So, that's a huge problem during a pandemic.

Dan:
I've always dreamed of having the LinkedIn for nurses, that it was mandatory for you to be on and you can put in all your skills and credentials and job changes and all that kind of stuff, and we could actually get some of that information in a more timely way. I love what the NCSBN was doing. I've spoken with their chief information officer recently about it as well. And I think that'll lead to some innovation. And I think the more we can get transparency in what nurses are doing and with the shift to a more mobile workforce, I think, of nurses not staying at facilities for 30 years and retiring, but really jumping around, whether it's per diem travel, local markets, we're going to have to have more timely data so that we can make some decisions there.

Dan:
But I'd love for you to talk about the moral injury piece, too. I think this is something that is one of those confounding factors, like we said, that's driving people out of the profession. And we did a survey of about a thousand nurses. 40% of them said they're questioning their longevity in the profession, which is really scary knowing that we need almost 200,000 nurses every year to just stay where we are, let alone the retirements and the people leaving the profession.

Polly:
Right. Right. Well, I think it's even worse than that. I think the critical care nurses just did a survey and it was 92% said that they-

Dan:
Oh, man.

Polly:
... thought that the crisis was going to shorten nurses' careers, and 66% were thinking of leaving their jobs. So, it's a big deal right now. And there are a number of reasons why COVID has layered on many other problems on top of the chronic problems. So, we have a perfect storm, if you will. I think it's important to differentiate the different categories of causes, because that means we can be more specific about the solution. So, for you all who are clinicians, you can't really treat the problem unless you've diagnosed it correctly. And I think there's a lot of talking past each other when it comes to understanding what the problems are. In fact, we often jump to solutions without understanding the problem.

Polly:
So, we're leading a project in partnership with the Association of Med-Surg Nurses, with AFT Health Care, and with a number of doctoral students in nursing schools around the country who've become, interestingly, probably are refugees from nursing themselves, have gone back to school to research and write about this issue, and they've contacted me. So, we have now a half dozen doctoral students really interested in this. So, we have a team that is looking at moral injury among nurses, and we are trying to do a number of things. I mean, essentially we're trying to collect stories to do a root cause analysis and classify the different kinds of causes. And we think that moral injury is a really important set of causes, but our hypothesis is that there are many others that we shouldn't call moral injuries. So, moral injury is not a replacement for the end outcome, which we might call burnout.

Polly:
It's one pathway, if you will. It might be the super highway, but it's not the only one. And it's really important for nurses and for nurse leaders to tease these things out so that we can address each with specificity. So, you all are probably familiar with this surge in interest in moral injury came about in 2018 when two physicians, Wendy Dean and Simon Talbot, put an article out in Stat that got tremendous traction in which they actually were arguing that we shouldn't talk about burnout because it has a connotation of being the result of not being strong enough or not being mindful enough, or basically not having thick enough skin to put up with the tough environment of healthcare, which I very much relate to that critique because my husband, who's a physician, often talks about, "Well, when I was a resident, things were so tough and I never slept either. Yeah." So there's sort of like, "I went through hell, so you should, too."

Dan:
Right, right. I've heard that a lot.

Polly:
But the critique really resonated with physicians, but also with all healthcare workers. And of course in nursing, nurses had been talking about moral distress since the mid-'90s and had done really interesting studies and survey instruments and assessments, particularly in the critical care setting around moral distress. But Wendy and Simon were saying, "Let's look to the military, understand what they have studied among both active and retired military personnel in terms of moral injury," and put out a definition that really resonated with people. And I think that there's just been a clamoring from the nursing community to say, "Whoa, whoa, whoa. Wait a second. Is this the same as moral distress? Is this the same as burnout? What are we talking about here? It resonates with me, but I'm confused about what the parameters of what we're talking about are." What Wendy and Simon proposed, which I think is still a really good definition, is that moral injury is a violation of one's code by witnessing, participating in or precipitating moral harms.

Polly:
And this part is the really important part. That it results from a betrayal of what's right by someone, or I would add some thing, with legitimate authorities in a high stake situation. And then the symptoms are distress, shame, guilt and physical symptoms as well. But I think the core to this is a sense of betrayal of what's right. And that it might be because you did something that you didn't think was right, or you participated in something, or you witnessed something, but there was something that just doesn't sit well with your own sense of ethics. And so I think that nurses, when they're asked about moral injury, have a lot of stories to tell, but they also have a lot of other stories to tell of things that hurt and things that are death by a thousand cuts that also result in the end outcome of burnout syndrome. And so part of what we're trying to do in our analysis of the stories is really tease out what we think is moral injury and what are some of the other phenomenon that are at play.

Dan:
I really resonate with the description that you have and I've experienced it in my life as well, in my career. I actually wrote a whole book chapter about what I called toxic leadership at the time. The only way I could describe it went 100% against your understanding and values as a professional. And in my experience, it was so life changing that it impacted the way I showed up, not only to work, but at home and how I perceived things, how I looked back at my career, how I tried to make decisions moving forward. That may be an extreme example. But I think people don't understand how deep these injuries go.

Polly:
That's right. I think that's why it resonated. Because this notion of injury, it's not stress. It's really physically and mentally injurious.

Dan:
100%. I mean, I remember coming home... And I think I probably experienced it as a clinician as well. As an ER nurse, you see things, you have no one to talk to about it. That builds up over time. But I think even in my leadership roles, just seeing decisions being made that were just against what you believe in, it changes you. And so I'm so excited that you're diving more into this work because we need to understand it. And for me, I've been trying to push that we need to put this into leadership education. The choices that you make as a leader, it's not some arbitrary thing. And the worst thing that you do is not firing somebody. The little micro interactions that you have with your teams can really change their entire life. And so I'm curious, what was the catalyst that kicked off this moral injury project and if you can talk a little bit more about that as well?

Polly:
Well, as an anthropologist, I'm always really interested in giving voice and helping people be heard. So, it comes naturally to me to think about, if there's a problem that intrigues me to think about it from the perspective of raising voices. And I've played a funny role in nursing, not being a nurse myself. I consider myself a nurse ally, but I'm also an academic. And so it's really important for nurse leaders to describe their own problem. Yes, it's also important for others who are not nurses to describe nurse problems, because we can see things often that you can't see, and vice versa. And so I think a robust and mature segment of the healthcare industry merits other people also studying these phenomenon. I mean, nurse labor is at the heart of our healthcare system. And whether it's economics or from a human caring and compassion perspective, nurses play a central role.

Polly:
And nevertheless, it's mostly doctors that are studied in health workforce circles. So, I feel special privilege of being a nursing anthropologist, if you will, as opposed to a medical anthropologist. And when this issue bubbled up, the lack of clarity. I mean, I know that there are many people who are studying this and they have clarity, but in general, in the broader nursing community, I think that there is intrigue and lack of clarity. And so it seemed like the kind of issue where I might be able to help. And so in talking to nursing leaders who are experts in different areas, I mean, you've interviewed Cynda Rushton, for example, who's a terrific leader on the issue of what she calls moral resilience, and there are other people as well, it's become clearer and clearer to me that we need to pool all of this and come up with a framework that includes a bunch of different concepts.

Polly:
For example, Terri Hinkley, who's one of the co-researchers on our project, did her dissertation on what is called in the literature, second victim syndrome, which is similar, but a little different. And then there's research on secondary trauma stress. There's research on compassion fatigue. There's research on something called mattering, which is this idea that the perception that your opinion and your contributions to the team aren't valued. And the interviews that I've done thus far for this project see a lot of those things also, which I think are different from moral injury. So, they're different pathways to burnout, and I think they have very different kinds of solutions.

Dan:
I think you're right. And I think there's a lot of terms that are used in this and we've discussed many of them, and it gets confusing. And they probably all have different interventions as well. I think what I've seen, and I helped build the Kaiser Permanente School of Medicine, this came up a lot because we wanted to reduce the trauma of medical school, basically, for the new students. And so we talked with a lot of the physicians about what was it like for you, what was hard, and that kind of thing. And they would come up with, "Well, we just had to suck it up," or, "Now they're telling us we're burned out or we're experiencing moral injury or some sort of stress at work as well, and they're telling us to go up to the rooftop and do yoga." And they're like, "If I get told to do yoga one more time." Because we're just generalizing all this into one big bucket. So, I would love if you could do a overview of some of the main differences between those and then we can go from there.

Polly:
Yeah, sure. So, these are coming out in the stories. And so what I'm doing is taking stories and putting them in the different buckets, right? So, first of all, it's important to define burnout as an outcome. And burnout, there are many different definitions out there, but the one that is most prominent is that it is composed of three things, emotional exhaustion, depersonalization, which are things like cynicism and apathy, and thirdly, a low sense of personal accomplishment. And sometimes people break out the low sense of personal accomplishment as something different. Sometimes the cynicism and apathy is broken out. It's often called compassion fatigue. I think compassion fatigue fits in that second part of burnout. So, let's put burnout at the far right side of your flow chart as an outcome. And where I started on the far left side is nursing's professional identity as essentially the social mission, as caring for patients, families, and communities.

Polly:
So, you have a professional identity with a social mission that bumps up against the reality of work environments. And in my mind, what is emerging are four types of conditions in the workplace that are problematic for nurses. The first is the one that's most talked about, and very clearly, I think, a moral injury issue, which is, to put it in very crude terms, profits over patients and healthcare workers well-being. So, anything about turning away patients that maybe don't have insurance or have Medicaid, witnessing health plans not agree to authorize certain procedures, as well as the actual hospital over-diagnosing, over-treating, those kinds of issues that are driven by the need to generate revenues of different actors in the healthcare system. I think the issue of safe staffing, which is so important and so much in the forefront of bedside nurses, especially now with so many nurses leaving, could be classified as an issue of profits over patients.

Polly:
But it's also could be a problem of a lack of resources, particularly in critical access hospitals and other kinds of hospitals that just don't have the money. So, it spans two domains. So, profits over, basically, patients and healthcare workers is one category of causes. Pure, what I would just call poor management, which is not necessarily anything to do with revenues. It might actually diminish revenues. It's just stupid managers not doing things very well. That's not moral injury. That's another problem. It's another problem that causes anxiety and causes an administrative burden and may mean that technology becomes a burden rather than a help. All these things that about management and workflow design, but it's not about ethics necessarily. At least I'm tentatively arguing that it isn't. I reserve the right to change my mind. And then the third is what I call insufficient organizational resources.

Polly:
So, even in countries like New Zealand, we hear from folks. Issues like wait times for procedures is very distressing to healthcare workers, but it's not necessarily because there is an issue of profits. It's just that demand exceeds supply. And particularly seasonally, particularly during natural disasters, you just sometimes don't have enough stuff. And it's not necessarily a betrayal by anybody. It's just a hard reality. And then the fourth, which causes a lot of distress and I think has a moral injury component is the broader cultural context. So, if you think about things like the distrust in science that we have right now and how that's leading to people not wanting to get vaccinated or to use masks, that is a driver of a feeling of betrayal by the community. Not for all nurses, but for some, for a lot of nurses talking about this. Issues around racism, both outside the context of the employment of nurses and inside the hospital, particularly. It exists.

Polly:
And that's something that is coming from outside, but is played out inside. Issues around how medicine wants to keep people alive no matter what and how hard it is to convince individual physicians to let people go, even if the patient is begging for them to let them go, can be very distressing to nurses. Issues around violence and bullying, guns, all those kinds of things are external cultural issues. So, in my mind, we have four big buckets of issues happening in the workplace that can be very problematic. The profits over patients and healthcare workers, poor management, insufficient resources, and then just broader cultural context. And so as I'm hearing these stories, I'm putting the problems in these buckets and that then translates into three major pathways, maybe four, that can lead to burnout. So, one is moral distress, which can become moral injury if it's an episode-based thing. And we've talked about that already.

Polly:
The second is just direct, for example, poor management means lots of administrative burden. It creates exhaustion and depersonalization. So, that's a direct relationship of the working conditions to burnout. It's not mediated by anything about moral distress or moral injury. And then the third and fourth are around secondary trauma stress and secondary victim syndrome. And those are things that are very inherent to the healthcare delivery process. So, secondary trauma stress can be death by a thousand cuts when you're just witnessing so much human suffering and death. And so of course that's a really big issue with COVID now. It's not necessarily a betrayal by anyone. It's not necessarily unethical. It's just tremendously distressing, to use the word stressed over and over again, but it's-

Dan:
But it's the right word, I feel like.

Polly:
But it's the right word. And it leads to burnout, right?

Dan:
Right.

Polly:
It leads to emotional exhaustion and depersonalization and a decreased sense of accomplishment. And then the other one is the second victim syndrome, which is a more traumatic precipitating event where, in this case, the nurse perhaps committed an error and is very distressed by it or for some reason is projecting things from their own life onto the patient or vice versa. There's some kind of personal relationship with a specific event that just really unsettles and creates trauma in the nurse. So, second victim syndrome is, I think, a really prevalent phenomenon. And I think it's different than moral injury because it doesn't necessarily... I mean, you could either put it as a subcategory of moral injury if you wanted to argue that an error is moral, but I think it's really different in nature.

Polly:
So, again, reserving the right to change where it is in our framework. I see it as outside moral injury. So, there you have four different pathways leading to burnout, and moral injury is one. And it could be the super highway. We don't know. We don't know how many cases there are in each of these buckets. But I would argue that each of those pathways have very different kinds of solutions. So, that's where we are in the conceptual analysis.

Dan:
Yeah. I love it. And I know you're early on in the research and so these are all hypothetical, but I love the way you're categorizing it so far. And I think that focus on the outcome and then the interventions, that's that golden goose egg that we haven't figured out yet because we've just dumped generic solutions on a big problem that has nuance to it. And even, I've tried some things here with our organization and setting up crisis lines for nurses who were having stress. And we get nurses calling us crying about their last assignment or what was going on. And we're trying to help provide resources, but healthcare workers also, like we said at the beginning, have a suit of armor on. It's hard for them to ask for help because they're the helpers.

Dan:
And so there's a lot to understand, and that's why I'm excited about these interviews you're doing. There's a lot to understand about what are these drivers and what would be interventions that they would actually take advantage of so that we can honestly save an entire profession at this point. I think the numbers are staggering on leaving and retiring and burnout and injury and ethics and all kinds of things at the moment. It's kind of overwhelming. Being in the profession myself, just like, "Are we the Titanic at this point? Could we avoid that iceberg?" And I hope that this research will be able to do that.

Polly:
Yeah. Then National Academy of Medicine came out with a report on clinician well-being in 2019. And the key conclusion that I think we all need to remember is that individual level solutions alone are not sufficient. Because if you think about these problems, no matter how much mindfulness or resilience you have, you also need to address the root cause. And I understand the argument that you also need to address resilience. You have to address the immediate symptoms. Otherwise, you're just asking healthcare workers and nurses specifically to continue to turn the other way when there's corruption, turn the other way when they see unsafe practices, turn the other way when they're not being respected and included as part of the team and their contributions are being ignored. And we don't want to ask nurses to do that. So, it's not just a question of getting thicker skin. It's actually a question of changing the level of aggression that nurses are receiving.

Polly:
So, then the next question is, "Okay, well, what do you mean by organizational and policy level solutions?" And one of the things that's really clear to me. There's a fair amount of this going on. For example, IHI has something called Joy in Work. They do a lot of leadership. They call it distributional leadership about teaching leaders to listen and have more participatory work environments, not mandating overtime, having flexible stopping schedules, all those kinds of things that are best practices increasingly are at the organizational level. But some of these things are also things that are at the policy level. So, the very scary issue of nurse to patient ratios that people have argued over for many decades is an issue that we need to wrestle to the ground.

Polly:
And we can't just have vested interests on one side and vested interests on the other side and, "Oh. That's an old fight. We're not going to talk about it anymore." Nursing, unfortunately, it's hard to break through these positional camps and actually find solutions that are practical. So, I think that's a nut that just has to be cracked and worked on hard. And then there are other issues like whistleblower protections and protest of assignment mechanisms, and really thinking about, from an accreditation perspective, how do we have ethics committees that are representative of the different professions and perspectives within a hospital helping to make decisions in a transparent way? , Those are issues that could be addressed, not just internally in the organization, but they can be addressed by accreditation and regulatory bodies.

Polly:
They can be addressed at the state level. They can be addressed at the federal level. And there's always an interesting synergy at those four levels, organization, regulatory, state, federal, and there's a back and forth of ideas, but that's the space that we have to work on. Those four additional levels. How does the organizational stuff, when organizations choose not to do things that are in best practices, how can we get accreditation and regulation to kick in? How can we use state and federal laws to really create some minimum standards and parameters around this stuff?

Dan:
Yeah. There's so much there. We could go on for hours, like ratios, all kinds of stuff. Ultimately what it comes down to from a frontline worker standpoint and what I see on social media and what has been in the conversation most recently has really been, the workers are blaming management, management's blaming the workers, and then the system's blaming everybody. And there's just this weird pass the buck around. And I love what you mentioned at the end there, which is when a clinician who is licensed and has ethical training and all the things that nurses have to go through to become licensed practitioners, how can they be supported to bring things up? Because I think a lot of times they feel that there's no hope. There's nowhere it goes, or it goes to management and we already don't have a trust with that in many places.

Dan:
And so to have some regulation that allows them to speak up and feel like it gets handled in a way that could make a change in the best entrance of the patients, that's a big gap in our healthcare system. We have nurses all over the country who have brought up safety issues. I encourage them, "Go talk to the State Department of Health. Go flag it with Joint Commission." And a few of them that have done that have seen real fast resolution that have almost removed that conflict with their values that they were experiencing because now it led to something that fixed the system.

Polly:
Yeah. The cure is empowering people. Because essentially moral injury's about disempowerment and a sense of hopelessness. I do think that there's a silver lining in the current crisis and that nurses are going to have to step in and really take advantage of this opportunity to redesign nursing work in the hospital. The current NAM report talks about redesigning work outside the hospital, as well as in the hospital. To be more oriented to equity. I would argue that workforce equity is part of equity. And I think that the report makes that argument as well in their wellness chapter. And so there is now an official call to action from the National Academy of Medicine to do this, and nurses should do it. They should step in because if they don't, there are going to be other solutions that they're not going to like.

Polly:
And just anecdotally, I was in a meeting yesterday and there were very senior leadership of the Emergency Medical Physician Workforce talking about the nursing shortage. These are older doctors. Hopefully younger doctors have more enlightened views. But there were two solutions that they threw out. One was, "Let's bring in more international nurses." Which, we've been there and seen that. We know what that is all about. That was the solution. Just bring in more people who will be locked into contracts and essentially won't talk back. And then the other was to eliminate nursing in the hospital and to essentially create a medical assistant role where they train the nursing assistants, but they report to the physicians, and push nurses out.

Polly:
I think that there will be change. And the question is, who's going to lead that change? And I think it's really important for the different sectors of nurses to come together with a set of ideas. And those ideas have to go beyond the individual level solutions and even the organizational level solutions. They have to focus at the policy level to create protections for nurses that are at the bedside, because those protections are not there now. And it's hard to argue that they're not needed when nurses are leaving in droves.

Dan:
Yeah. Oh, man. We, I want to just rebuttal those two things so bad right now, those two solutions. I mean, they're linear solutions to a complex problem. They're not going to work. They can't work. And so I think it is ability for nursing to step up. And that's something I've been saying, is crisis is your opportunity as an innovator to break through some of that hierarchy that's been there in the past and actually disrupt a little bit. And so I think nursing's ready for that. And we have to protect our patients, ultimately. And that requires licensed trained people to do a lot of the work, and also teaching those physicians and others what nurses do, that they're not the handmaidens that everyone thinks they are in the past, that there's a lot of value in having nurses. And when you remove them, you put people's lives at risk very quickly.

Dan:
And so I think we need to save our profession from the inside, from what we talked about, the injury and the workforce pieces. We also need to educate the outside and come up with some different model. It may not be just throwing nurses at the problem. It may be having nurses elevated to the top of scope and putting other practitioners in the care setting to do the work that's needed to do. But we need to do it really intentionally. And so what we like to do here is we like to hand off one or two nuggets that our healthcare leaders can take away and implement tomorrow. So, I'd love to hear what you'd like to hand off to our leaders.

Polly:
I would just reiterate the two main points I've been trying to make, which are one, the issue of moral injury has to be addressed, not even just at the organizational level, but also at the policy level. And that nurses, number two, have to be the ones to take advantage of the current crisis to define those policy solutions. Because if they don't, other people will.

Dan:
I think those are two awesome nuggets. And it's a call to action. There needs to be a fire in our belly as a profession and as researchers working with the profession as well. Patricia, thank you so much for being on the show. This has been amazing. Where can people find you if they have more questions or want to get involved or help promote the research, the Moral Injury Project?

Polly:
Oh, thank you for asking. So, you can go to our website, which is GWHWI, GW Health Workforce Institute, .org. You can write me at ppittman@gw.edu. And we're really trying to orient this study in a participatory way. We're using nurses around the country to collect stories. And so we'd love for individual nurses to tell their own stories. They can upload them on the website or they can contact us and we'll reach out to them. Or they can become citizen researchers and help us collect stories themselves. And we have some materials that they can use to collect stories. So, we're hoping that this will be a mechanism for a lot of people to engage in the experience of nursing and what we can do to make it better.

Dan:
Yeah. And just to double down on that, I've had a lot of nurses recently ask me, "How do I get involved in policy? How do I change the system/" and doing this work, participating in these type of studies and these conversations, is one way that you can change the system. And so from the nurses out there, we'll put this in this show notes. Become a citizen researcher. Get out there and share your stories. Because there's people listening and we can do something about it. So, please, please log in and contact the Moral Injury Project. Patricia, thank you so much. I really appreciate it. Let's get out there and let's change that system for nurses.

Polly:
Sounds great. Thanks so much, Dan. It was a pleasure being on your show.

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