Healthcare Workers Are Hurting.
How Do We Help Them Heal?

The pandemic didn’t just strain the healthcare system; it laid bare its flaws. In the process, those sworn to heal also suffered profound psychological wounds. Researchers call this phenomenon “moral injury,” defined as the mental, behavioral, social, and spiritual aftermath of exposure to events that transgress deeply held beliefs. For Andrew Smith, PhD, assistant professor of psychiatry at the Geisel School of Medicine at Dartmouth, moral injury was “a signature wound of the pandemic,” one whose effects persist to this day.

“What we saw during COVID was the unveiling of some illusions about healthcare that created a real divide between frontline healthcare workers and hospitals,” Smith explains. This divide was exacerbated by what are known as potentially morally injurious events (PMIEs).

“Family members asked me how I was able to sleep at night knowing that I was killing patients,” recalls Heather Stiles, BSN, RN, an ICU/MICU nurse at Dartmouth Hitchcock Medical Center (DHMC). This comment was made despite Stiles and other ICU staff saving the lives of 129 of 154 COVID-19 patients, or 83.7%, a tally higher than the national average. “I worked harder than I’ve ever worked before or since to try and keep these patients alive, and I never harmed anyone in any way.”

Once, Stiles heard an outside staff member refer to the MICU as “the leper colony,” which only aggravated her sense of isolation. “It felt like the rest of the world, even our own coworkers in other ICUs, just kept going without us. There really was very little recognition from anybody outside the walls of our unit that we were going through hell.”

Recent studies show that 17% to 60% of healthcare workers have been exposed to PMIEs like the ones Stiles experienced, with more than half of those exposed developing significant impairments in their work and mental health. This exposure is a key driver of turnover and burnout in healthcare settings. So Smith decided to do something about it.

A Reckoning—and RECONN

Before the COVID-19 pandemic, burnout was already rampant among healthcare workers, affecting 40% to 60% of the workforce. Annual turnover rates were around 16% to 18% for healthcare workers, and of particular concern for nurses. When the pandemic hit, hospital workforce turnover rates rose sharply, increasing to around 20% to 25%.

Now, Smith argues that healthcare workers are “in the midst of a post-pandemic reckoning, with burnout, turnover, and attrition taking a toll on their well-being,” as he writes in a recent paper published in Behavioral Sciences in September 2024.

Implementing RECONN was not without challenges, however. Stiles, who helped with the study, says, “ICU nurses do not like to be told what to do, and they do not like doing new things, particularly if they are unproven. It was not easy to get any buy-in from these folks, and I still think it was remarkable that we got as much participation as we did.” Stiles emphasized that having an ICU nurse run the sessions was “absolutely critical” for gaining acceptance.

Despite what Smith describes as a “low-dose” intervention over a six-month period, preliminary results showed moderate improvements in social support, moral injury, loneliness, and emotional recovery. Qualitative feedback from ICU nurses highlighted positive experiences and identified opportunities for change in both organizational and unit-level culture.

Smith acknowledges that implementing organizational well-being interventions can be challenging, and nurse skepticism is often a normative component of any change process within health systems. Despite these challenges, nurses found RECONN to be “feasible, acceptable, and doable.”

Nurses have also expressed a need for professional mental health counseling, especially after traumatic events. Heather Klein, RN, a RECONN participant, believes the ideal intervention would combine community building with mental health support. And for either to be effective, a “culture shift”—among nurses and leadership—is necessary.

“Nurses need to know it’s okay to talk about challenging things. That culture shift will create a stronger community of nurses, so in that sense, the project is a great start. But to be truly successful, leadership and nurses need to come together to recognize that.”

Plans for scaling RECONN beyond the ICU are now underway, driven by Nursing Shared Governance and under the leadership of Tracy Galvin, MSN, RN, chief nursing officer for DHMC. Scaling efforts include establishing RECONN in six nursing units starting in March 2025, with eventual integration into regional and national Nurse Residency Program curricula.

Is Social Support Enough?

“Healthcare workers are extremely resilient. But the challenges they face can’t be resolved by individual resilience alone,” Smith says. “Social support and cohesion are ancient ways we’ve known and used after disasters. With social distancing, we lost so much of that natural cohesion during the pandemic. Now, we need to consciously rebuild it.”

In other words, social support is essential to heal. But is it sufficient?

“While this initiative is a critical step toward fostering supportive work environments, it remains a necessary but not sufficient intervention to reclaim our workplaces as mission-driven spaces for collaboration and patient care,” Smith says.

Nurses have also expressed a need for professional mental health counseling, especially after traumatic events. Heather Klein, RN, a RECONN participant, believes the ideal intervention would combine community building with mental health support. And for either to be effective, a “culture shift”—among nurses and leadership—is necessary.

“Nurses need to know it’s okay to talk about challenging things. That culture shift will create a stronger community of nurses, so in that sense, the project is a great start. But to be truly successful, leadership and nurses need to come together to recognize that.”