Tom Bonner

Tom Bonner


Sara E. Miller

Sara E. Miller


You are an ICU nurse, two hours from the end of your shift, when you hear the familiar call of an alarm for a coding patient. As you rush into the room, the whole team gets to work to resuscitate, but to no avail. Time of death is called. Hardly a moment has passed before you feel the urge to respond to the patient call lights that have flickered on across the floor. The hospital is short-staffed, and a recent initiative has emphasized shortening response times on your floor. But you and your team are drained. It feels callous to run off immediately.

Before you have a chance to walk away, a hospital chaplain speaks up. You’re not even sure when they entered the room. They, along with the nurse manager, ask—rather than give permission—for everyone to take a “pause” for the next 30 seconds. You take a moment to breathe, acknowledge the loss, and sit with the heaviness that comes with your work. Knowing you’ve done everything you can, you feel confident to finish your shift with this sense of closure.

Rabbi Rebecca Kamil, a chaplain who’s worked with hospitals in major Midwest cities, shared this story with us an example of her experience before and during the height of the first waves of the COVID-19 pandemic. At CFAR, a company with decades of experience partnering with hospital systems and academic medical centers, we found her insights into the concept of moral injury and its role in burnout to be a powerful reminder of the challenges facing healthcare systems nationwide.

What is moral injury?

Rabbi Kamil says moral injury impacts 70% of critical care nurses. While losing a patient can be traumatic for providers, moral injury occurs when “someone engages in, fails to prevent, or witnesses acts that conflict with their values or beliefs” (National Center for PTSD). This could occur, for example, when a nurse disagrees with a treatment plan for a patient or when a patient’s family’s wishes conflict with the provider’s point of view.

In these contexts, the injury occurs from the conflict between what the organization asks you to do and your personal and professional moral commitments.

How a system handles moral injury can tell us something about culture.

Generally, in healthcare, and particularly in the nursing workforce, an unprecedented exodus of professionals from the field has begun. There is a long list of reasons behind this worrisome trend, but it’s topped by burnout.[1] How does moral injury figure in? Moral injury cuts to the heart of the work: “Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.”[2]

According to Rabbi Kamil, moral injury “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control”—it is a system-level problem, and “the solution cannot be found with more work/life balance or yoga,” Rabbi Kamil reminded us. Considered through this lens, moral injury can contribute to burnout.

In many health systems, for example, austerity measures can eliminate important resources to support both patients and providers. This can lead to moral injury when staff can no longer access resources like chaplaincy teams to help them process traumatic events.

Wendy Dean, MD, is the co-author of If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First. She is one of the first scholars to argue that the concept of moral injury applied to clinicians and has explicitly tied austerity measures to Moral Injury. At last year’s AAMC Annual Meeting, she cited a 2020 study of U.S. healthcare workers that found 45% of them felt betrayed by leaders at their institutions.[3]

What is culture?

 At CFAR, we have been thinking about organizational culture for nearly 40 years. Your culture is the way you make sense of the world. It is a mental map of your environment’s processes, relationships, expectations, and unspoken rules. As pervasive as it is invisible, culture shapes how we think and behave.

A broken culture can be an especially challenging hurdle in the rapidly changing and pressure-filled healthcare environment. According to research published in the Journal of Healthcare Leadership, “a lack of preparedness and perceived lack of empathy and respect from supervisors have been found to be potent risk factors for [moral injury] development.”[4]

While healthcare systems share a common set of issues based on the competition for talent, patients, and financial constraints, the complexity of the landscape has not yet led to a “cure-all,” a common set of answers to solve these sustainability challenges. Because each system is unique, diagnosing and solving cultural challenges should be similarly distinct. When CFAR supports a system in examining culture’s impact on teams, we start with a “diagnostic” phase. This first step enables us to listen deeply and directly to those “on the ground” who are experiencing “the way things get done around here”—often in ways different from one another and different from what leadership may have hoped. In healthcare systems, the concept of moral injury—its causes and its impacts—provides CFAR with helpful language to understand the levers and stakes for providers across the continuum of care.


Influencing Culture: Found Pilots

Having made sense of the data and determined the direction leadership wants to go, we often look for “found pilots”, a concept explored by our colleagues Mal O’Connor and Barry Dornfeld in The Moment You Can’t Ignore. Based on CFAR’s work in organizations working through cultural challenges, we define found pilots as instances in which people, projects, and efforts where behavior is moving in the direction you want to go.

For a new leader focused on reducing burn-out and attrition, the “pause” highlighted at the beginning of this piece could be seen as a found pilot to test systemwide. Stopping for 30 seconds, alongside all the members of a care team, could have a powerful impact on nurse well-being and is an example of a practice, a building block of culture, that leverages institutional support to make positive behavior change possible. Not every practice will fit every challenge or context, but listening deeply to the competing priorities and needs of front-line staff often leads to ideas to implement or “found pilots” to learn from and replicate when useful.

Other examples Rabbi Kamil has seen include “interdisciplinary floor-wide huddles, system-wide town halls, or signs on patient doors that state ‘Please call the nurse to join if rounding!’” The specific initiative design depends on each system’s cultural goals.

At the end of the day…

Empowerment of the individual makes for a stronger team and can reduce incidences of burnout and moral injury, Kamil says. The factors that contribute to burnout could be alleviated by taking a pause, enhancing the accessibility of nurse managers, or creating better reporting tools, but because the challenge is systemic and not individual, it’s vital healthcare leaders at all levels think globally about the solution that works best for their specific teams. It might seem counterintuitive, but systems-level solutions are the first step towards individual empowerment.

Despite the multi-dimensional and challenging experiences for so many frontline healthcare workers, a responsive culture is one way to alleviate the pressures that contribute to the trauma of moral injury and burnout.

But we don’t just have to take Kamil’s word for it: think about a time you have felt at odds with a strategy or culture. What were the levers you had to make an impact?

[1] “What Happened to the Nursing Workforce?” Webinar, the Leonard Davis Institute of Health Economics. December 1, 2023.

[2] Dean, W., Talbot, S., & Dean, A. (2019). Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner, 36(9), 400-402. 

[3] Weiner, S. (2023, November 6). Moral injury harms providers and patients. AAMC.