Healthcare Workers Are Hurting. How Do We Help Them Heal?
In the spring of 2020, hospitals became battlegrounds. Nurses, exhausted and overwhelmed by the relentless influx of critically ill COVID-19 patients, wept openly in hallways. Doctors faced agonizing decisions about who would receive life-saving ventilators as supplies ran short. Clad in full-body PPE, healthcare workers witnessed patients die alone, separated from their loved ones by strict isolation protocols. Outside hospital walls, some members of the public accused these frontline workers of exaggerating the pandemic’s severity, even as they risked their lives treating the millions who became infected.
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.
To address the crisis of moral injury and burnout among healthcare workers, Smith and his team developed a structured intervention called RECONN (Reflection and Connection). This initiative aims to mitigate the effects of moral injury and strengthen social support among healthcare workers.
RECONN was designed and implemented in collaboration with a multidisciplinary team that included ICU nurses, mental health experts, and unit leadership at DHMC. By leveraging the expertise of these stakeholders, the team tailored the intervention to the specific needs and challenges faced by healthcare workers in the ICU.
Smith also received critical support from The Susan & Richard Levy Health Care Delivery Incubator, a joint venture between The Dartmouth Institute for Health Policy & Clinical Practice and Dartmouth Health. “The Levy Incubator really helped with mentorship, resources, and implementation,” Smith says. “They structured our meetings and sent team members to help us stay on task.”
The Incubator, Smith says, also helped ensure that RECONN was accessible, which is to say practical. Each 30-minute session was integrated into regular staff meetings to avoid adding to nurses’ workloads. This simple detail allowed nurses to participate during paid work hours without additional time commitments.
By Nurses, For Nurses
For Smith, it was also vital that the program be nurse-led and grounded in their experiences. “When we teach within tribes how to understand, own, and carry these things forward, it’s much more effective than an outsider coming in and lecturing,” he says. For this reason, sessions were facilitated by a trained ICU nurse, with auxiliary support from a mental health expert such as a chaplain, psychologist, or advanced practice psychiatric nurse practitioner.
During sessions, the facilitator would create a safe space for open dialogue, then invite a nurse to share a challenging event. The group would observe a moment of silence, reflect on their own experiences, and offer feedback if requested. The session ended with a plan for follow-up support and a reflective reading.
Smith found that this structure fostered both empathy and peer support among participants. Over six months, 76% of the ICU’s permanent staff attended at least one session, with 70% finding the program effective.
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.”
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.”
If interventions like RECONN are met with better mental health access and cultural change, they could represent a hopeful and powerful step forward. By prioritizing human connection within healthcare teams, these efforts can help heal not just individual healthcare workers but the healthcare system itself.
To learn more about The Susan & Richard Levy Health Care Delivery Incubator, please contact Bethany Solomon at 603-646-5134 or at Bethany.Solomon@hitchcock.org.
