Our voice: reactions of healthcare professionals to Executive Orders and institutional response

Introduction

Healthcare professionals have previously wondered how we can and should respond when pressures outside of the patient-clinician relationship affect care in ways that do not align with individual practice or commitments to patient care (1,2). Increased attention has been devoted to understanding the moral distress experienced by healthcare professionals, occurring when one knows the right thing to do, but is unable to act accordingly due to constraints outside of one’s control (3). Most commonly, these constraints originate outside the exam room, including but not limited to the social determinants of health that describe the conditions in which we are born into and the environments in which we live, go to school, work, transport within, and die. These determinants include the limitations enacted by insurance companies restricting the length of healthcare visits and hospital stays, or the types of medications, treatments, procedures and interventions that can be prescribed (4,5). Healthcare professionals in the USA have previously experienced state-level restrictions limiting the provision of safe and supportive environments for patients seeking reproductive health care (6), gender-affirming care (7,8), and healthcare as unauthorized immigrants (9-11). Most recently, USA health systems have experienced federal-level influence to restrict patient care through Executive Orders (EO).

For example, and related to the experience described in this manuscript, EO 14168 describes that federal funds shall not be used to promote “gender ideology” and defines gender ideology as “replac[ing] the biological category of sex with an ever-shifting concept of self-assessed gender identity” (12). Additionally, EO 14151 seeks to end diversity, equity, and inclusion (DEI) mandates, policies, programs, preferences and activities in the USA federal government (13). While many health systems in the USA are not federal institutions, their care and research efforts are supported by federal funding. The threat of losing federal funding has forced institutions to consider adjusting policies and practices, especially those directed towards health equity. The subsequent decisions have been made not based on scientific evidence, best interests of patients, or clinical recommendations but due to the potential legal and financial impacts of not complying with EO (14,15).

Given this unique time in the USA, with political pressures directly affecting individual healthcare practice, we wanted to know, for healthcare professionals in a single institution, how this experience is affecting their practice, their personal values, and their view of their professional role. Our institution is a nationally ranked (16), free-standing children’s hospital, academic medical center, and research institution that describes itself as mission-driven safety-net hospital. The mission is to “create hope and build healthier futures” through patient care, discovery and innovation, education and training of health professionals, and “supporting our communities, especially underserved populations” (17). It is within this mission that Children’s Hospital Los Angeles (CHLA) led one of the oldest and largest transgender youth health programs: the Center for Transyouth Health and Development. In February 2025, citing its response to EO, CHLA temporarily paused some aspects of gender-affirming care, specifically the initiation of gender-affirming hormone therapies for patients under age 19 years, and convened working groups to address the risks, mitigation plans, and strategies to achieve compliance with EO. We wanted to understand how this institution’s response was felt by it’s healthcare professionals. We also wanted to gather information about future concerns related to patient care. Although this study was conducted in a single institution, children’s hospitals across the USA have faced similar difficult decisions, and we believe this information can help to better support future decision-making. We also hope to provide transparent information to the public about the challenges and distress that healthcare professionals are currently experiencing. Since the time of this study, CHLA officially closed the Center for Transyouth Health and Development on July 31, 2025, and ended it’s care for transgender patients (18).

Methods

A mixed-methods survey (Supplementary Material 1, available at https://cdn.amegroups.cn/static/public/jhmhp-25-61-1.pdf) was developed based on the literature, included validated questions on professional fulfillment (19), and refined with feedback from hospital leadership. The survey was piloted with the CHLA Cultural Humility and Equitable Care Council. Survey topics included demographics, personal and professional values, professional fulfillment, and inquired about feelings towards external political pressures and institutional response. Of the 23-question survey, 9 questions asked for free-text comments. For example, to better understand the experience of health professionals, we asked, “Are there other thoughts you would like to share on how external political pressures might affect your work?” and “Are there other thoughts you would like to share on how you might wish CHLA to respond to future external political pressures?” The survey asked participants to describe vulnerable populations that they were concerned about as a result of external political pressures and then asked quantitatively-measured questions to assess concern about specific vulnerable populations of patients who are transgender, undocumented migrants or the children of undocumented migrants, and patients with limited financial resources. To understand how external political pressures and institutional responses might affect professional fulfillment, a subset of questions from the Professional Fulfillment Index (PFI) (19) was included. PFI includes questions to measure the positive reward the individual derives from their work, including happiness, meaningfulness, contribution, self-worth, satisfaction, and feeling in control when dealing with difficult problems at work.

The survey was anonymous and voluntary and completion of questions was optional, with no question being required to answer to participate in this study. Surveys were distributed via CHLA listservs of hospital departments, divisions, and committees, and were able to be forwarded. Within the email was the Research Information Sheet and survey link to the survey hosted by Research Electronic Database Capture (REDCap^®) (20). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was deemed exempt by the CHLA Institutional Review Board (CHLA-25-00061).

Statistical analysis

Survey responses were collected by REDCap^® with quantitative data organized into charts. Qualitative data were inductively reviewed by 2 coders (G.A. and V.N.) and analyzed by using the 6-phase model of thematic analysis (21). Each coder reviewed the qualitative data and generated initial codes. The coders then collaboratively reviewed the codes to form themes and returned independently to group the codes into the identified themes. Where a qualitative response had codes that met multiple themes, each was entered as a theme. In cases in which differences in organizing codes into themes occurred, coders refined definitions of themes by re-evaluating the themes against the coded data. Through this iterative process, themes emerged to describe respondents’ emotional reactions, personal and professional values, and guidance for how institutions could respond to similar future challenges.

Results

The survey was opened on March 25, 2025, and closed on April 18, 2025. A total of 164 respondents participated in the survey. Of the 164 participants, 98.9% (n=162) self-reported demographic information (Table 1). The majority of respondents were nurses (38.4%), followed by physicians (15.7%). Most respondents (74.2%) identified their gender as female. To describe race and ethnicity, participants were able to select more than one choice, with the majority of respondents identifying as white (49.0%).

When asked if “As a result of current external political pressures in the USA, do you have concerns about the care of vulnerable populations of patients that CHLA cares for?”, 91.5% of respondents said yes (Figure 1). When asked to further describe the patient populations that they were concerned about, 145 participants responded. Their comments were coded into themes, with 61.4% of respondents describing concerns about how care might be affected for patients who are lesbian, gay, bisexual, transgender, queer, intersex, asexual (LGBTQIA+), 55% of comments with concerns about patients and their families identified as a non-USA citizen, and 42.8% of concerns related to insurance status (Table 2).

Figure 1 Concerns about vulnerable populations as a result of external political pressures. Counts/frequency: yes (n=150, 91.5%), no (n=14, 8.5%).

Participants were also asked, on a Likert-scale, how important the care of certain vulnerable populations was to the work of their institution. Of the 164 participants who responded, 87.2% (n=143) described gender-affirming care as somewhat important (n=133) or very important (n=110) to CHLA’s work, with 3.7% (n=6) describing gender-affirming care as not an important part of the work that CHLA does. When asked about the care of patients who are undocumented migrants or the children of undocumented migrants, 95.8% of the 162 respondents described this care as somewhat important (n=12) or very important to CHLA’s work (n=143). Similarly, 98.8% of respondents described the care of patients with limited financial resources as somewhat important (n=9) or very important (n=151) to CHLA’s work.

Of respondents, 155 described personal or professional emotions arising from CHLA’s decision to temporarily pause some of the care provided by CHLA’s Center for Transyouth Health and Development (Table 3). The most common theme identified was “Expressions of Disappointment”. Participants also expressed frustration regarding how the decision to pause care was communicated to staff. As described in their responses, many staff members learned of this news through the media prior to learning about it from the institution (22).

Nearly all participants responded “yes” to “Is it important to you that the institution you work at shares similar values to you?” (n=152, 93.8%). When asked to describe those “values that anchor you as a professional (i.e., what is your mission or what drives you to do the work that you do)?”, all 164 participants provided a response (Table 4). Participants described themes of providing quality health care for all (n=88, 53.7%) with statements of caring for patients who are vulnerable, marginalized, and underserved and highlighting principles of equity and social justice. Respondents also described their values being anchored in providing compassionate care (n=28, 17.1%) and ethical care (n=13, 7.9%). Three respondents described values deriving from spiritual beliefs.

Four of the survey questions sought to elicit feedback on how this institution could respond in support of their employees’ personal values, well-being, and any additional ways in which the institution could respond to external political pressures or other hopes, wishes or asks from the institution. As similar themes emerged across these four questions, the responses were combined and summarized (Table 5). Responses and the themes to each of the four questions separately are also presented (Supplementary Material 2, available at https://cdn.amegroups.cn/static/public/jhmhp-25-61-2.pdf). The most commonly identified theme across the four questions was of “advocacy” with codes including “be bold”, “resist”, “stand up”, and “fight”. Participants asked for the institution to leverage its voice in support of vulnerable patient populations. The next most commonly identified theme was “Communication and Transparency”, with participants asking for more “open communication”, “honesty”, and “include the voices of [staff]” in decision-making. While the theme of greater advocacy was the most expressed request among participants’ comments, in asking for communication and transparency, participants shared that when difficult decisions must be made, it is important for staff to better understand and be engaged in the decision-making process. Participants also expressed a need for additional support to employees through compensation, benefits, improved staffing, education, and wellbeing and wellness support. The fourth most expressed theme was supportive statements towards the institution in appreciation for advocacy, communication, workplace, and support. Five participants (participants 70, 112, 114, 128, and 138) provided responses that contrasted with the themes emerging from the majority of respondents in their agreement for pausing and/or stopping gender affirming care services and a desire to separate political issues from work and medical care.

When asked if participants had anything else they would like to share, respondents offered:

• “[For the institution] to continue to be open to team members and responsive to them and their concerns. I don’t expect perfection, just grace, thoughtfulness and care.”—Participant 104
• “We all work here because we care. Please show us that you care too.”—Participant 40

As a measure of professional fulfillment, respondents were asked about their feelings of happiness, worthiness, satisfaction, support, and meaning in their work. Nearly all survey participants (between 162 and 164, 98.9–100%) responded to the Likert-scale questions when asked the following: “In thinking about the past one month, do you feel that external political pressures have affected the following statements about you at work?” (Table 6). Most participants reported some effect on all six measures of professional fulfillment, with the greatest effect on happiness at work.

Discussion

Healing professionals see themselves as care implementers and care advocates, such that when determinants outside health systems impact the provision of healthcare, health professionals may feel compelled to speak up. Recent examples include pediatricians advocating for childhood vaccines (23) and firearm injury prevention (24). More broadly, USA health professionals and professional organizations have advocated for access to reproductive health services (7) and eliminating racial discrimination in healthcare (25). There have been attempts to restrict advocacy and professional practice; however, these have previously been at a state-level, such as Florida’s 2011 Privacy of Firearm Owners Act and Texas’s 2023 abortion ban. While pediatric, safety-net hospitals often declare mission, vision, and value statements centered on serving the local communities and aspiring for health equity, the effect of EO has made the reality of enacting those ideals more complex with institutions weighing multiple and competing interests. Prompting this study was the institution’s decision to pause some aspects of gender-affirming care out of concern that continuing care for a single patient population would threaten federal funding for the institution as a whole (26). Hospitals and academic medical centers are in a precarious position, as they serve and advocate for marginalized populations and are dependent on federal funding to operate. The ability to take a firm stand, to resist or reject policies that conflict with institutional values, may be a privilege that is available more readily to organizations that are financially secure or have alternative sources of support. This dynamic creates a troubling contradiction: those most embedded in the service of vulnerable populations may be the most knowledgeable and best positioned to address disparities, but least able to challenge the larger systems that perpetuate harm. Until we reckon with the fiscal constraints that have the potential to control advocacy efforts and limit health care, even well-intentioned mission-centered hospitals may struggle to engage in meaningful action. Given the current influence of EO on health institutions within the USA, this study describes the perspectives of those closest to providing that care by hearing from healthcare professionals themselves.

Participants in this study expressed concern about the impact of external political pressure on the care of patients in need of gender-affirming care, patients who are undocumented migrants or the children of undocumented migrants, and patients with limited financial resources. Caring for these same vulnerable populations was identified as being important to the work of this institution. Participants described their work as rooted in quality care for all and in compassion and see the institution as the conduit through which they provide this care.

In describing how CHLA can better support personal values and how participants might wish CHLA to respond to future external political pressures, the main theme identified was “advocacy”. The American Medical Association recognizes that ethical obligations in health care take precedence over legal duties, stating, “In general, when physicians believe a law is unjust, they should work to change the law. In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal objections.” (27). It may be that when facing what these healthcare professionals believe to be injustice, participants would have liked to have seen disobedience at the institutional level. If disobedience is not thought to be possible, institutions may have a role in empowering, encouraging, or allowing advocacy in solidarity with vulnerable populations. As noted by participants in this study, healthcare leaders can leverage their roles, networks, and platforms to advocate at state and federal levels and in the media for policies that prioritize patient care and provide opportunities for staff, patients, and community organizations to have platforms from which to advocate. Health systems can build more robust infrastructure to center the voices of the patients when making policy and practice decisions that will directly affect them, such as community-based bioethics committees (28) and patient advisory groups (29). These end-users of health systems can help guide institutions towards priorities and decision-making that most directly impact those that the care is intended to serve.

An often-expressed request by participants in this study was a desire for greater communication and transparency when making policy and practice changes in response to EO. This hospital later acknowledged that the decision to restrict treatment while the hospital administration assessed the EO “was communicated poorly and for this, we apologize” (15). Given the values-driven care of the healthcare professionals and the mission-driven aims of the hospital, it may be important that institutions find ways to continue to stand in solidarity with healthcare professionals, patients, families, and communities and share in fear and frustration while recognizing that the decisions made at the institutional level may not be consistent with expressed mission and values.

Institutions that make decisions that are not in alignment with their mission are likely doing so after weighing the benefits and risks of complying with or resisting external pressures. There are immediate financial risks of non-compliance (30). This study suggests that there are also risks that may not be as immediate or measurable as withholding of federal funding but also need to be weighed and mitigated. External political pressure over the month prior to the study period was found to have an impact on happiness at work, with smaller but important effects on satisfaction, meaning, feeling supported at work, and feelings of contribution. Given the crises of burnout in healthcare (31,32), health institutions must include the impact of supporting the values and integrity of their healthcare workers when making difficult decisions. There are also important risks to consider in trust erosion, particularly in relation to marginalized populations where trust may have been hard-won. If vulnerable populations are made further vulnerable by being “sacrificed” for the greater good, the health system must then account for our untrustworthy behavior. In the generations ahead, when health systems lament a lack of trust between patients and their clinicians, it will be important to remember that we have given patients, families, and communities reasons to continue not to trust our systems.

There are limitations in this study. This study was conducted in a single institution, in an urban city, and in a state that identifies as politically liberal. Additionally, due to institutional restrictions, the invitation to participate in this study could not be sent by email to all employees but through smaller listservs of departments, divisions, units, committees, or other organized groups. Even though the survey could be completed in privacy and anonymously, it is important to note that the survey asked about beliefs, values, and identity and not all potential participants may have felt safe to provide this information. Those who did participate in the study may have been motivated to do so by strong feelings, either positively or negatively, in response to the pause on some aspects of care for trans youth, thereby contributing to selection bias. The timing of the study may have also influenced which vulnerable populations were at the forefront of concerns. It is possible that different vulnerable populations would be identified as most concerning if the study were repeated at a time of increased immigration enforcement, after comments from the USA Health and Human Services Secretary about vaccines, or in association with cuts to Medicaid.

Conclusions

Healthcare professionals are often brought to their work by values of compassion, care for those in need, and service. These values are further supported through education, training, professional organizations, and health systems that align their missions with these values and, in doing so, receive dedicated workers to carry out their aims. If these larger systems make decisions that are no longer in alignment with their expressed mission and with the values of those who work within their systems, those same professionals may no longer see themselves as healers but instead as being unable to prevent harm. When institutional decisions diverge from healthcare professionals’ core values, transparent and inclusive communication is essential. Those guiding hospital policy and practice must proactively engage with healthcare workers, patients, and their communities to fully appreciate and understand the ethical tensions created when legal, financial, or other external pressures result in actions inconsistent with the mission and values of the institution. To mitigate feelings of hopelessness and helplessness, health institutions may benefit from more transparent sharing of information about their decision-making process, explicit recognition of the potential harms of such decisions, and understanding the moral distress that arises when asking healthcare professionals to abandon their patients.

Acknowledgments

The authors gratefully acknowledge CHLA’s Cultural Humility and Equitable Care Council and Center for Bioethics for their work in creating safer spaces of support in healthcare. There were three authors for this paper.

Footnote

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-61/dss

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-61/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-61/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was deemed exempt by the CHLA Institutional Review Board (CHLA-25-00061).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Reinhart E. Doctors aren’t burned out from overwork. We’re demoralized by our health system. Opinion section. [Accessed May 14, 2025]. Available online: https://www. nytimes.com/2023/02/05/opinion/doctors-universal-healthcare.html
2. Berwick DM. The Moral Determinants of Health. JAMA 2020;324:225-6. [Crossref] [PubMed]
3. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall; 1984.
4. Macauley R. The Hippocratic underground: civil disobedience and health care reform. Hastings Cent Rep 2005;35:38-45.
5. Abelson R. Insurers deny medical care for the poor at above-average rates, report finds. [Accessed May 14, 2025]. Available online: https://www.nytimes.com/2023/07/19/health/health-insurance-medicaid-denials.html
6. Hofler LG, Taper GL. Post-Abortion Care in Abortion-Restrictive and Abortion-Protective States. Obstet Gynecol Clin North Am 2025;52:255-67. [Crossref] [PubMed]
7. American Medical Association. Advocacy in action: protecting reproductive health. [Accessed May 20, 2025]. Available online: https://www.ama-assn.org/delivering-care/public-health/advocacy-action-protecting-reproductive-health
8. Gridley SJ, Crouch JM, Evans Y, et al. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. J Adolesc Health 2016;59:254-61. [Crossref] [PubMed]
9. Marrow HB. Deserving to a point: unauthorized immigrants in San Francisco's universal access healthcare model. Soc Sci Med 2012;74:846-54. [Crossref] [PubMed]
10. Callaghan T, Washburn DJ, Nimmons K, et al. Immigrant health access in Texas: policy, rhetoric, and fear in the Trump era. BMC Health Serv Res 2019;19:342. [Crossref] [PubMed]
11. Van Natta M. First do No harm: Medical legal violence and immigrant health in Coral County, USA. Soc Sci Med 2019;235:112411. [Crossref] [PubMed]
12. President Donald J Trump. Executive Order No. 14168, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. Available online: https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/
13. President Donald J Trump. Executive Order No. 14151, Ending Radical and Wasteful Government DEI Programs and Preferencing. Available online: https://www.whitehouse.gov/presidential-actions/2025/01/ending-radical-and-wasteful-government-dei-programs-and-preferencing/
14. Portnoy J. After Trump order, hospitals suspend some health care for trans youths. The Washington Post. Available online: https://www.washingtonpost.com/dc-md-va/2025/01/31/trans-children-trump-hormones-healthcare/
15. Reyes EA. Children’s Hospital L.A. keeps limits on transgender care amid challenges to Trump order. Available online: https://www.latimes.com/california/story/2025-02-19/childrens-hospital-la-transgender-care-pause-trump-order
16. Children’s Hospital Los Angeles. U.S. News & World Report. [Accessed September 8, 2025]. Available online: https://www.chla.org/about-childrens-hospital-los-angeles/us-news-world-report
17. Children’s Hospital Los Angeles. About Children’s Hospital Los Angeles: Mission and History. [Accessed May 14, 2025]. Available online: https://www.chla.org/about-childrens-hospital-los-angeles
18. Sharp S. End of transgender care at Children’s Hospital L.A. signals nationwide shift under Trump. Available online: https://www.latimes.com/california/story/2025-07-23/childrens-hospital-los-angeles-ends-transgender-care-program
19. Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry 2018;42:11-24. [Crossref] [PubMed]
20. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81. [Crossref] [PubMed]
21. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77-101.
22. Reyes EA. Children’s Hospital L.A. stops initiating hormone therapy for transgender patients under 19. [Accessed May 14, 2025]. Available online: https://www.latimes.com/california/story/2025-02-04/childrens-hospital-to-stop-initiating-hormonal-therapy-for-trans-patients-under-19
23. DeBrakeleer D. AAP efforts put vaccines front and center in hearings for HHS secretary. [Accessed May 20, 2025]. Available online: https://publications.aap.org/aapnews/news/31299/AAP-efforts-put-vaccines-front-and-center-in?autologincheck=redirected
24. Behrens D, Haasz M, Dodington J, et al. Firearm Injury Prevention Advocacy: Lessons Learned and Future Directions. Pediatr Clin North Am 2023;70:67-82. [Crossref] [PubMed]
25. Garvey A, Woode DR, Austin CS, et al. Reclaiming the White Coat for Black Lives. Am J Public Health 2016;106:1749-51. [Crossref] [PubMed]
26. Tidmarsh K. In a landmark move, Children’s Hospital LA closes its gender-affirming care center today. [Accessed September 15, 2025]. Available online: https://laist.com/news/health/in-a-landmark-move-childrens-hospital-la-closes-its-gender-affirming-care-center-today
27. Opinion 1.02 The Relation of Law and Ethics. American Medical Association. Code of Medical Ethics 2002-2003 Edition. Chicago, IL: American Medical Association; 2003.
28. Gallegos T, Mrgudic K. Community bioethics: the health decisions community council. Health Soc Work 1993;18:215-20. [Crossref] [PubMed]
29. Lewis B, Cochran C, Marquez E, et al. Use of Hospital Patient and Family Advisory Councils: A Scoping Study. J Patient Exp 2025;12:23743735251316995. [Crossref] [PubMed]
30. Closson T. Columbia Vows to Reject Any Trump Deal That Erodes Its Independence. The New York Times. 2025. Available online: https://www.nytimes.com/2025/04/15/nyregion/columbia-trump-president-response.html
31. Murthy VH. Confronting Health Worker Burnout and Well-Being. N Engl J Med 2022;387:577-9. [Crossref] [PubMed]
32. LeClaire M, Poplau S, Linzer M, et al. Compromised Integrity, Burnout, and Intent to Leave the Job in Critical Care Nurses and Physicians. Crit Care Explor 2022;4:e0629. [Crossref] [PubMed]