5 Healthcare Workers and COVID-19
Unit Authored by:
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Jan Oosting, PhD, RN-BC. Assistant Professor of Nursing, CUNY School of Professional Studies.
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Fabienne Snowden, MSW, PhD. Assistant Professor, Field Education Director, Medgar Evers College – City University of New York.
Goals:
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To elaborate on the ethical and moral dilemmas experienced by healthcare workers while providing services during the COVID pandemic.
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To provide case studies that center the perspectives of healthcare workers that are also members of marginalized populations and how they experienced disproportionate impacts of vaccine mandates.
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Provide best practices for healthcare workers to address implicit bias during the COVID pandemic.
Learning Objectives:
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Identify the challenges that health care workers encounter and navigate while providing services during the COVID pandemic.
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Examine the relationship between COVID, health care workers, and service delivery during the COVID pandemic using case studies and individual level experiences.
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Provide some of the lessons that healthcare workers have been learned thus far that enable them to provide better care during the COVID pandemic.
Unit Table of Contents
During the first two years of the COVID-19 pandemic, nurses and physicians have been lauded for their heroism and have seen their incomes and job security rise dramatically. Those workers, however, make up less than 20% of all health industry workers, with the remaining 80% of workers filling roles in a wide variety of places of employment and jobs. The health care industry remains the United States’ largest employment sector and as such, health care workers represent a cross-section of American workers.
Health care workers represent a wide range of income levels, education levels, food security levels, and economic stability; they come from a range of neighborhoods and physical environments, and experience variance in home community, safety, and social contexts. Often, health care workers are asked to leave these social determinants of their own health “at the door” when they arrive at work, but we must instead draw attention to how these essential workers are impacted as greatly as the patients, clients, and families that they serve. During the first two years of the COVID-10 pandemic, these differences in social determinants of health amongst health care workers became even more evident. Exploration of each category of social determinants of health demonstrates a need for the health care industry to address these issues head on.
A career in health care has often been touted as a secure and well-paying ticket to lifting families out of poverty and into the middle class, but that effect can vary between different health careers. A physician or nurse can make considerably more income than many patient care aides and technician positions. The COVID-19 pandemic has drawn particular attention to the economic value of nurses, with many nurses choosing to take higher paying or travel nursing positions that increase their income greatly. That flexibility and opportunity is not offered to all levels of health care workers, and lower paying hospital or clinical employees might not have the chance to increase their income in the same ways (Heath, 2021).
The healthcare system of the United States has tiered and often cost-prohibitive health insurance options for families. Health care workers are no exception, with health insurance options that vary between various levels of employment. Some health care workers may work in part-time or contract positions that offer little to no health insurance, and/or may rely on the insurance exchange to cover themselves and their families. Some health care workers may make less than the minimum and many qualify for Medicaid, state plans such as Child Health Plus, and other public options. Health care workers, particularly those in lower wage positions, face higher levels of chronic health conditions and experience worse health outcomes than those in other industries. During the first two years of the COVID-19 pandemic, health care workers faced elevated levels of infection. The World Health Organization (2021) estimates health care worker deaths from the disease to have been approximately 115,000 during the first sixteen months of the pandemic alone.
Another strong social determinant of health is education. Education can create opportunities for better health while at the same time poor health can prevent motivated students from achieving their educational goals. Health conditions faced by individuals even beginning in early childhood can impact health and education throughout their lifespans. Many lower-income health care workers work their way slowly through their educational experiences to rise in income level, but these opportunities are not universal. Educational challenges faced in lower income communities are a frustrating roadblock to greater success among students in these environments, who with additional resources and funding would achieve at much higher levels. Lower wage health care workers have often not had access to expensive educational resources, which in turn give them access to health insurance and benefits that promote better health (VCU, 2017).
One positive aspect of the COVID-19 pandemic relates to positive pressure on organizations to attract and retain personnel. This pressure has significantly increased some of the incentives that organizations provide to their employees, including tuition reimbursement and other policies that support education. These incentives can add a considerable value to health care workers and have the dual benefit of empowering them to advance their education.
5. Neighborhood and Physical Environment
Many of our lowest paid health care workers are employed in home care and other community settings, and face concerns about their safety in the neighborhoods that they serve. They may be exposed to physical hazards or toxic substances without proper protection, especially in the less regulated home settings of the patients who they serve (Kinder, 2022).
Within the context of the COVID pandemic, home care and community health care workers face unknown and elevated risks of contracting COVID in their clinical settings. There is much less ability to control the environment in a home or community setting, so workers might be exposing themselves to ill patients or family members. Strategies to assist to minimize risk include increasing the number of visits that can be conducted via telehealth, observing universal precautions, and pre-visit self-reports from family members as to the health status/symptoms of all residents in the home. From a pharmaceutical aspect, home medication delivery can be an option. Additionally, delivery options for necessary foods and non-prescription medications should be considered in order to minimize health care worker exposure in the home (Kinder, 2022).
Food insecurity is related to socioeconomic status in that many food insecure individuals and families share characteristics of lower paying jobs and under- or unemployment. Women, people of color, and households with children are more likely to be food insecure. Even at times despite employment, many of our lower paid health care workers may still qualify for SNAP or other food assistance programs. Women are overrepresented in the American health care workforce (76.4% of health care workers) (Heath, 2021).
Women of color are more likely to have lower paying jobs within the health care industry, including challenges with rotating schedules or contract employment. Health care workers who work in certain settings, such as residential or long-term care, are also more likely to experience food insecurity (Heath, 2021).
Food insecurity began to increase at the onset of the COVID-19 pandemic, due to high unemployment and increased demand on food banks. With schools closed, children who depended on free breakfast and lunch were more challenged to access food. Continued interruptions in supply chains left families looking for preferred products on empty shelves. The initial lockdowns prompted some to hoard food, leaving inadequate amounts for those families who could not afford to purchase extra food in a given time period. Though unemployment has decreased significantly, food costs have risen dramatically, leaving families with continued food insecurity concerns, especially among lower paid health care workers.
7. Community, Safety, and Social Context
The interconnectedness of social determinants of health means that lower paying health care workers must often commute farther to work, spending more time on public transportation or utilizing less reliable vehicles. They might live in environments where fresh food choices are suboptimal or where they fear for their safety and their families’ well-being.
At the height of the beginning of the COVID-19 pandemic, lower wage health care workers faced greater hurdles in acquiring appropriate personal protective equipment (PPE). Home care workers especially, due to lower budgets in their agencies and employers, received no PPE from their employers and instead many were forced to procure it themselves. This led to a great discrepancy in the quality of PPE that workers had, putting them at greater risk than necessary (Kinder, 2022).
Setting a policy agenda for health care workers at all income levels should be of highest priority as we as a country move forward into the next phases of the COVID-19 pandemic. In addition to ensuring the safety, health, and wellness of lower-wage health care workers, we must push to raise their pay to a living wage, expand their benefits and stability in their places of employment, and emphasize respect for all workers from their employers. The future of the health care system is a future in which lower wage health care workers continue to make up the vast majority of health care industry employees. As we minimize health disparities for all Americans, we will see the positive outcomes for lower-wage health industry workers as well. Looking closely at factors of economic stability, educational opportunities, health care, safety, community, food security, and other issues will ensure a future of which we can be proud.
Healthy People 2020: Determinants of Health. Determinants of Health | Healthy People 2020. (n.d.). Retrieved May 6, 2022, from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health
Heath, S. (2021, September 7). How do healthcare workers face social determinants of health? PatientEngagementHIT. Retrieved May 1, 2022, from https://patientengagementhit.com/news/how-do-healthcare-workers-face-social-determinants-of-health
Kinder, M. (2022, March 9). Essential but undervalued: Millions of health care workers aren’t getting the pay or respect they deserve in the COVID-19 pandemic. Brookings. Retrieved May 1, 2022, from https://www.brookings.edu/research/essential-but-undervalued-millions-of-health-care-workers-arent-getting-the-pay-or-respect-they-deserve-in-the-covid-19-pandemic
Virginia Commonwealth University & Robert Wood Johnson Foundation. (2017). Why education matters to health: Exploring the causes. Center on Society and Health. Retrieved May 1, 2022, from https://societyhealth.vcu.edu/work/the-projects/why-education-matters-to-health-exploring-the-causes.html
World Health Organization. (2021). The impact of COVID-19 on health and care workers: a closer look at deaths. World Health Organization. https://apps.who.int/iris/handle/10665/345300. License: CC BY-NC-SA 3.0 IGO
Research continues to identify the unconscious biases in health care – that is, preferences and prejudices that service providers may have and may not be unaware of, can lead to preferential and differential treatment of patients according to the characteristics of age, gender, income, insurance status, language, race, sex and sexual identity, and weight. Implicit bias directly effects patient safety and well-being (The Joint Commission, 2022). Implicit Bias in health care decision-making results in problems that can directly lead to patient harm. The harm that implicit bias can cause is exacerbated during public health crises, such as the COVID-19 pandemic (Brown, 2021).
2. Implicit Bias and Social Determinants of Health
Implicit bias is sometimes referred to as subconscious bias and hidden bias. Both terms refer to the perspectives, predispositions, attitudes or stereotypes that affect how we interpret and understand actions and decisions in ways that we are not aware of (The Joint Commission, 2022). These biases or predispositions can be comprised of favorable and unfavorable assessments. These biases are often activated and or applied involuntarily, without an individual being aware of it or conscious action. The idea that implicit bias affects health care and health care related contexts is an extension of interpreting the phenomena health inequalities as a product of social determinants of health (The Joint Commission, 2022).
Health inequalities are frequently interpreted as referring to socioeconomic differences in health, such as income and proximity to quality health care. However, scholars have expanded this definition of health inequalities to also include negative health outcomes that are preventable, unnecessary, avoidable, and unjust, unfair and inequitable (The Joint Commission, 2022). Health equity entails everyone – every person in any society having the opportunity to attain their full health potential and no one being marginalized from actualizing this full potential (Brown, 2021). Implicit bias can be informed by life and on the job stress, limited resources, and lack of knowledge about personal and professional predispositions. The COVID-19 pandemic exacerbates these factors and puts service providers at risk of maintaining the disproportionate rates of access to resources that are already present amongst marginalized communities in the U.S. A direct outcome of implicit bias in healthcare in the midst of the COVID-19 pandemic are the disproportionate rates of infections and COVID-related deaths among low income Black and Latine adults (Snowden, Tolliver & McPherson, 2021).
3. How Implicit Bias is Measured
There are various tests that measure implicit/unconscious/hidden bias. These tests measure what the test taker’s unconscious or automatic implicit biases may and may not be. A healthcare worker’s, such as a social worker’s or a nurse practitioner’s willingness to examine their own possible automatic or unconscious biases is an important step in becoming aware of and understanding individual level prejudice and how these unconscious prejudices inform patient care related decisions (The Joint Commission, 2022). Completing the implicit bias test periodically can also assist the service delivery practitioner to identify the roots of oppression and the stereotypes that serve this inequity in U.S. society. Unconscious bias has its roots in the humanistic ability to distinguish friend from foe and how this skill served primitive human groups survive (The Joint Commission, 2022).
One of the tests that assess hidden bias is the Implicit Association Test (IAT). This text is a computerized and timed dual-categorization task. This assessment tool measures implicit preferences by bypassing conscious processing by asking the test taker to make immediate selections of preference without having the time to interpret or reflect on the preferences that are selected in the moment (The Joint Commission, 2022). The IAT is part a collaborative investigation effort between researchers at Harvard University, University of Virginia, and University of Washington. This project is called Project Implicit. These studies examine the thoughts, feelings, preferences and predispositions that exist outside of conscious awareness and or in the participant’s conscious control (The Joint Commission, 2022). The goal of the project is to make this technique available for formal education, self-education, and awareness.
Quickly and automatically categorizing situations and people is a fundamental quality of the human mind. Categories can provide a much-needed order to day to day exchanges and access to basic needs. However, in a country and context where societal resources are rationed based on the classifications of race, class and gender, implicit bias can uphold these macro-level arrangements. This is the foundation of stereotypes, prejudice and, ultimately, discrimination, particularly in health care (Brown, 2021; The Joint Commission, 2022; Snowden, Tolliver, McPherson, 2021).
Implicit bias can be challenging to address, and then unlearn because these stereotypes, prejudices, likes and dislikes resist change, even when the present evidence points to the contrary and or does not support them. Human nature includes embracing the experiences that affirm and reinforce biases, and disregarding the experiences that contradict these predispositions. A common statement that can capture this tendency to be able to interpret one or very few exceptions to our biases, without challenging or changing these predispositions is: “Some of my best friends are _____.” This statement is an example of how biases that can be thought to be addressed can still remain (The Joint Commission, 2022). Research continues to illustrate how people can be consciously wedded to values that support egalitarianism, equity, anti-sexism and anti-racism, including deliberately working to act without prejudice, and yet still possess implicit negative stereotypes (The Joint Commission, 2022).
Studies continue to produce the same or similar findings that despite being grouped together and in the same classes, school children that are of color and school children that are white receive educations based on the implicit bias of the teachers (The Joint Commission, 2022). Human beings are biologically programed to place individuals in age, gender, race and role categories, and this category then maps out how we interact and interpret our exchanges with this person or these groups. Researchers and scholars agree that implicit bias is the product of repeated reinforcement of social constructs, such as stereotypes, and develops early in life. Studies have shown that racialized pro-White implicit bias occurs among children as young as three to five years of age (Brown, 2021; The Joint Commission, 2022).
5. Examples of Implicit Bias in Service Delivery
Disproportionate health care outcomes can be evidence of the various ways that implicit bias plays out in health care settings and among service delivery. One example is how implicit gender bias among service providers and how it can sway treatment decisions, unbeknownst to the service provider (The Joint Commission, 2022). For instance, when a knee arthroplasty is clinically appropriate, women are three times less likely than men to receive treatment. One of the stereotypical reasons for this gender-based inequity and underuse problem is that men are stereotyped as being more likely to participate in strenuous or rigorous activity more frequently (The Joint Commission, 2022). Some additional examples of how implicit bias is present in health care related decisions among service providers include:
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Black patients and patients of color receiving fewer cardiovascular interventions and fewer renal transplants
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Black women disproportionately more likely to die after being diagnosed with breast cancer
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Black patients and patients of color being less likely to be prescribed pain medications
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Black men are more likely to have testicle(s) removed and less likely to receive therapy for prostate cancer
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Black patients and patients of color being more likely to be blamed by health care professionals for being too passive about receiving health care
6. What Service Providers Can Do
Many health care training programs and health care organizations administer the Implicit Association Test (IAT). Studies have shown that when this test is applied to medical doctors, significant pro-white bias has been found. Similarly, when the IAT has been administered at an obesity conferences, test takers implicitly associated people that were interpreted as being obese with various negative cultural stereotypes (Brown, 2021).
The differences in treatment, clinical decision-making, and resource allocation through implicit or hidden bias can, and too often does, lead to failures in patient-centered care, interpersonal treatment, communication, trust, and contextual knowledge, which is your physician’s knowledge of your values and beliefs. How a service provider communicates, such as their body language and verbal cues can all be an expression of subconscious bias. These unconscious preferences can be easier to develop an awareness of through periodic completion of an implicit bias test, such as the IAT. Service providers can also utilize the The Upstate Bias Checklist: A Checklist for Assessing Bias in Health Professions (Brown, 2021) to assist them in the process of addressing subconscious bias.
Brown, A. C. (2021). The Upstate Bias Checklist: A Checklist for Assessing Bias in Health Professions Education. https://unmcredcap.unmc.edu/redcap/surveys/?s=YXYJW87H9CWHAXRC
The Joint Commission (2022). Quick Safety 23: Implicit bias in health care. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/implicit-bias-in-health-care/#.YnkBeofMLD5
Snowden, F., Tolliver, W., McPherson, A. (2021). Needing, Kneading, and Eating Black Bodies: The History of Social Work and Its Concern for Black Citizenship in the U.S. Journal of Advances in Social Work, 21(2/3), 217-240, DOI: 10.18060/24469
1. Impact of the Moral Decisions Made by Healthcare Workers Regarding Who Received Care and Needed Resources That Were in Limited Supply
Moral injury is a concept that has been studied for many years. Usually applied to the military, it is analogous to post traumatic stress disorder (PTSD). Moral injury (MI) is a particular type of trauma that results in inner conﬂict. The individual experiencing moral injury may suffer from psychological and religious/spiritual symptoms of internal ethical conﬂicts that result from perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs (Koenig, Ames, Youssef, Oliver, Min,Volk, Teng, Haynes, Erickson, Arnold, O’Garo & Pearce, 2018). The idea that psychological injury can result from transgressions of deeply held moral and ethical beliefs and expectations is far from new (Nash, Marino Carper, Mills, Au, Goldsmith & Litz, 2013). Recently, however, moral injury has become prevalent in the healthcare industry with the events surrounding the COVID-19 pandemic. Frontline hospital nurses have been described as working in the trenches, language usually associated with wartime.
Moral distress (MD) refers to the psychological experience of individuals in response to moral stressors. Jameton (2013) defines MD as the experience of psychological distress in situations where individuals are prevented from acting in ways they would have considered right based on personal values. Moral stress can be described external factors preventing health care providers from doing what is best for the patient and health care providers feeling that they have no control over a specific situation. Central values in the health care profession have been articulated to include a commitment to excellence of practice, including accuracy in caring as well as individual and professional competence; a commitment to integrity and ethical practice; the maintenance of justice; and compassionate, respectful behavior toward patients and relatives.
During the COVID-19 pandemic, health care workers (HCWs) have faced risks to patients’ lives as well as health risks to themselves. Acute care institutions rarely, if ever, fail to provide the equipment or medications/treatments needed to care for seriously ill patients. It has been unprecedented that HCWs have had to decide which patient should receive a ventilator or which patient should receive potentially life-saving anti-viral medication. In general, HCWs have been conceptualized as individuals who actively engage in the protection and the improvement of the health of society. Moral injury/moral distress may be experienced when the ethics of patient-centered care and the requirements for protecting society come into conflict. For example, HCWs have been confronted with increased workloads and insufficient resources. Furthermore, HCWs are confronted with fears of infecting themselves and family members. Under conditions of frequently changing teams and lack of personal protective equipment (PPE), health care workers may feel powerless. Asking nurses/health care providers to provide direct patient care during the COVID 19 pandemic without appropriate PPE was the equivalent of asking a fire fighter to enter a burning building without water. In addition, the government’s inability to procure masks, gloves and gowns, and the suggestion to use inferior materials such as garbage bags as PPE undermines the principles of infection control and microbiology that are inherent in nursing/medical education. As a result, both patients and healthcare workers succumbed to COVID 19. Particularly in the context of a pandemic, the care of seriously ill patients, patients whose conditions deteriorate quickly, triage decisions (who gets what and when), or the treatment of colleagues represent extreme stressors in the workplace. In one institution in Queens, New York, a physician who worked along sides other physicians and nurses during the early stages of the pandemic became ill with COVID. Despite the team’s best efforts, the doctor died several days later. This left the staff with profound sadness, helplessness, and the devastating thought, “That could have been me” and/or the guilt that came with survival.
In a mixed method study in the UK and Ireland, the qualitative comments from HCWs were distressing.
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“Still having PPE below WHO standards i.e., no FFP3 masks for standard use, no protective eye wear—I had to buy my own goggles and using those plastic aprons while the Far Eastern doctors have full body suits to do even swab. Plus no negative pressure zones in my ED.”
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“Did not feel good when loads of patients [were] generating aerosol [secretions]… and a lot of staff getting infected.”
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“Unrelenting. Groundhog day.”
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“I am already very tired, worn out, burn[ed] out, and this looks like it will never end.” “A major incidence is fine but this has basically been a nearly 12 month major incident.
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“There’s one patient who was only comfortable on 60 litres optiflow but we were running out of oxygen and I insisted he change to CPAP to conserve supplies. He needed intubation and then died and I feel guilty that his last conscious memory was of me torturing him with the CPAP mask.”
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“ A young mother was admitted to ICU on CPAP and we’d just been given an ipad to help families video call: I kept asking the nurses to help her speak to her family but they delayed until it was too late and we had to intubate her, she died without saying goodby (goodbye).”
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“Trying to communicate with patients when wearing a mask especially the elderly as they can’t hear and [are] unable to lip read. You can’t smile at them to reassure them.”
Both nurses and doctors take oaths that publicly affirm their commitment to patient care. It is an oath that is taken seriously and is the foundation of why individuals enter the health care professions. HCWs inability to uphold that oath is morally distressing. Making decisions about who receives what treatment/equipment and when they receive it is a new concept for care in the acute care setting. The idea that resources, basic PPE, would not be available and would have to be re-used over multiple shifts/days was a practice not previously experienced in acute care prior to the COVID-19 pandemic and counters the underlying tenets of infection control. Being forced to make clinical decisions, based on resource scarcity, that are inconsistent with therapeutic values is painful and distressing. Knowing that one patient will receive life-sustaining treatment while another will be denied that same treatment takes a significant emotional toll on the care provider.
The COVID-19 pandemic has generated stress and subsequently, distress for health care workers. Psychological first aid tenets provide a road map that fosters resilience for providers, and health care systems to navigate the ethical dimensions of the COVID-19 pandemic. Acknowledgement of stress, pressure, and sacrifice, by organizational leaders and peers is vital for normalizing staff reactions and knowing that experiences are shared. Lean on colleagues, talk about reactions and the distress that providers are experiencing. Delivery evidence-based interventions to promotes self-efficacy and reminds health care providers to not give up in the midst of overwhelming circumstances. There is continual need for resources that foster moral repair and resilience. Without such resources, personal guilt will erode professional confidence. Health care organization and society need to realize that health care providers may grapple with the moral residue of COVID- 19 beyond its actual period of immediate threat. (Williams & Brundage & Williams, 2020).
https://www.ama-assn.org/delivering-care/public-health/caring-our-caregivers-during-covid-19
https://www.cdc.gov/mentalhealth/stress-coping/healthcare-workers-first-responders/index.html
https://jamanetwork.com/journals/jama/article-abstract/2787536
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193121/
Jameton, A. (2013). A Reflection on Moral Distress in Nursing Together With a Current Application of the Concept. Bioethical Inquiry, 10:297–308 DOI 10.1007/s11673-013-9466-3.
Koenig, H., Ames, d., Youssef, N., Oliver, J., Volk, F., Teng, E., Haynes, K., Erickson, Z., Arnold, I., O’Garo, K., & Pearce, M. (2018). Screening for Moral Injury: The Moral Injury Symptom Scale – Military Version Short Form, Military Medicine, 183, 11/12:e659.
Nash, W., Marino Carper, T., Mills, M., Au, T., Goldsmith, A., & Litz, B. (2013). Psychometric Evaluation of the Moral Injury Events Scale, Military Medicine, 178, 6:646.
Williams, R., Brundage, J., & Williams, E. (2020). Moral injury in times of COVID 19, Journal of Health Service Psychology, https://doi.org/10.1007/s42843-020-00011-4.