Moral injury

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A moral injury is an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression on the part of themselves or others. [1] It produces profound feelings of guilt or shame, [1] moral disorientation, and societal alienation. [2] In some cases it may cause a sense of betrayal and anger toward colleagues, commanders, the organization, politics, or society at large. [2] [3]

Contents

Moral injury is most often studied in the context of military personnel. The term has also been applied to frontline health workers during the COVID-19 pandemic who have had to deal with extremely stressful situations in which they were unable to provide care at a level that they considered appropriate, to people involved in accidents, and to people who have been raped or abused. [4]

Definition

Psychiatrist Jonathan Shay and colleagues coined the term moral injury to describe experiences where someone who holds legitimate authority has betrayed what is morally right in a high-stakes situation. [5] The concept of moral injury emphasizes the psychological, social, cultural, and spiritual aspects of trauma. [6]

According to the International Centre for Moral Injury, it "involves a profound sense of broken trust in ourselves, our leaders, governments and institutions to act in just and morally 'good' ways" and the experience of "sustained and enduring negative moral emotions - guilt, shame, contempt and anger - that results from the betrayal, violation or suppression of deeply held or shared moral values." [7]

The US Department of Veterans Affairs uses the term moral injury to describe the experiences of military veterans who have witnessed or perpetrated actions in combat that transgressed their deeply held moral beliefs and expectations. [8]

History

In 1984, the term moral distress was first conceptualized by philosopher Andrew Jameton in his book on nursing issues, Nursing Practice: The Ethical Issues to describe the psychological conflict nurses experienced during "ethical dilemmas". He wrote that "moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action." [9]

In the 1990s the term moral injury was coined by psychiatrist Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay's definition of moral injury had three components: 'Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation. [10] [11] [12] As of 2002, Shay defined moral injury as stemming from the "betrayal of 'what's right' in a high-stakes situation by someone who holds power." [5]

In 2009, the term moral injury [12] was modified by Brett Litz and colleagues as "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially" (2009, p. 695). According to Litz et al., the term moral injury had been developed in response to the inadequacy of mental health diagnoses, such as post-traumatic stress disorder (PTSD), to encapsulate the moral anguish service members were experiencing after returning home from war. [1] Unlike PTSD's focus on fear-related symptoms, moral injury focuses on symptoms related to guilt, shame, anger, and disgust. [13] The shame that many individuals face as a result of moral injury may predict symptoms of posttraumatic stress disorder. [14]

As of 2017, no systematic reviews or meta-analyses exist on the construct of moral injury, although a literature review of the various definitions since the inception of moral injury has been undertaken, [15] [16] as well as psychological and interdisciplinary literature reviews of how moral injury develops and the factors involved. [17] [18]

In 2019, researchers surveyed previous literature and expertise to compile a list of events that could distress civilians at a level consistent with moral injury. Examples include causing a car accident or experiencing sexual assault, but researchers emphasize that not everyone will respond to an event in the same way. [4] [19]

In the early 2020s moral injury emerged as one of the explanations for the wave of employee resignations across industries. In particular, Ludmila Praslova proposed that moral injury might be a better explanation for a segment of resignations and employee distress than burnout, and provided suggestions for organizational-level interventions. [20] [21]

In 2022, researchers identified associations between moral injury and complex post-traumatic stress disorder (CPTSD). [22] CPTSD's disturbances in self-organisation constitute the three additional clusters of symptoms distinguishing it from PTSD (i.e. emotional dysregulations, interpersonal difficulties, negative self-concepts around beliefs of worthlessness or failure and related guilt or shame). [23] Veterans with possible CPTSD reported greater moral injury related to perpetration- and betrayal-based events compared to those with and without possible PTSD and findings suggesting the special relevance of moral injury among veterans with CPTSD. [24]

Military

To understand the development of the construct of moral injury, it is necessary to examine the history of violence and the psychological consequences. Throughout history, humans have been killing each other, and have shown great reluctance in doing so. [25] Literature on warfare emphasizes the moral anguish soldiers feel in combat, from modern military service members to ancient warriors. [26] Ethical and moral challenges are inherent to warfare. [27] Soldiers in the line of duty may witness catastrophic suffering and severe cruelty, causing their fundamental beliefs about humanity and their worldview to be shaken. [1]

Service members who are deployed into war zones are usually exposed to death, injury, and violence. Military service members represent the population with the highest risk of developing post-traumatic stress disorder. [28] PTSD was first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual classifying mental health disorders published by the American Psychiatric Association, to begin to address the symptoms that Vietnam veterans exhibited after their wartime experiences. [1] As PTSD has developed as a diagnosis, it requires that individuals are either directly exposed to death, threatened death, serious injury, or sexual violence, witness it in person, learn about it occurring indirectly to a close relative or friend, or are repeatedly exposed to aversive details of traumatic events. [28] PTSD includes four symptom clusters, including intrusion, avoidance, and negative mood and thoughts, and changes in arousal and reactivity. [28] Individuals with PTSD may experience intrusive thoughts as they re-experience the traumatic events, as well as avoiding stimuli that reminds them of the traumatic event, and have increasingly negative thoughts and moods. Additionally, individuals with PTSD may exhibit irritable or aggressive, self-destructive behavior, and hypervigilance, amongst other arousal-related symptoms. [28]

Moral injury can also be experienced by warriors who have been transgressed against. The injury may in those cases, which are often about transgressions by the soldier and others (e.g. the commander) at the same time, include a sense of betrayal and anger. [3] For example, when one goes to war believing that the purpose of the war is to eradicate weapons of mass destruction, but finds that not to be the case, or when the soldier is sent to war with an impossible mandate rendering him powerless in the face of human suffering, the soldier can experience moral injury. [3] Those who have seen and experienced death, mayhem, destruction, and violence and have had their worldviews shattered – the sanctity of life, safety, love, health, peace, etc. – can also suffer moral injury. [2]

The exposure to violence during war times puts the military and veteran population at a higher risk of developing moral injury. According to statistics collected in 2003, 32 percent of American service members deployed to Iraq and to Afghanistan were responsible for the death of an enemy, 60 percent had witnessed both women and children who were either ill or wounded to whom they were unable to provide aid, and 20 percent reported being responsible for the death of a non-combatant. [1] Similar work has been conducted in a Canadian military context – out of Canadian Armed Forces personnel deployed to the mission to Afghanistan, more than half endorsed a traumatic event that was conceptually linked to moral injury. [29] Specifically, 43 percent saw ill or injured women or children who they were unable to help; 7 percent felt responsible for the death of Canadian or allied personnel, and 38 percent had difficulty distinguishing between combatants and non-combatants. [29] Controlling for other fear-based deployment-related stressors, exposure to such potentially morally injurious events has been related to increased prevalence of PTSD and depression in military personnel. [29]

During times of war a service member's personal ethical code may clash with the decisions they are expected to make or the behavior they are expected to display. Approximately 27 percent of deployed soldiers have reported having an ethical dilemma to which they did not know how to respond. [14] Research has shown that longer and more frequent deployments can result in an increase in unethical behaviors on the battlefield. [30] This is problematic considering deployment lengths have increased for the war in Iraq and Afghanistan. [1] [30] During times of war the military promotes an ethical pardon on the killing of an enemy, going against the typical moral code for many service members. [1] While a service member is deployed, killing of the enemy is expected and often rewarded. Despite this, when a service member returns home the socio-cultural expectations are largely different from when they were deployed. [1] The ethical code back home has not changed, making the transition from deployment to home difficult for some service members. [14] This clash between personal ethics and the ethics and expectations of the military can further increase a service member's deep-seated feelings of shame and guilt for their actions abroad.

Healthcare professionals

Moral distress among healthcare professionals was first conceptualized in 1984 by Andrew Jameton. [9] The concept was gradually explored over the subsequent 30 years in both nursing and veteran literature, though as above the definitions were slightly different. In the healthcare literature, moral injury refers to the accumulation of negative effects by continued exposure to morally distressing situations. [31] In 2000 the concept of moral distress being generated by systemic issues had been termed "the ethical canary". [32] to draw attention to the sensation of moral distress signaling a need for systemic change.

In 2018, it was suggested that moral injury can occur among physicians and other care providers which affect their mental health and well-being. The concept of moral injury in healthcare is the expansion of the discussion around compassion fatigue and 'burnout' [33] was first discussed by Simon G. Talbot and Wendy Dean.

Physicians in the United States were caught in situations that prevented them from doing what they perceive is the right course of action, i.e. taking care of the patient well. Instead, they were caught in double and triple and quadruple binds between their obligations of electronic health records, their own student loans, the requirements for patient load through the hospital and number of procedures performed. [33] Often, physicians are trained to the "gold standard" but due to institutional double-binds, cannot actually execute that best-in-class treatment.

Nurses, particularly those who work in intensive-care settings, are highly likely to experience moral injury or burnout. [34] [35] The injury stems from the proximity to secondary trauma and the inability provide patients with the level of care to which they are called. [36]

As of 2018, moral injury has been studied in medical students working within the National Health Service (NHS). [37] In her TED talk in October 2019, Sammy Batt-Rawden argued that doctors come to psychological harm as a result of not being able to give patients the care that they need in an under-resourced NHS. [38]

Since the beginning of the COVID-19 pandemic in 2020, healthcare workers in the United States in particular have been faced with decisions like rationing care while hospital policy and insurance constraints remain, without support or training on how to psychologically process the toll these decisions can take. Driven by changes in health care reimbursement structures, systems were “optimized” to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic. As such, COVID-19 has only exacerbated an already deeply challenged system. [4] [39]

First responders

The concept of moral injury has more recently also been discovered among police, [40] and likely exists among firefighters as well and other forms as first responders work and should include such Emergency Medical Services, legal defenders/lawyers, and Child/Adult Protective Services. [41] Professions with non-human subjects such as veterinarians are also beginning to be studied. [42]

Psychology

Brett Litz and colleagues define moral injury as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations." [1] Litz and colleagues focus on the cognitive, behavioral, and emotional aspects of moral injury, positing that cognitive dissonance occurs after a perceived moral transgression resulting in stable internal global attributions of blame, followed by the experience of shame, guilt, or anxiety, causing the individual to withdraw from others. [1] The result is increased risk of suicide due to demoralization, self-harming, and self-handicapping behaviors. [1]

Psychological risk factors which make an individual more prone to moral injury include neuroticism and shame-proneness. Protective factors include self-esteem, forgiving supports, and belief in the just-world hypothesis. [1]

Sociology

Research by anthropologist Tine Molendijk [43] integrates insights from psychology, philosophy, theology and social sciences to achieve a holistic understand of not only the psychological but also the ethical, spiritual/existential, organizational, political and societal dimensions of moral injury. Her research has shown that as unresolved conflicts at the political level create potentially morally injurious situations for soldiers on the ground, "experiences of institutional betrayal" and "a resultant search for reparations" by veterans can also be part of moral injury. [3] It further demonstrates that not only public condemnation of veterans, but public heroification, too, may contribute to moral injury, given that both are generally experienced by veterans as alienating distortions of their war experience, meaning that both may entail an "injustice" being done to the experience. [44]

As the causes of moral injury lie not only in the individual but also at the organizational, political and societal levels, Molendijk further argues, solutions should be sought at these levels as well. The practical implications of a holistic approach to moral injury, for instance, include that we need 'a more elaborate moral vocabulary, the decision-making framework of the Just War Tradition, and purification and reintegration practices'. [43]

Theology

Rita Nakashima Brock and Gabriella Lettini emphasize moral injury as "…souls in anguish, not a psychological disorder." [45] This occurs when veterans struggle with a lost sense of humanity after transgressing deeply held moral beliefs. [45] The Soul Repair Center at Brite Divinity School is dedicated to addressing moral injury from this spiritual perspective. [46]

Treatment

While moral injury can be experienced by people other than military service members, research has paid special attention to moral injury in military populations. [1] Seeking professional mental health help for moral injury may present with some challenges, particularly for military personnel. Moral injury is frequently associated with socially withdrawing emotions, such as guilt and shame. These emotions may further reduce the likelihood of individuals reaching out for help in the fear of being rejected or judged by others. Additionally, military personnel may be hesitant to seek help due to actual or perceived career repercussions. Recent research on this topic showed that among active deployed military personnel, those who were exposed to potentially morally injurious experiences were more likely to avoid military mental health services and instead seek help from a professional in a civilian health care system. [47]

According to Shay, the process of recovery should consist of "purification" through the "communalization of trauma." Shay places special importance on communication through artistic means of expression. Moral injury could only be absolved when "the trauma survivor... [is] permitted and empowered to voice their experience....". Fully coming "home" would mean integration into a culture where one is accepted, valued and respected, has a sense of place, purpose, and social support. [5]

According to Litz for this to occur, there needed to be openness on the part of civilians to hear the veterans' experiences without prejudice. The culture in the military emphasizes a moral and ethical code that normalizes both killing and violence in times of war. Litz and colleagues (2009) have hypothesized a modified version of cognitive-behavioral therapy (CBT) that addresses three key areas of moral injury: "life-threat trauma, traumatic loss, and moral injury Marines from the Iraq and Afghanistan wars." [1] Despite this, decisions made by service members who engage in killing or violence through this cultural lens would still experience psychological and spiritual impact. [1]

It is hypothesized that treating the underlying shame associated with service member's symptoms of PTSD is necessary and it has been shown that allowing feelings of shame to go untreated can have deleterious effects. [14] This can make the identification of moral injury in a service member difficult because shame tends to increase slowly over time. [1] Shame has been linked to complications such as interpersonal violence, depression, and suicide. [14]

Neurological research suggests that there are differences in how physical threat and moral injury affect the brain. [4] In 2015, Gaudet and colleagues wrote that treatment interventions are lacking and new treatment interventions specific to moral injury are necessary, and that it was not enough to treat moral injury in the same way that depression or PTSD are commonly treated. [1] Treatments for PTSD have been described as “backwards-acting” in that they tend to focus on reframing negative thoughts about a past trauma. For someone who has violated their moral code by doing or failing to do something, such reframing may not be appropriate or effective. For example, many front line health workers during the COVID-19 pandemic have had to deal with extremely stressful situations in which they were unable to provide care at a level which they considered appropriate. Those experiencing moral injury may be better served by “forward-looking” treatment that supports “adaptive disclosure”, combining acceptance of responsibility for their past choices with a focus on their ability to contribute in the future, and where appropriate, steps towards reparation. [4]

Treating moral injury has been described as "soul repair" due to the nature of moral anguish. [26] “Spiritually integrated” therapies for moral injury that deal with feelings of guilt and shame often draw upon religious traditions. [4] In spite of the lack of research on the treatment of moral injury, factors such as humility, gratitude, respect and compassion have shown to either be protective or provide for hope.

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Acute stress reaction and acute stress disorder (ASD) is a psychological response to a terrifying, traumatic or surprising experience. Combat stress reaction (CSR) is a similar response to the trauma of war. The reactions may include but are not limited to intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. It may be exhibited for days or weeks after the traumatic event. If the condition is not correctly addressed, it may develop into post-traumatic stress disorder (PTSD).

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

A trauma trigger is a psychological stimulus that prompts involuntary recall of a previous traumatic experience. The stimulus itself need not be frightening or traumatic and may be only indirectly or superficially reminiscent of an earlier traumatic incident, such as a scent or a piece of clothing. Triggers can be subtle, individual, and difficult for others to predict. A trauma trigger may also be called a trauma stimulus, a trauma stressor or a trauma reminder.

As defined by the United States Department of Veterans Affairs, military sexual trauma (MST) are experiences of sexual assault, or repeated threatening sexual harassment that occurred while a person was in the United States Armed Forces.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

Jonathan Shay is an American doctor and clinical psychiatrist. He holds a B.A. from Harvard (1963), and an M.D. (1971) and a Ph.D. (1972) from the University of Pennsylvania. He is best known for his publications comparing the experiences of Vietnam veterans with the descriptions of war and homecoming in Homer's Iliad and Odyssey.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

<span class="mw-page-title-main">Transgenerational trauma</span> Psychological trauma

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary modes of transmission are the uterine environment during pregnancy causing epigenetic changes in the developing embryo, and the shared family environment of the infant causing psychological, behavioral and social changes in the individual. The term intergenerational transmission refers to instances whereby the traumatic effects are passed down from the directly traumatized generation [F0] to their offspring [F1], and transgenerational transmission is when the offspring [F1] then pass the effects down to descendants who have not been exposed to the initial traumatic event - at least the grandchildren [F2] of the original sufferer for males, and their great-grandchildren [F3] for females.

Psychological first aid (PFA) is a technique designed to reduce the occurrence of post-traumatic stress disorder. It was developed by the National Center for Post Traumatic Stress Disorder (NC-PTSD), a section of the United States Department of Veterans Affairs, in 2006. It has been endorsed and used by the International Federation of Red Cross and Red Crescent Societies, Community Emergency Response Team (CERT), the American Psychological Association (APA) and many others. It was developed in a two-day intensive collaboration, involving more than 25 disaster mental health researchers, an online survey of the first cohort that used PFA and repeated reviews of the draft.

Perpetrator trauma, also known as perpetration- or participation-induced traumatic stress , occurs when the symptoms of posttraumatic stress disorder (PTSD) are caused by an act or acts of killing or similar horrific violence.

Institutional betrayal is a concept described by psychologist Jennifer Freyd, referring to "wrongdoings perpetrated by an institution upon individuals dependent on that institution, including failure to prevent or respond supportively to wrongdoings by individuals committed within the context of the institution". It is an extension of betrayal trauma theory. When institutions such as universities cover up violations such as rape, sexual assault and child sexual abuse, this institutional betrayal undermines survivors' recovery. In a landmark study in 2013, Carly P. Smith and Freyd documented psychological harm caused by institutional betrayal. A legal analysis concludes that this study is reliable under the Frye standard and the Daubert standard.

<span class="mw-page-title-main">Post-traumatic stress disorder among athletes</span> Prevalence of PTSD among athletes

Posttraumatic stress disorder (PTSD) is a cognitive disorder, which may occur after a traumatic event. It is a psychiatric disorder, which may occur across athletes at all levels of sport participation.

Operational stress injury or OSI is a non-clinical, non-medical term referring to a persistent psychological difficulty caused by traumatic experiences or prolonged high stress or fatigue during service as a military member or first responder. The term does not replace any individual diagnoses or disorders, but rather describes a category of mental health concerns linked to the particular challenges that these military members or first responders encounter in their service. There is not yet a single fixed definition. The term was first conceptualized within the Canadian Armed Forces to help foster understanding of the broader mental health challenges faced by military members who have been impacted by traumatic experiences and who face difficulty as a result. OSI encompasses a number of the diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system, with the common thread being a linkage to the operational experiences of the afflicted. The term has gained traction outside of the military community as an appropriate way to describe similar challenges suffered by those whose work regularly exposes them to trauma, particularly front line emergency first responders such as but not limited to police, firefighters, paramedics, correctional officers, and emergency dispatchers. The term, at present mostly used within Canada, is increasingly significant in the development of legislation, policy, treatments and benefits in the military and first responder communities.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

<span class="mw-page-title-main">Post-traumatic stress disorder after World War II</span>

Post-traumatic stress disorder (PTSD) results after experiencing or witnessing a terrifying event which later leads to mental health problems. This disorder has always existed but has only been recognized as a psychological disorder within the past forty years. Before receiving its official diagnosis in 1980, when it was published in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-lll), Post-traumatic stress disorder was more commonly known as soldier's heart, irritable heart, or shell shock. Shell shock and war neuroses were coined during World War I when symptoms began to be more commonly recognized among many of the soldiers that had experienced similar traumas. By World War II, these symptoms were identified as combat stress reaction or battle fatigue. In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), post-traumatic stress disorder was called gross stress reaction which was explained as prolonged stress due to a traumatic event. Upon further study of this disorder in World War II veterans, psychologists realized that their symptoms were long-lasting and went beyond an anxiety disorder. Thus, through the effects of World War II, post-traumatic stress disorder was eventually recognized as an official disorder in 1980.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Psychological trauma in adultswho are older, is the overall prevalence and occurrence of trauma symptoms within the older adult population.. This should not be confused with geriatric trauma. Although there is a 90% likelihood of an older adult experiencing a traumatic event, there is a lack of research on trauma in older adult populations. This makes research trends on the complex interaction between traumatic symptom presentation and considerations specifically related to the older adult population difficult to pinpoint. This article reviews the existing literature and briefly introduces various ways, apart from the occurrence of elder abuse, that psychological trauma impacts the older adult population.

References

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  35. ↑ Chen, Ruey; Sun, Chao; Chen, Jian‐Jun; Jen, Hsiu‐Ju; Kang, Xiao Linda; Kao, Ching‐Chiu; Chou, Kuei‐Ru (February 2021). "A Large‐Scale Survey on Trauma, Burnout, and Posttraumatic Growth among Nurses during the COVID‐19 Pandemic". International Journal of Mental Health Nursing. 30 (1): 102–116. doi:10.1111/inm.12796. ISSN   1445-8330. PMC   7894338 . PMID   33107677.
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