Nurses' perception of ethical challenges in caring for patients with COVID-19: a qualitative analysis.

Nurses face several challenges in providing care for patients with coronavirus disease in 2019 (COVID-19). The study aimed to explain the nurses' perception of ethical challenges in this regard. The qualitative study was carried out using a content analysis method. Individual and semi-structured interviews were conducted with 24 nurses. Inductive content analysis was used to categorize the data. Nurses' narratives indicated that ethical challenges in caring for patients with COVID-19 included threats to professional values ​​and the absence of a holistic COVID-19 care approach. The first category was subcategorized into the risk of declining quality of patient care and a stigmatized public image about COVID-19 care. The second category was divided into poor spiritual care, poor compassionate care, and lack of family-centered care. Health care managers must develop protocols for nurses that address these issues to alleviate the ethical challenges of COVID-19 care.

Introduction

The year 2020 may be considered as the "year of Corona" (1). The Coronavirus disease 2019 (COVID-19) is considered a challenge for the health systems around the world (2, 3). The challenge of caring for COVID-19 patients (4) has imposed a substantial burden on health care (5, 6). Nurses are the key stakeholders in the development and implementation of policies on patient care standards during the COVID-19 pandemic (7). They are in the front-line of COVID-19 care (8,9). As a result, nurses are affected in various ways (10). They experience moral distress and long working hours while caring for patients with COVID-19 (11). They may also experience discomfort, fatigue, and feeling of helplessness (12). COVID-19 engages nurses in a complex situation in which they face several problems (13), mainly as providing clinical care to a patient in an infectious environment (14) can cause severe stress (15). Besides, they face challenges due to the short distance between hospital beds (16). Nurses are also at risk of skin injuries and pressure sores on their faces because of the long-term use of protective equipment needed to take care of COVID-19 patients (17). Due to certain ethical challenges, they sometimes compromise the safety of themselves, their colleagues, patients, and their families as they consider the patient's interests as their priority (18).

Several international studies have been conducted on caring for patients with COVID-19, the problems caused by providing care to patients during the pandemic. Studies in China have shown that apart from feeling fatigued due to overwork, nurses experience emotional fatigue (16) and suffer from stress while caring for high-risk infectious patients (16). In Taiwan, the problems linked with taking care of COVID-19 patients led to uncertainty in care (20). An Iranian study showed that nurses providing care to COVID-19 patients experience stress, anxiety, and lack of organizational support (21). A study in Turkey stated that the caregivers experience burnout due to exposure to the disease and death of patients and were also deprived of social support (22). Furthermore, the experience of health workers about home care in New York showed that nurses felt being at risk while taking care of patients in times of such crisis. (23).

A review article suggested that caring for patients with COVID-19 and generally providing care to these patients during the pandemic, in addition to some psychological challenges such as fatigue, stress, and burnout, was accompanied by some ethical challenges such as insecurity in care, lack of organizational and social support for nurses, and injustice and marginalization for healthcare workers. However, the perception of Iranian nurses of the ethical challenges in caring for COVID-19 patients has not yet been explored. Given that the nurses' perception of ethical challenges in caring for COVID-19 patients can be a context-based concept, it is more effective to explore and understand these challenges using a qualitative approach. Therefore, the present study evaluates the nurses' perception using their narratives in a natural setting to identify their understanding of ethical challenges in caring for patients with COVID-19.

Method

The qualitative study was conducted using the content analysis approach. Content analysis is a technique for analyzing written, spoken, or visual messages on a concept. In inductive content analysis, the available information about a concept is limited and the concept under study is explored from the data context via categories and names (24).

The research setting was two educational and medical centers affiliated to Zahedan University of Medical Sciences (ZAUMS), in which patients with COVID-19 were treated and cared for. The participants were nurses working in COVID-19 intensive care units and were selected by maximum variation in terms of age, gender, education, work experience, history of caring for COVID-19 patients, and the ward they worked in. The participants were selected using purposeful sampling and the sampling process continued until data saturation was achieved. The inclusion criteria were full-time employment in the COVID-19 wards and having at least one month of experience in caring for COVID-19 patients. The participants were 24 nurses, mainly women (15 participants), aged between 27 and 49 years. Most participants had a bachelor's degree (18 participants), and the remaining a master's degree. Their nursing experience ranged from 4 to16 years and they worked with COVID-19 patients between 1 to 5 months. Most nurses worked in general wards (14 participants) whereas others were from the COVID-19 intensive care units (Table 1).

Table 1

Characteristics of the participants

Participant	Age(years)	Gender	Education	Work setting	Nursing work experience(years)	experience related to COVID-19 care (months)
1	47	Female	Bachelor's degree	Intensive care unit	10	3
2	38	Male	Bachelor's degree	General ward	8	4
3	30	Female	Bachelor's degree	Intensive care unit	6	2
4	37	Male	Master's degree	General ward	5	3
5	49	Female	Bachelor's degree	General ward	16	4
6	36	Male	Bachelor's degree	General ward	12	2
7	42	Male	Bachelor's degree	General ward	13	3
8	29	Female	Master's degree	General ward	4	1
9	47	Male	Bachelor's degree	Intensive care unit	16	5
10	40	Male	Bachelor's degree	General ward	8	2
11	30	Female	Master's degree	General ward	12	4
12	39	Male	Bachelor's degree	General ward	8	3
13	29	Female	Bachelor's degree	Intensive care unit	5	4
14	42	Female	Bachelor's degree	General ward	14	5
15	40	Male	Bachelor's degree	General ward	12	2
16	49	Female	Bachelor's degree	Intensive care unit	14	1
17	34	Female	Bachelor's degree	Intensive care unit	13	4
18	47	Female	Bachelor's degree	Intensive care unit	11	4
19	33	Female	Bachelor's degree	General ward	10	4
20	41	Male	Bachelor's degree	Intensive care unit	12	1
21	49	Female	Master's degree	Intensive care unit	15	1
22	31	Female	Bachelor's degree	General ward	9	2
23	43	Female	Master's degree	General ward	14	4
24	27	Female	Master's degree	General ward	4	4

After sending the letter of introduction, the researcher made the required arrangements with the head nurses to introduce the qualified nurses. Then, the researcher recorded the nurses’ phone numbers with their permission. Given the restrictions caused by the COVID-19 pandemic, such as controlling the entry of people into inpatient wards to prevent the transmission of the virus as well as the high workload of nurses, it was not possible to conduct face-to-face interviews with the nurses in their workplace. Therefore, the interviews were conducted using WhatsApp mobile software in the form of video calls (21 nurses) and voice calls (3 nurses). The semi-structured interviews were conducted individually and lasted between 30 and 45 minutes. Data were collected between September and October 2020. All nurses were interviewed once and a total of 24 interviews were conducted. The interviews were conducted at the times that the participants were not at work. The main interview questions were, How would you describe caring for people with COVID-19? What are the ethical challenges of providing care in your opinion? Data collection and analysis were performed simultaneously. The collected data were analyzed using the approach proposed by Graneheim and Lundman (2004) (25). For this purpose, each interview was recorded and then typed and converted into text. Then, the texts were reviewed several times to extract meaning units. The related codes were then extracted from the meaning units. The codes were then placed in relevant subcategories based on their similarities and differences. Finally, the subcategories were merged into categories.

To check the rigor of the findings, the credibility, dependability, confirmability, and transferability criteria were used (25). To ensure the credibility of the findings, there was a constant engagement with the subject and data. The members of the research team expressed their opinions about data collection and analysis. The findings were shared with some of the participants and experts with a Ph.D. degree in nursing. To check the dependability of the findings, an external reviewer who was familiar with both the clinical setting and qualitative research was asked to review and confirm the results. To ensure the confirmability of the findings, all procedures taken to conduct the study were recorded and a report of the research process was provided. Finally, to check the transferability of the findings, the results were shared with 2 nurses who were not participants but had a history of caring for COVID-19 patients.

To comply with the requirements for ethical considerations, a permit to conduct the study was obtained from the Research Ethics Committee of the Zahedan University of Medical Sciences (ZAUMS) (ethics code: IR.ZAUMS.REC.1399.263). After informing the participants about the objectives of the study, the interviews were recorded with their consent. The participants were assured that the information will remain confidential and that they could withdraw from the study at any time.

Results

The analysis of the nurses’ narratives indicated that the ethical challenges in caring for patients with COVID-19 included threats to professional values ​​and the absence of a holistic COVID-19 care approach. The threats to professional values were subcategorized into the risk of declining quality of patient care and a stigmatized public image about COVID-19 care. The absence of a holistic approach to COVID-19 care was divided into subcategories such as poor spiritual care, poor compassionate care, and lack of family-centered care (Table 2).

Table 2

Results of data analysis

Categories	Subcategories
The threats to professional values	The risk of declining quality of patient care
	A stigmatized public image about COVID-19 care
The absence of a holistic COVID-19 care approach	Poor spiritual care
	Poor compassionate care
	Lack of family-centered care

The participants believed that the threats to the nursing professional values ​​pose an ethical challenge to caring for COVID-19 patients. They perceived this ethical challenge in the form of declining patient care quality and a stigmatized public image about COVID-19 care.

A.1.The risk of declining quality of care

The participants stated that for reasons such as nursing shortage or fatigue due to consecutive shifts, they are not at the patient's bedside at the time of need. As a result, responsibility and accountability in caring for patients are threatened:

“Declining sense of responsibility and accountability in patient care is really painful ... These problems are caused by factors such as the limited number of nurses or fatigue due to consecutive shifts. I have to tell you that under these challenging conditions, we cannot be at the patient's bedside when he/she needs us; although, this is part of our nursing duties.” [Participant No. 5]

Besides, the participants believed that inadequate competence along with lack of experience and clinical skills leads to insufficient and unsafe patient care. Poor quality care with an increased possibility of errors ultimately leads to the death of the patient.

“Caring for COVID-19 patients requires experienced nurses and any inadequacy in caring for these patients leads to the violation of their rights. For example, when a low-skilled nurse works in the COVID-19 intensive care unit, the patient is provided with incorrect or poor-quality care”. [Participant No. 16]

“The presence of unskilled nurses in the ICU itself is a big moral problem ... A nurse with insufficient skills needs time to learn, and patients may die during this time”. [Participant No. 9]

A.2. A stigmatized public image about COVID-19 care

According to the nurses, after providing care to COVID-19 patients, their professional dignity has been endangered by family, friends, and relatives. This ultimately leads to a threat to their social respect by the community:

“It's interesting that my father asks me to get away from these patients and recommends me to leave my job. He asks me if I am short in money that I have to care for these dying patients in the deathward. He says I would lose my life. For these stigmata, all my colleagues want to change their workplace and go to another ward”. [Participant No. 22]

“In the community, we have been stigmatized as corona-infected nurses, and we are known by this name among friends and relatives. Neighbors think that I have been infected with coronavirus because of working with COVID patients, so our family is also regarded as a corona-infected family. I think there has been a kind of cultural sensitivity towards nursing”. [Participant No. 11]

The participants believed that issues such as poor spiritual or compassionate care, and lack of family-centered care could lead to the absence of a holistic COVID-19 care approach.

B.1. Poor spiritual care

According to the nurses, there is a lack of spiritual care in treating COVID-19 patients, which may lead to spiritual distress in patients:

“The patients in this ward are in dire need of spiritual care, which unfortunately is not available right now, and that is why COVID-19 patients suffer from spiritual distress”. [Participant No. 24]

This is while the spiritual care shows the patients the path of life, enabling them to continue living and having spiritual vitality.

“Our patients know they are on the verge of death because of COVID-19. Well, there is a lack of spiritual care here ... Spiritual care shows the patient the path of life and tells him/her that even if COVID is the end of life, this is fate, and death is part of it that has come to an end”. [Participant No. 18]

“I believe that if we could provide spiritual care to the patients, they could continue to live more peacefully ... If the nurse can provide spiritual care to the patient, he/she will be spiritually refreshed and empowered”. [Participant No. 2]

B.2. Poor compassionate care

According to the nurses, empathy and compassion-focused care as well as listening to patients with COVID-19 are missing due to time restrictions. Besides, for this reason, there is no mutual sense in caring for the patients and understanding them at the moment:

“Our nurses give mainly physical care to the patients and have no time to offer empathy and/or compassion-focused care ... I dare say that listening to the patient meets their needs and meeting these needs means offering good care to the patient”. [Participant No. 10]

“When there is no mutual understanding of caring for these patients, I think caring for a patient becomes problematic. In the current situation, because of our workload, we really cannot understand the patient and put ourselves in their shoes. This is missing in COVID-19 intensive care units”. [Participant No. 3]

The nurses stated that the sudden outbreak of COVID-19 has prevented them from receiving the necessary training on compassion-focused care:

“Because COVID came suddenly, our colleagues never received the necessary training on compassion-focused care for patients, and that is why we have many problems in providing this type of care”. [Participant NO. 14]

B.3. Lack of family-centered care

The nurses considered the lack of family-centered care for patients with COVID-19 as an ethical challenge. Lack of family-centered care means that there is no system to support and follow up families, especially at the time of patient discharge:

“When patients are discharged, the family is very worried about relapse. For example, if there is a problem with their patient, as they are no longer in the hospital, who is in charge of providing support to them? Morally, it is not clear who is in charge of supporting the families after discharge. One reason is perhaps there is no family-centered care at all, and we do not have a system to follow up and support families”. [Participant No. 19]

The moral challenge of not having family-centered care also deprives the family of saying farewell to the patient at the end of life. Besides, the family is abandoned after the patient's death, and the health system fails to manage their grief:

“When the patient is at the end of life, there should be a possibility for the family to say goodbye. I do not know what to say. This moral problem torments me when the family comes to ask about the patient’s condition and we have to say that he/she has died as there is no possibility of the family members seeing the patient wearing the protective equipment, and being with him/her at the time of death”. [Participant No. 1]

“After the death of the patient, the family is abandoned, especially because no mourning ceremony can be held in the current situation. The family has no chance of holding any mourning ceremonies and there is a possibility that the family goes through an abnormal lamentation. It's not clear when the disease disappears. But the fact that our burial and mourning ceremonies have changed is a big challenge. What can be done to manage the mourning of these families, and this is a vague issue”. [Participant No. 23]

Discussion

The present study explored the nurses' perception of ethical challenges in caring for patients with COVID-19. The results showed that these challenges included threats to professional values ​​and a lack of a holistic COVID-19 care approach.

According to the nurses participating in this study, the professional values ​​governing nursing are threatened in the form of declining quality of patient care and a stigmatized public image about COVID-19 care. In other words, these threats range from workplace to community factors. They added that the low level of responsibility and accountability in caring for the COVID-19 patients, which is due to the insufficient number of nurses and them being fatigue from work pressure, results in failure for timely bedside attention to the patients. Besides, the employment of inexperienced and unskilled people leads to poor quality, inadequate, unsafe, and error-prone care for these patients. Ultimately, this may cause a violation of the patient's rights and even their death. According to the results of a Chinese study, caring for patients with COVID-19 placed nurses under pressure that led to a decline in their professional performance (14). Therefore, hospital managers should employ sufficient nursing staff in terms of quantity and quality to prevent the risk of any decline in the quality of COVID-19 patient care. While employing more nurses, their experience and skills should also be considered to guarantee quality care. Besides, the studied nurses stated that caring for a patient with COVID-19 posed a threat to the professional dignity and social respect for the nursing profession from family, friends, relatives, and the community as a whole. The nurses believed that such threats were due to the cultural sensitivity to nursing. Metaphors such as the "death ward" equivalent to the COVID-19 ward, the provision of care for "dying" instead of the patients with COVID-19, the "corona-infected nurse" and the "corona-infected family” indicated that providing care for the COVID-19 patients was accompanied by stigma. Since stigma has cultural roots, it can be suggested that the nurses participating in the present study viewed this type of care with a stigmatized public image. Similarly, existing research has shown that healthcare workers in Africa experienced a similar stigma while providing care for COVID-19 patients (26). Therefore, to overcome this moral challenge, a culture-based education must be provided for the community. Anti-stigma education is necessary to teach people that taking care of a patient with COVID-19 is the same as caring for other illnesses and that the nurse is responsible to provide the required care to the patients. These training programs can help result in the de-stigmatization of the topic.

The nurses also stated that one of the ethical challenges was the absence of a holistic COVID-19 care approach, which included poor spiritual care, poor compassionate care, and lack of family-centered care. The nurses acknowledged that spiritual care could lead to the patient's spiritual vitality. Lack of this type of care, on the other hand, can cause spiritual distress to the patients. For patients with COVID-19, however, spiritual care is considered a vital component of their health management that helps them cope with illness and suffering (27). Given the significance of the issue, it is necessary to provide spiritual care in addition to physical care to provide holistic care for these patients. According to the nurses, spiritual care can help show the path of life to COVID-19 patients and allow them to continue living.

The nurses stated that compassion-focused care was not provided for patients with COVID-19 due to time restrictions and substantial workload. According to the researchers, caregivers do not have enough time to communicate constructively with the patients when providing care to COVID-19 patients so there is no compassion and empathy in their relationship (28). However, for COVID-19 patients, humanistic care based on mutual understanding between the nurse and the patient is necessary (29). In other words, providing optimal care for these patients requires empathy, which only occurs through an effective sense of empathy by the patient (30). According to the nurses, the sudden outbreak of COVID-19 has prevented them from receiving the necessary training on compassion-focused care. This highlights the need for compassion-focused education for nurses caring for patients with COVID-19. Due to the high prevalence of COVID disease, it is not possible to provide this type of training in person, and thus online courses by the psychologists and psychiatric nurses would be useful.

According to the nurses, the lack of family-centered care for patients with COVID-19 is a moral challenge. It can be argued that they considered these ethical challenges not only for the patients themselves but also for their families. It should be noted that when patients with COVID-19 are discharged from the hospital, they face certain health-related challenges. To this end, a model has been developed for older adults to help them return to the community. Families are also considered in this model. The components of this model include improving the patient's cooperation with the treatment team, managing the relapse symptoms, training family caregivers, cooperating with social services, and improving the continuity of care (31).

The nurses in the present study acknowledged that the family has no chance of saying farewell to patients with COVID-19 if they die. This highlights the need to provide family-centered care in these cases. In this regard, and to alleviate the suffering of the families at the time of death and to offer the opportunity of a good farewell to the patients, healthcare professionals provide daily video conferencing in Spain between the patients and their families. This close communication allows families to see their patients and improves the connection between professionals, patients, and their families (32). On the other hand, lack of family-centered care also causes ambiguity for nurses about family mourning after the patient's death. The nurses believed that since families do not follow the normal mourning and burial rites, they may lament abnormally. However, it is not clear how the health system should act in managing family mourning. According to previous studies, when COVID-19 patients die, the burial and mourning ceremonies are important to their families. Since mourning ceremonies are held for these patients without customary social etiquette, their survivors may develop prolonged grief disorder (33). Therefore, to resolve the ethical challenge of the lack of family-centered care for patients with COVID-19, the health system must take effective measures. For example, these measures could include supporting families with an educational approach to raise their awareness of symptom management by physicians and nurses. Furthermore, teamwork with the participation of psychologists is needed to support families. Since it is not currently possible to say goodbye to the patients in the COVID-19 intensive care units, this teamwork becomes more important to prevent morbid mourning for families.

The participant recruitment approach and the nature of the qualitative study limited the ability to generalize the presented findings.

Conclusion

To address the ethical challenges of nurses in caring for COVID-19 patients, the professional values ​​of nursing should be considered by healthcare managers. This can be accomplished by employing highly experienced nurses to care for patients with COVID-19 as these nurses can provide safe and error-free care. The ethical challenges that threaten the nurses' professional dignity and social respect were generally cultural in origin. To address these challenges, nursing professionals and professors must provide cultural education fitting the cultural context of the community to the public through the media, such as television, so as not to tarnish the nursing profession. Besides, this study found that the lack of a holistic COVID-19 care protocol is another challenge for nurses. In this regard, an ethics-based model for COVID-19 care should be developed, according to which, in addition to routine care, concepts such as spiritual, compassionate, and family-centered care is considered and provided by nurses. It is also essential that comprehensive training courses on compassionate care are organized and held for nurses providing care for COVID-19 patients. It must be acknowledged that one of the requirements in caring for these patients is family-centered care, which needs to be taken into account by healthcare policymakers.