Ethical dilemmas experienced by nurses while caring for patients during the COVID-19 pandemic: An integrative review of qualitative studies.

AIM: This study aimed to identify ethical dilemmas faced by nurses while caring for patients during the COVID-19 pandemic.
BACKGROUND: Nurses express several concerns during disease outbreaks, some of which are related to ethical dilemmas. EVALUATION: It is an integrative review in which four databases were searched. Critical appraisal tools and PRISMA guidelines were used. Content analysis was performed to analyse the obtained data. KEY ISSUES: A total of 14 studies were identified. The results are presented into four categories: concerns with beneficence-nonmaleficence; awareness of need for autonomy; challenges to justice; and coping with ethical dilemmas.
CONCLUSION: While caring for patients during the COVID-19 pandemic, nurses often put their own health and that of their families at risk. The ethical dilemmas faced by nurses are mainly caused by the lack of Protective Personal Equipment (PPE), shortages of medical supplies and personnel and the uncertainties that permeate an environment threatened by a new and highly contagious disease such as COVID-19. IMPLICATIONS FOR NURSING MANAGEMENT: This review provides information that can inspire nurse managers working during the COVID-19 pandemic to support and empower nurses to act in accordance with ethical principles, which is important in order for nurses to protect themselves while providing efficient and effective care.

INTRODUCTION

The advent of the COVID‐19 pandemic has had a significant impact on humanity; although several fields have been affected by the pandemic, the most impacted was undoubtedly the health care sector (al Thobaity & Alshammari, 2020). Since its emergence in late December 2019, the disease has infected and caused the death of millions of people (World Health Organization [WHO], 2022), and still today, more than 2 years later, it continues to challenge scientists and health professionals with the emergence of mutations and variants (Ramesh et al., 2021).

Lack of knowledge about the disease, its contagion and treatment; fear of getting infected; fear for loved ones; discriminatory acts; and shortage of human and medical resources are some of the challenges faced by health professionals since the beginning of the pandemic (al Thobaity & Alshammari, 2020; Moussa et al., 2021; Mulaudzi et al., 2021; Sperling, 2020). Especially nurses, who are health professionals present at all times on the front line of the battle against the COVID‐19, faced and still face several difficulties due to the pandemic. Rationing of limited resources, restrictions on the freedom and autonomy of patients and their families and the distinction between groups, in choosing who should receive care when patients are many and nurses are few, are among the many ethical problems faced by nurses (Sperling, 2020). Nurses face yet another huge ethical dilemma, as they have an obligation to care for patients and for themselves and their families (Binkley & Kemp, 2020; Linton & Koonmen, 2020). When providing care to patients with COVID‐19; nurses have to deal with all these ethical dilemmas, which, in addition to putting pressure on them, interfere with the quality of care (al Thobaity & Alshammari, 2020; Sperling, 2020). Thus, it is important to examine the ethical dilemmas faced by nurses during the COVID‐19 pandemic.

BACKGROUND

Nurses in their daily practices have to protect their patients and their families without neglecting self‐care; these ethical problems are obviously exacerbated in periods of crisis (Linton & Koonmen, 2020). As in previous outbreaks, nurses are currently facing excessive workload, shortages of medical supplies and human resources, lack of knowledge and skills and fear of getting infected and infecting loved ones (Kollie et al., 2017; Sperling, 2020), which can trigger ethical dilemmas due to the risk of harming themselves and others. During the decision‐making process, nurses are guided by ethical principles such as respect for autonomy, beneficence, nonmaleficence and justice (Mulaudzi et al., 2021).

Whereas the ethical principle of beneficence is related to doing good, the principle of nonmaleficence is about not causing harm to the patient (Varkey, 2021). During the pandemic, both principles were threatened since nursing shortages, lack of knowledge about the disease, treatment limitations, lack of resources, such as Protective Personal Equipment (PPE), and other medical materials prevented some patients from receiving assistance promptly, in addition to threatening the health of caregivers (Mulaudzi et al., 2021).

The ethical principle regarding autonomy refers to the rights of individuals to dignity, to be informed about their health and to be able to make choices without suffering external pressure (Mulaudzi et al., 2021); patients are also entitled to confidentiality regarding their health status and treatment (Shekhawat et al., 2020). Holistic and humanized care is centred on the individuals, including attention to their values, preferences and needs; patients must be free to choose their treatment, therefore having the right to be informed about their illness and the entire assistance process, including nursing care (Fontes et al., 2020). Nurses are trained to provide this type of care to patients. However, in periods of crisis, lack of knowledge and uncertainties arise and profound changes in the world health scenario give rise to situations that threaten the patient's autonomy over his/her own life, and nurses are also affected by these changes, facing major ethical problems (Fontes et al., 2020). Still, on the ethical principle of autonomy, it is necessary to emphasize that nurses also have the right to make autonomous decisions about their obligations to serve others when their lives are threatened by PPE shortages (Mulaudzi et al., 2021).

Justice implies equity, fairness and proportionality; thus, the concept of justice in the field of health also refers to the elimination of unequal access to health services, guaranteeing access to quality health for all (Jaziri & Alnahdi, 2020). If before the pandemic for some countries guaranteeing quality health care for all was a huge challenge, with the emergence of the COVID‐19, the situation has worsened worldwide (Jaziri & Alnahdi, 2020; Mulaudzi et al., 2021). It is still necessary to consider the situation of health professionals, especially nurses, who, due to an unequal distribution of PPE, faced great risk when providing care to patients with COVID‐19 (Mulaudzi et al., 2021).

Health institutions must be well organised to provide care during times of crisis. Pandemics lead to the rapid spread of disease affecting the ability of these institutions to provide assistance to the population. Health care institution administrators and also nurse managers must envision this possibility and must be prepared for such events before they occur (Gul & Yucesan, 2021). It is also important to ensure organisational fairness so that everyone who is part of the health team feels valued and indispensable (Yildirim et al., 2021). Efficient and effective management of human resources, equipment, materials and information is essential for the control of pandemics (Gul & Yucesan, 2021). In addition, nurse managers play an important role in supporting their team so that frontline nurses can develop emotional and professional competence to respond to emergencies (Tan et al., 2020).

Health professionals must develop their functions based on scientific knowledge, technical and communication skills associated with ethical and professional values (Varkey, 2021). However, during the COVID‐19 pandemic, ethical principles are being threatened in several dimensions, putting at risk not only the quality of care but also the physical and mental health of nurses and other health care workers (Linton & Koonmen, 2020; Mulaudzi et al., 2021). Thus, organisational support is pivotal for nurses to cope with ethical dilemmas (American Nurses Association [ANA], 2020). Importantly, the focus of this review is to examine the ethical dilemmas experienced by nurses while caring for patients with COVID‐19.

AIM

This study aimed to identify ethical dilemmas faced by nurses while caring for patients during the COVID‐19 pandemic.

METHODS

Design

This integrative review of qualitative studies was conducted using the Whittemore and Knafl (2005) framework. As qualitative research allows exploring people's lived experiences (Creswell, 2013), the selection of studies in which this method was used was considered better suited to identify ethical dilemmas experienced by nurses during the COVID‐19 pandemic.

Search strategy

The search for original primary qualitative research articles on ethical dilemmas experienced by nurses while caring for patients during the COVID‐19 pandemic was carried out in December 2021. The descriptors used for the database searches were ‘Covid’ AND ‘ethical dilemmas’ AND ‘nurses’. The electronic databases searched were PubMed, Google Scholar, MEDLINE and Scopus.

Inclusion and exclusion criteria

Original primary qualitative research articles reporting ethical dilemmas of nurses caring for patients with COVID‐19, whose full texts were available on the Internet in English, were included. Articles that included other participants besides staff nurses (other health care workers, nurse managers, nursing assistants), those that despite addressing experiences did not assess ethical dilemmas perceived by nurses while caring for patients during the COVID‐19 and non‐qualitative studies were excluded.

Search outcome

The Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) was used to guide the selection of articles (Figure 1). Through the electronic databases, 918 articles were found, with the inclusion of four more articles found through other sources, a total of 922 articles were identified, then 19 duplicate articles were excluded, and the result decreased to 903. Titles and abstracts were read, and 889 articles were excluded for not matching the inclusion criteria of the review. The remaining 14 articles were read and re‐read, and all were included in the quality appraisal.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) flow diagram of search, screening and selection of articles for the integrative literature review

Quality appraisal

The articles were appraised using the Critical Appraisal Skills Programme (CASP) (CASP, n.d.). The CASP is a checklist with 10 main questions used to evaluate qualitative studies (CASP, n.d.). Each main question was rated as ‘Yes’ (2 points), ‘Unclear’ (1 point) or ‘No’ (0 points). The included studies scored between 17 and 20 points. Regarding the methodological quality of the studies, the most common weaknesses found were a lack of information on the relationship between researcher and participants and geographic limitations. No articles were excluded based on critical appraisal; all 14 evaluated articles were included in this review (Table 1).

TABLE 1

Critical Appraisal Skills Programme (CASP) checklist

	Questions b										Total score
Reference	1	2	3	4	5	6	7	8	9	10
Abbasinia et al. (2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y	19
Alloubani et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	20
Jia et al. (2021)	Y	Y	Y	U	Y	N	Y	Y	Y	Y	17
Karaca and Aydin Ozkan (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18
Kelley et al. (2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y	19
Kwon and Choi (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18
Liu et al. (2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y	19
McMillan et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	20
Moghaddam‐Tabrizi and Sodeify (2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y	19
Mohammadi et al. (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18
Muz and Erdogan Yuce (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18
Rezaee et al. (2020)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18
Silverman et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	20
Stenlund and Strandberg (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	18

Critical Appraisal Skills Programme (CASP) checklist is a 10‐question tool used to evaluate qualitative studies.

Questions: 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research? Y = ‘Yes’ (2 points); U = ‘Unclear’ (1 point); N = ‘No’ (0 points).

Data extraction

General information was extracted from the selected studies and organised through an evidence‐based instrument developed and pilot tested on the first two included articles by the author. The form contains the following headings: reference, title, journal, country, aim, design, participants, main results and limitations. Relevant data are included in quality appraisal (Table 1) and summary table (Table 2).

TABLE 2

Reviewed articles and summary of results

Author (year)	Title/journal/country	Aim	Design/participants	Results	Limitations
Abbasinia et al. (2021)	‘Nurses experiences of providing ethical care to the patients with COVID‐19: A phenomenological study’/Ethics, Medicine and Public Health/Iran	‘To explore the nurses experiences of providing ethical care for patients with COVID‐19’.	A qualitative study of 18 nurses. Data were collected through unstructured interviews.	Themes: Clinical dilemma, professional values and human‐organisational communication.	Single site. The relationship between researchers and participants was unclear.
Alloubani et al. (2021)	Nurses ethics in the care of patients during the Covid‐19 pandemic’/Frontiers in Medicine/Jordan	‘To explore nurses ethics in the care of patients during the coronavirus disease 2019 (COVID‐19) pandemic’.	A qualitative study of 10 nurses. Data were collected through semi‐structured interviews.	Themes: The obligation to provide care, ethical dilemma and responsibility to care for themselves.	‐
Jia et al. (2021)	‘Nurses ethical challenges caring for people with COVID‐19: A qualitative study’/Nursing Ethics/China	‘To examine the ethical challenges encountered by nurses caring for patients with the novel coronavirus pneumonia (COVID‐19) and to provide nurses with suggestions and support regarding promotion of their mental health’.	A qualitative study of 18 nurses. Data were collected through structured interviews.	Themes: Ethical challenges, coping styles and impacts on the career.	Lack of information about the participants and the relationship between researcher and participants. Geographical limitations.
Karaca and Aydin Ozkan (2021)	‘Intensive care nurses ethical challenges caring for people with Covid‐19: A qualitative study’/Acibadem Universitesi Saglik Bilimleri Dergisi (Acibadem University Journal of Health Sciences)/Turkey	‘To analyze the ethical challenges experienced by nurses, who provide care for COVID‐19 patients in intensive care units’.	A qualitative study of 15 nurses. Data were collected through semi‐structured interviews.	Themes: The concept of ethical dilemma, conditions in which an ethical dilemma is experienced, ethical challenges, guiding ethical principles and ways to cope.	Lack of information about the relationship between researcher and participants.
Kelley et al. (2021)	‘United States nurses experiences during the COVID‐19 pandemic: A grounded theory’/Journal of Clinical Nursing/the United States of America (USA)	‘To explore nurses experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID‐19 pandemic’.	A qualitative study of 43 nurses. Data were collected via focus group discussions.	Themes: Challenges, feelings, coping and ethics.	The relationship between researchers and participants was unclear.
Kwon and Choi (2021)	‘Experiences of hospice and palliative nurses in response to the COVID‐19 pandemic: a qualitative study’/Journal of Hospice and Palliative Care/Korea	‘To explore the experiences of hospice and palliative care (HPC) nurses at inpatient hospice centers in South Korea during the coronavirus disease 2019 pandemic’.	A qualitative study of 15 nurses. Data were collected via interviews.	Themes: Dilemmas, strengthening the basic meaning and value of hospice and palliative care and role of nurses.	Lack of information about the relationship between researcher and participants.
Liu et al. (2021)	‘Ethical dilemmas faced by frontline support nurses fighting COVID‐19’/ Nursing Ethics/China	‘To explore the ethical dilemmas of frontline nurses of Jiangsu Province in China during deployment to Wuhan to fight the novel coronavirus pneumonia, and to provide a basis for developing strategies to help nursing staff address personal and practice concerns in order to work more effectively during this pandemic and other disasters in the future’.	A qualitative study of 10 male nursing students. Data were collected via semi‐structured interviews.	Themes: Ethical dilemmas in clinical nursing, interpersonal relationships and nursing management.	The relationship between researchers and participants was unclear.
McMillan et al. (2021)	‘Visitor restrictions, palliative care, and epistemic agency: a qualitative study of nurses relational practice during the coronavirus pandemic’/Global Qualitative Nursing Research/ Canada	‘To answer the question: What ethical issues do palliative care nurses experience as a result of COVID‐19 related circumstances, and how do they navigate these issues?’	A qualitative study of 17 nurses. Data were collected through interviews.	Themes: Ethical impressions of visitor restriction policies, visit restrictions and palliative care philosophy, nurses ethical reasoning and advocacy and rule breaking.	‐
Moghaddam‐Tabrizi and Sodeify (2021)	‘Lived experiences of nurses in the care of patients with COVID‐19: A study of hermeneutic phenomenology’/Iranian Journal of Nursing and Midwifery Research/Iran	‘To reveal the lived experiences of nurses in the care of patients with COVID‐19’.	A qualitative study of 14 nurses. Data were collected through semi‐structured interviews.	Themes: Ethical dilemma, emotional turmoil, professional commitments and seeking help.	The relationship between researchers and participants was unclear. Geographical limitations.
Mohammadi et al. (2021)	‘Workplace challenges and nurses recovered from Covid‐19’/Nursing Ethics/Iran	‘To determine the workplace challenges faced by nurses who had recovered from COVID‐19’.	A qualitative study of 17 nurses. Data were collected via semi‐structured interviews.	Themes: Ethical values, infected nurses, forgotten patients, quitting the job and corona phobia.	Lack of information about the relationship between researcher and participants. Geographical limitations.
Muz and Erdogan Yuce (2021)	‘Experiences of nurses caring for patients with COVID‐19 in Turkey: A phenomenological enquiry’/Journal of Nursing Management/ Turkey	‘To reveal the experiences of nurses who care for COVID‐19 patients during this process’.	A qualitative study of 19 nurses. Data were collected via semi‐structured interviews.	Themes: Unpreparedness, social isolation and loneliness, dilemma and conflict, power born from difficulties and organisational expectations.	Lack of information about the relationship between researcher and participants.
Rezaee et al. (2020)	‘Nurses perception of ethical challenges in caring for patients with COVID‐19: a qualitative analysis’/Medical Ethics and History of Medicine/ Iran	‘To explain the nurses perception of ethical challenges in this regard (ethical challenges in caring for Covid‐19 patients)’.	A qualitative study of 24 nurses. Data were collected via semi‐structured interviews.	Themes: Threats to professional values and the absence of holistic care.	Lack of information about the relationship between researcher and participants. Geographical limitations.
Silverman et al. (2021)	‘Moral distress in nurses caring for patients with Covid‐19’/Nursing Ethics/the United States of America (USA)	‘To explore causes of moral distress in nurses caring for Covid‐19 patients and identify strategies to enhance their moral resiliency’.	A qualitative study of 31 nurses. Data were collected via focus group discussions and semi‐structured interviews.	Themes: Lack of knowledge and uncertainty, being overwhelmed, fear, adopted team model of nursing, policies to reduce viral transmission, crisis standards of care and medical resource scarcity.	‐
Stenlund and Strandberg (2021)	‘Intensive care nurses experiences of Covid‐19 care: A practical and ethical challenge – a qualitative descriptive design’/Nordic Journal of Nursing Research/Sweden	‘To describe intensive care nurses experiences of Covid‐19 care and its ethical challenges’.	A qualitative study of 11 nurses. Data were collected via semi‐structured interviews.	Themes: To meet Covid‐19 patients' needs, approach to the excluded relatives and to strive to protect ethical values needs.	Lack of information about the relationship between researcher and participants. Geographical limitations.

Data synthesis

Data analysis involved a long process in which comparisons of information were conducted resulting in codes organised into categories (Whittemore & Knafl, 2005). Data were thoroughly and repeatedly analysed by the author. Grammatical methods were used for coding similar information contained in the studies included in this review (Saldana, 2013). The codes originated by comparing the data of the reviewed studies were organised into four categories: concerns with beneficence–nonmaleficence; awareness of need for autonomy; challenges to justice; and coping with ethical dilemmas (Table 3).

TABLE 3

Categories and codes

Beneficence–nonmaleficence	Autonomy	Justice	Coping with ethical dilemmas
Lack of knowledge and skills Lack of information sharing Lack of PPE Lack of human resources Lack of time Limited medical supplies Lack of holistic care Long shifts Visitor restrictions Role confusion Fear of getting infected Lack of professionalism	Neglect of patients' rights to be informed Mandatory visitor restrictions Not being able to freely choose treatment Lack of privacy	Inequities in care Unequal visitor policies Inequalities between nursing and other professions Unequal PPE distribution	Discussion groups Planning and control Support (colleagues, administrators, nurse managers and community) Talking to loved ones Professional values and sense of obligation Catharsis Journaling Exercising Scientific research Learning new skills Improvement of interpersonal relationships

Abbreviation: Protective Personal Equipment.

RESULTS

The 14 selected articles are from 10 different journals. Thirteen (92.8%) of the studies were carried out in 2021. The number of participants varied from 10 to 43 nurses. Studies were conducted in Iran (n = 4), China (n = 2), Turkey (n = 2), the United States (n = 2), Canada (n = 1), Jordan (n = 1), Korea (n = 1) and Sweden (n = 1). In nine studies, the majority of participants were female; in two studies, all participants were female (Kwon & Choi, 2021; McMillan et al., 2021); in two studies, gender was not mentioned (Kelley et al., 2021; Silverman et al., 2021); and in one study, the majority of participants (60%) were male (Alloubani et al., 2021).

A total of seven articles had the main objective related to topics on nurses' ethics during the COVID‐19 pandemic (Abbasinia et al., 2021; Alloubani et al., 2021; Jia et al., 2021; Karaca & Aydin Ozkan, 2021; Liu et al., 2021; McMillan et al., 2021; Rezaee et al., 2020; Stenlund & Strandberg, 2021), four articles (Kelley et al., 2021; Kwon & Choi, 2021; Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021) had nurses' experiences in care of patients with COVID‐19 as main objective, one article (Silverman et al., 2021) was about moral distress in nurses caring for patients with COVID‐19, and the remaining article (Mohammadi et al., 2021) was conducted with nurses who were infected with COVID‐19. The participants' perceptions of ethical dilemmas are presented in the results of all 14 articles. The results of this review are presented into four categories: beneficence–nonmaleficence; autonomy; justice; and coping with ethical dilemmas.

Concerns with beneficence—Nonmaleficence

According to the analysed literature, nurses questioned themselves at various moments due to different circumstances, having doubts if they were doing what was good and right for patients during the COVID‐19 pandemic. Nurses reported that at times, they no longer knew what was ethical and what was not, that many decisions were made without nurses being consulted, and they were the last ones to know for example about the placement of patients (Kelley et al., 2021). Nurses faced dilemmas as they had to protect themselves, fight for their rights and, at the same time, be beneficial to patients and the community (Alloubani et al., 2021; Kelley et al., 2021; Liu et al., 2021; Muz & Erdogan Yuce, 2021; Silverman et al., 2021). Nurses faced clinical dilemmas due to fighting an unknown virus and, consequently, lack of information about the illness and its treatment (Abbasinia et al., 2021; Kelley et al., 2021; Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021; Rezaee et al., 2020; Silverman et al., 2021). Ethical dilemmas in nursing management were identified as important information was not shared with frontline nurses in time (Kelley et al., 2021; Muz & Erdogan Yuce, 2021), equipment was not equally distributed and nurses had to work with limited PPE (Kelley et al., 2021; Liu et al., 2021; Moghaddam‐Tabrizi & Sodeify, 2021). Some nurses reported a lack of time (Muz & Erdogan Yuce, 2021; Silverman et al., 2021; Stenlund & Strandberg, 2021), human resources (Liu et al., 2021; Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021) and medical supplies (Jia et al., 2021; Liu et al., 2021; Silverman et al., 2021; Stenlund & Strandberg, 2021) to provide the necessary care.

Not being able to provide holistic patient care was another fact pointed out by nurses as a trigger for ethical dilemmas. Difficulties in providing psychological (Jia et al., 2021; Muz & Erdogan Yuce, 2021), physical (Jia et al., 2021; Karaca & Aydin Ozkan, 2021; Liu et al., 2021; Muz & Erdogan Yuce, 2021) and social care (Jia et al., 2021;Kwon & Choi, 2021; McMillan et al., 2021) and lack of spiritual care (Rezaee et al., 2020), comfort care (Kelley et al., 2021; Silverman et al., 2021), end of life care (Kelley et al., 2021; McMillan et al., 2021) and family‐centred care (Rezaee et al., 2020) were identified by nurses during the COVID‐19 pandemic. These dilemmas emerged because nurses had a lack of knowledge and skills to work in COVID‐19 wards (Jia et al., 2021; Karaca & Aydin Ozkan, 2021; Kelley et al., 2021; Liu et al., 2021); thus, they feared that they were not doing their job correctly (Jia et al., 2021; Kelley et al., 2021; Muz & Erdogan Yuce, 2021; Silverman et al., 2021) and that they were harming the patient due to inexperience or lack of necessary training (Karaca & Aydin Ozkan, 2021). In addition, due to nursing shortages and long shifts, nurses were not able to stay at patients' bedsides at the time of need (Rezaee et al., 2020; Stenlund & Strandberg, 2021).

Nurses also experienced moral distress because they felt unable to provide the necessary support to patients who suffered from the loss of loved ones or because they felt lonely in isolated rooms (Jia et al., 2021; Kelley et al., 2021; Kwon & Choi, 2021; Stenlund & Strandberg, 2021). Nurses faced dilemmas due to the prohibition of visits to patients during the COVID‐19 pandemic, as they had doubts whether this measure was more beneficial or harmful to patients and their families (Kwon & Choi, 2021; Stenlund & Strandberg, 2021). Nurses pointed out that family visits are not only important to provide emotional support but also to give information about patients (Stenlund & Strandberg, 2021). Especially in palliative care services, visitor restrictions were pointed out as a huge ethical dilemma for nurses, because contact with family is considered a palliative intervention (Kwon & Choi, 2021; McMillan et al., 2021). Nurses also emphasized the lack of support for families after the patient's discharge or death (Rezaee et al., 2020). Patients were in dire need of spiritual care, which unfortunately could not be provided at that time, so nurses witnessed the loss of spiritual vitality of patients (Rezaee et al., 2020).

Due to the chaotic situation characteristic of a pandemic period, confusion, denial of reality and indecision were perceived by nurses who cared for patients with COVID‐19 (Abbasinia et al., 2021; Kelley et al., 2021; Silverman et al., 2021), facts that can affect the nursing care. Nurses experienced role confusion as some of them had to perform practices that doctors should do (Karaca & Aydin Ozkan, 2021; Kelley et al., 2021) or provide the support that should be given by a psychologist (Liu et al., 2021). The low sense of responsibility in the nursing units and the insufficient assistance to the emergency can result in problems related to professional ethics (Jia et al., 2021). Nurses reported that some doctors were monitoring patients by video or telephone, avoiding entering the wards (Jia et al., 2021; Silverman et al., 2021). In addition, the fear of becoming infected can make health professionals act slower than usual while providing care to patients or entering COVID‐19 wards (Jia et al., 2021).

Even if nurses were afraid of caring for patients with COVID‐19, they were aware that it was their duty as nurses to care for patients regardless of their illnesses (Alloubani et al., 2021; Kelley et al., 2021; Liu et al., 2021; Muz & Erdogan Yuce, 2021; Silverman et al., 2021); they were concerned with providing safe care to patients updating themselves (Karaca & Aydin Ozkan, 2021), and they were reminding each other all the time about the need to protect themselves and patients (Liu et al., 2021). However, nurses believe that they should not be forced to care for COVID‐19 patients because some nurses could be pregnant or have elderly family members (Alloubani et al., 2021), and an unhealthy and stressful nurse is not able to take care of others well (Mohammadi et al., 2021; Muz & Erdogan Yuce, 2021). Nurses can feel powerless when trying to do the right thing in a time of uncertainty (Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021; Stenlund & Strandberg, 2021).

Awareness of need for autonomy

The studies identified that in some situations, the patient's autonomy and self‐determination were not maintained, which led to the emergence of ethical dilemmas in nurses. Patients' rights were neglected, and some patients could not even choose their treatment or care plans because they could not communicate (Jia et al., 2021; Karaca & Aydin Ozkan, 2021) and were forced to give consent as they had no other options (Karaca & Aydin Ozkan, 2021).

Some studies pointed out that patients' opinions, perspectives, values and beliefs were not taken into account as visits restrictions were mandatory (Kwon & Choi, 2021; Liu et al., 2021; McMillan et al., 2021; Silverman et al., 2021; Stenlund & Strandberg, 2021). Nurses emphasized that because visits were not allowed, patients could not choose to be close to a loved one at the time of death, and many families were unable to see the patient for the last time (Kelley et al., 2021; Kwon & Choi, 2021; Silverman et al., 2021; Stenlund & Strandberg, 2021). Nurses reported dilemmas regarding visitor restrictions, stating that it was too hard to see patients far from their families (McMillan et al., 2021; Stenlund & Strandberg, 2021). Some nurses described the visitor restrictions as cruelty, a robbing time (McMillan et al., 2021) and a threat to the freedom of patients, staff and visitors (Liu et al., 2021).

Some issues addressed in the studies imply both patients' autonomy, concerning the right to receive information about his/hers health status and treatment, and nurses' duty to act with professionalism. Nurses reported that information such as oxygen saturation was omitted to protect the patient's mental health (Liu et al., 2021). Relatives did not have full access to information about patients as communication was done by telephone, which limited the interaction between nurses and family members (Stenlund & Strandberg, 2021). Decisions on not to resuscitate elderly patients were made without the patient or family being able to choose (Silverman et al., 2021), and some patients and family members were deciding about maintaining treatments that, according to nurses, were useless (Silverman et al., 2021). Nurses faced ethical dilemmas due to violation of patient privacy and dignity; as there were too many patients to care for in the same unit, patient privacy was neglected (Karaca & Aydin Ozkan, 2021; Stenlund & Strandberg, 2021). Nurses also pointed out as an ethical dilemma, the importance of keeping individual patient confidentiality and providing the necessary information to the authorities (Karaca & Aydin Ozkan, 2021).

Challenges to justice

Nurses need to be impartial and fair when giving care. The scientific literature reported many challenges faced by nurses regarding justice during the COVID‐19 pandemic. Nurses faced dilemmas especially in the first days of the pandemic due to limited medical resources (Jia et al., 2021; Liu et al., 2021; Silverman et al., 2021), which makes it difficult to provide equal care. Nurses also reported the difficulty of choosing among patients who needed more care (Karaca & Aydin Ozkan, 2021). Young patients with wives and children waiting for them desired to live too strong; on the other hand, older patients would refuse the treatment, but nurses knew that all patients should receive care (Liu et al., 2021).

It is difficult to provide equal care when patients are admitted according to hospital capacity, not based on their medical needs (Silverman et al., 2021). Inequalities in caring and visitor policies were identified (Kelley et al., 2021). Nurses reported that there were so many COVID‐19 patients to care for that they were unable to provide the necessary care for all of them and had to choose between patients (Silverman et al., 2021). Unequal care was also noticed when nurses emphasized that whereas in some institutions patients did not receive any visits, in others, the rules of time and scheduling of visits varied (McMillan et al., 2021).

The principle of justice was mentioned by nurses who became infected with COVID‐19, according to them, while they were patients their rights were not respected and they did not receive equal treatment (Mohammadi et al., 2021). Nurses also emphasized the lack of professionalism that generated inequality between nursing and other professions (Kelley et al., 2021; Mohammadi et al., 2021); nurses stayed at patients' bedsides at all times, whereas doctors avoided entering the wards (Jia et al., 2021; Kelley et al., 2021). Even cleaning staff avoided entering the patients' rooms, and cleaning was often done by nurses (Kelley et al., 2021). Nurses felt as if their lives were less important than the lives of other professionals (Kelley et al., 2021), and they emphasized that nurse managers should advocate for frontline nurses (Silverman et al., 2021). On the other hand, some nurse participants pointed out that due to the pandemic period, the community looked at them with different eyes, and the nursing profession was valued (Muz & Erdogan Yuce, 2021).

Coping with ethical dilemmas

Studies identified ways to cope with ethical dilemmas. Study and discussion groups with the presence of doctors and nurses (Liu et al., 2021) and planning, control, support, catharsis, focus (Jia et al., 2021), talking to loved ones, journaling, exercising (Silverman et al., 2021), learning specialized skills in nursing, scientific research and management were the means used by nurses to solve problems related to ethical dilemmas (Jia et al., 2021). Thus, through their professional values and sense of obligation, nurses solved some of the emerged dilemmas providing the best possible care during the pandemic (Abbasinia et al., 2021; Karaca & Aydin Ozkan, 2021; Liu et al., 2021; Moghaddam‐Tabrizi & Sodeify, 2021).

Nurses pointed out that working in such a critical period has improved interpersonal relationships at the workplace and that intra‐ and inter‐professional relationships were important for solving their dilemmas (Abbasinia et al., 2021; Kelley et al., 2021); they tried to see the situation as an opportunity to serve the community and the profession (Moghaddam‐Tabrizi & Sodeify, 2021). Nurses sought support from the government, nursing association and the community (Moghaddam‐Tabrizi & Sodeify, 2021), and they also emphasized that support from administrators of health institutions (Abbasinia et al., 2021; Alloubani et al., 2021; Jia et al., 2021; Rezaee et al., 2020), and especially, nurse managers (Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021; Silverman et al., 2021) are pivotal to resolving their ethical dilemmas. Clear and strategic communication by nursing leaders was identified as an important point to alleviate the ethical dilemmas experienced by frontline nurses (Kelley et al., 2021). Also, continuing education and counseling programmes were reported as important measures not only to afford nurses knowledge but also to provide a safe environment for patients (Moghaddam‐Tabrizi & Sodeify, 2021; Muz & Erdogan Yuce, 2021). However, some nurses pointed out a lack of further organisational support (Kelley et al., 2021; Silverman et al., 2021).

DISCUSSION

This integrative review sought to identify ethical dilemmas faced by nurses while caring for patients during the COVID‐19 pandemic. Nurses reported ethical dilemmas related to lack of knowledge and skills to care for patients with COVID‐19, lack of human and medical resources and absence of holistic care; because of these facts, they had doubts about whether or not they were being beneficial for patients. During the pandemic, autonomy and privacy of patients were threatened, and due to some circumstances, equal care was not provided to patients; thus, nurses experienced ethical problems. Participants also mentioned the inequality between nurses and other health care workers, stating that the risks of infection were greater for members of the nursing team as they were at the patient's bedside all the time. To solve ethical problems, nurses resorted to their own professional values and also had the support of government, community, family members, administrators and nursing team, especially nurse managers.

The ethical principles of beneficence (do good) and nonmaleficence (do no harm) mean providing benefits to people (Varkey, 2021) and must be followed by nurses in the exercise of their functions. During periods of crisis, nurses often do not have much choice and have to adopt attitudes less than perfect that end up generating ethical dilemmas (Robert et al., 2020). Nursing is a science and an art that, to be practised efficiently and effectively, requires specialized knowledge and skills, which, in turn, are acquired through years of study and experience (Vega & Hayes, 2019). Nurses must be well‐prepared for providing care, but with the emergence of the pandemic, many of them had to work in COVID‐19 wards and use medical equipment they had never used before without receiving adequate training (Morley et al., 2020; Sperling, 2021). Similar situations were described by nurses who cared for patients with Middle East Respiratory Syndrome (MERS) (Kim, 2018) and Ebola (Raven et al., 2018). Furthermore, fear of COVID‐19 can undermine nursing care, and the fear of becoming infected is mentioned by nurses in several studies carried out during the COVID‐19 pandemic (Moussa et al., 2021; Sperling, 2021); despite being afraid of becoming ill, nurses must be aware of their obligation to care for their patients (Casey, 2015). On the other hand, self‐care is more than an ethical obligation because nurses need to be physically, mentally and socially healthy to provide quality care to patients and the community (Linton & Koonmen, 2020; Souza e Souza & Souza, 2020). Thus, nurse managers need to understand the impact of the COVID‐19 pandemic on frontline nurses and support them by providing training and promoting a safe environment for staff and patients (Tan et al., 2020; Yildirim et al., 2021). Also, ethics consultants can help nurses to develop the necessary skills to deal with ethical dilemmas (Bampi & Grande, 2020) arising from the COVID‐19 pandemic.

The rapid shift from patient‐centred care to public health‐centred care has also shifted the focus of ethics in nursing, and nurses had to adapt to this new reality immediately, which caused ethical problems (Hossain & Clatty, 2021). Nurses are trained to provide holistic patient care; however, during the COVID‐19 pandemic, mainly due to the lack of human and medical resources, this care was not always possible (Hossain & Clatty, 2021). Nurses had to make difficult ethical decisions, often contrary to their training and understanding of beneficence (Hossain & Clatty, 2021; Mulaudzi et al., 2021). Nurses caring for patients with COVID‐19 emphasized the need for special training to provide care during the pandemic (Rathnayake et al., 2021). In addition, the fact that patients are isolated and distant from their families can generate dehumanizing scenarios; it can negatively affect care and generate ethical dilemmas for nurses. It is important to find imaginative solutions that protect the community and at the same time do not harm the psychosocial health of the patient and their loved ones (Morley et al., 2020). Rights, such as autonomy, trust, minimizing harm and proportionality must be considered when adopting strategies concerning hospital and nursing home visitors during the COVID‐19 pandemic (Hartigan et al., 2021).

Autonomy is a person's right to make choices based on his/her own values and beliefs (Varkey, 2021) so patients have the right to be fully informed about their illness and its treatment and may, therefore, accept or not medical procedures and nursing care; thus, before any health care worker can provide assistance, the patient's consent is required (Varkey, 2021). The individual has a right to privacy, which is the right to self‐determination in which the person has moral authority over his/hers personal characteristics (Demirsoy & Kirimlioglu, 2016). In crises such as the COVID‐19 pandemic, patient privacy can be threatened (Shekhawat et al., 2020). Due to the COVID‐19 pandemic, measures were taken to protect the community, and the individual interests were pushed; thus, nurses faced ethical problems because of such changes (Fontes et al., 2020). It is important to highlight that the healthy nurse–patient relationship is pivotal for the success of caring, and patients must trust in nurses; ethical problems experienced during the COVID‐19 pandemic should not harm the long history of trust between nurses and patients (Morley et al., 2020). Therefore, nurses must be guided by leaders who are transparent in their communication, thus being role models to support the nursing team with adequate knowledge and judgement for ethical decision‐making (Markey et al., 2021).

According to the ethical principle of justice, nursing care must be fair, equitable and adequate (Varkey, 2021). Concerning patients with COVID‐19, it is difficult to make a decision to optimize the use of medical devices, excluding low‐risk individuals, treating patients similarly and choosing those worse off (Jaziri & Alnahdi, 2020). The distribution of resources requires health professionals to make fair and transparent decisions. During the pandemic period, the distribution of scarce resources often prioritized young people over elderly ones because young patients have the highest life expectancy (Jaziri & Alnahdi, 2020). In addition, nurses are facing challenges due to a shortage of staff, beds and medical supplies during the COVID‐19 pandemic (al Thobaity & Alshammari, 2020); therefore, providing fair care is not an easy task.

Not only patients but also health professionals must be treated equitably. Nurses are on the front line in the fight against COVID‐19; they have numerous roles in the treatment of patients with COVID‐19; and compared to other health professionals, they remain in direct contact with patients for longer periods; therefore, they are a group with a high risk of getting infected (al Thobaity & Alshammari, 2020; Souza e Souza & Souza, 2020). In addition, due to reduced numbers of PPE, some health professionals do not enter the rooms of patients with COVID‐19, and the duties that should be done by them end up being performed by nurses (Morley et al., 2020). During the COVID‐19 pandemic, nurses are making difficult choices because, as they run the risk of becoming infected when treating patients with COVID‐19, their choices can be a decision between their own lives or the lives of patients (Mulaudzi et al., 2021); this decision becomes even more difficult if the distribution of PPE is not equal (Moradi et al., 2021; WHO, 2020). Nurses in risk groups or who do not feel safe due to lack of necessary PPE should not care for patients with COVID‐19 (ANA, 2020).

Nurses' professional values (Sperling, 2021) and moral resilience (Hossain & Clatty, 2021), hospitals, institutions, administrators (ANA, 2020) and especially nurse managers' support are pointed out as important factors in helping nurses resolve ethical dilemmas during the COVID‐19 pandemic (Markey et al., 2021). The approach of nurse managers, being role models, respecting team members and patients, thus developing a work environment supported by ethical principles, is of fundamental importance for nurses to be able to make appropriate decisions and resolve their ethical dilemmas (Markey et al., 2021; Zhou & Zhang, 2021).

Limitations

Using a search approach that specifically looked for the term ‘ethical dilemma’ may have overlooked sources discussing ethical conflicts without using this exact descriptor. In addition, only studies published in English, whose full texts were available on the Internet, were included; thus, relevant studies may have been excluded. It is important to emphasize that because the COVID‐19 pandemic remains ongoing, different nursing ethical dilemmas may be noticed in the future.

CONCLUSIONS

Nurses are facing huge ethical dilemmas during the COVID‐19 pandemic, mainly because in providing the care, they often put their own health and that of their families at risk. Ethical nursing dilemmas regarding beneficence, nonmaleficence, autonomy and justice were identified in this literature review. The reasons for these ethical problems are usually related to the lack of PPE, shortages of medical supplies and personnel and the uncertainties that permeate an environment threatened by a new and highly contagious disease such as COVID‐19.

Knowing about the various ethical dilemmas faced by nurses during the COVID‐19 pandemic provides information for support programmes to be developed in health institutions to minimize the problems faced by these professionals whose roles are fundamental for the control of the pandemic. Further research carried out using broader search criteria should be done to identify and describe additional sources of nursing ethical conflicts during the pandemic.

IMPLICATIONS FOR NURSING MANAGEMENT

This review provides information that can inspire nurse managers working during the COVID‐19 pandemic to support and empower nurses to act in accordance with ethical principles, which is important in order for nurses to protect themselves while providing efficient and effective care. It is known that nurses need, in addition to training and knowledge, to feel safe to provide quality care. The nurse manager must develop an appropriate and secure working environment in which nurses are well supported to make decisions based on ethical principles. The support of nurse managers is widely cited by nurses as being fundamental for solving problems during routine nursing practices; in cases of crisis such as the COVID‐19 pandemic, the role of the nurse manager as a model for the nursing team becomes even more important.

CONFLICT OF INTEREST

The author declares that there is no conflict of interest with respect to the research, authorship and/or publication of this article.

ETHICAL APPROVAL

No ethical approval was required for this integrative review.