Ethical issues experienced by nurses during COVID-19 pandemic: Systematic review

Abstract

Background Frontline nurses who care for patients with COVID-19 work in stressful environments, and many inevitably struggle with unanticipated ethical issues. Little is known about the unique, ethically sensitive issues that nurses faced when caring for patients with COVID-19. Aim To better understand how frontline nurses who care for patients with COVID-19 experience ethical issues towards others and themselves. Methods Systematic review of qualitative evidence carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses on ethical literature (PRISMA-Ethics). The electronic databases PubMed, Embase, Cinahl, Web of Science, Philosopher's Index, and Scopus were queried to identify candidate articles. Articles appearing from March 1, 2020 to December 31, 2022 were considered if they met the following inclusion criteria: (1) Published qualitative and mixed method studies and (2) ethical issues experienced by nurses caring for patients with COVID-19. We appraised the quality of included studies, and data analysis was guided by QUAGOL principles. Findings Twenty-six studies meeting our inclusion criteria for how nurses experience ethical issues were characterised by two key themes: (1) the moral character of nurses as a willingness to respond to the vulnerability of human beings and (2) ethical issues nurses acted as barriers sometimes, impeding them from responding to requests of vulnerable human beings for dignified care. Conclusion Our review provides a deeper understanding of nurses’ experiences of ethically sensitive issues, while also highlighting the critical need for adjustments to be made at organisational and societal levels. Ethical issues that emerged in situations where organisational and situational constraints impeded nurses' ethical responses to patients’ appeals suggests that early practical support should be made available to resolve ethical issues recognised by nurses. Such support contributes to protecting and promoting not only the dignity of patients with COVID-19 but also of fellow humans in need during crisis.

Care of patients undergoing withdrawal of life-sustaining treatments: an ICU nurse perspective

“…Some left their positions or quit their jobs because they realised their limited power and were unable to change their organisations’ systems or stances. Oh and Gastmans’s systematic review on ethical issues among ICU nurses caring for patients with COVID-19 reported that the most distressing issue in end-of-life care involved threatening patients’ dignity [ 14 ]. This consistency can be attributed to the moral distress experienced by nurses.…”

“…Moral uncertainty occurs when ICU nurses are obliged to work despite unclear guidelines or regulations regarding the treatment of their patients [ 30 , 31 ]. Indeed, during the COVID-19 pandemic, numerous nurses experienced moral uncertainty as they queried what principles should be applied to resolve ethical issues [ 14 ]. This was because of inconsistent healthcare policies or the absence of guidelines for dealing with ethical issues such as protecting human rights [ 14 ].…”

“…Indeed, during the COVID-19 pandemic, numerous nurses experienced moral uncertainty as they queried what principles should be applied to resolve ethical issues [ 14 ]. This was because of inconsistent healthcare policies or the absence of guidelines for dealing with ethical issues such as protecting human rights [ 14 ]. The establishment of clear guidelines or rules can alleviate confusion among nurses due to moral uncertainty, thereby promoting their professional commitment to nursing care [ 46 ] and quality of care [ 47 ].…”

“…For this reason, ICU nurses report that they rarely provide dignified care for dying patients, leading them to confront ethical difficulties, like ethical uncertainty, ethical conflicts, or moral distress, causing them to burnout [ 5 ] or even to consider leaving their jobs [ 12 , 13 ]. Moreover, they report that they experience role confusion and emotional distress [ 14 ]. Nurses’ confusion over their roles in end-of-life care is amplified by the ambiguity of the one legal means to which they can refer, the Life-sustaining Medical Determination Act, which does not clearly delineate their role in end-of-life care [ 2 ].…”