Trends and ethical issues in nursing during disasters: A systematic review

Abstract

Background

During a disaster, nurses face complex ethical challenges because of risky situations. It is necessary to identify trends and ethical issues of nurses in disasters to improve the quality of care and impact for nurses.

Method

This systematic review enrolled in the international registration with PROSPERO: CRD42022350765. We searched the following databases: PubMed, EBSCO MEDLINE, SCOPUS, ProQuest, ScienceDirect, and Sage Pub. The inclusion criteria were developed according to PICO and D; are Population (F): involving nurses; intervention/Exposure (I): disaster, Comparison (C): none; outcome (O): ethical practice. And Design (D): qualitative, quantitative, and mixed methods. Years of publication were 2012–2022, with full text in English. The quality of study assessment used was The Joanna Briggs Institute (JBI) Critical Appraisal tool and Mixed Methods Appraisal Tool (MMAT) version 2018. Analysis used PICO synthesis.

Results

There were 15 studies reviewed from 2093 results, including cross-sectional (4/15, 26.6%), qualitative (9/15, 60%), and mixed methods (2/15, 13.3%) studies. The types of disasters were: COVID-19 (7/15, 46.6%), infectious (4/15, 26.6%), and all disaster events (4/15, 26.6%). The main themes were: (1) ethical issues in disasters have the potential to address ethical dilemmas, (2) factors applying nursing ethics to support ethical decision-making in disasters, (3) strategies for applying ethics and dealing with ethical issues in disasters, and (4) the impact of applying ethics in disasters.

Conclusion

Applying ethics nursing in a disaster is influenced by various factors. This framework for ethical nursing in disasters aims to help nurses, educational institutions, and policymakers develop schemes or scenarios to enhance responsible ethical decisions in disasters.

Keywords

Nurses disaster ethical issues ethical practice systematic review

Introduction

In a recent pre–COVID-19 systematic review, Yildiz in 2019 described the code of ethics for nurses as a professional guide for nurses in facing challenges and making ethical decisions.¹ However, the challenge of applying ethics during a disaster is more complex and often creates dilemmas. For example, the American Nurses Association found that nurses actively respond to disasters even though they may endanger their safety or vice versa they avoid being involved in disasters because they are worried about their safety.² Accordingly, adequate ethical knowledge is needed to increase the readiness of nurses in dealing with ethical problems in order to avoid violations of human rights, and deal with ethical dilemmas during disasters.³

A study from Alrahji in 2018 showed that nurses who have adequate knowledge can provide effective and ethical care when a disaster occurs.⁴ This is in accordance with what was mentioned by Moradi in 2020 that ethics is considered as one of the main competencies of nursing performance which requires nurses to use their critical thinking skills and rational reasoning abilities when facing the complex problems that intersect with ethics during a disaster crisis.⁵ It is necessary to develop the knowledge of nursing ethics by understanding ethical trends and issues that occur when a disaster occurs because the concept of ethics has different terms and the conditions of a disaster are always changing.⁶

In addition to describing the trends within the nursing profession to help identify developments and changes in specific contexts of recent disasters, it is also beneficial to raise awareness of the possible problems and prevent or prepare for them in the future.⁷ This systematic literature focuses on the context regarding the ethics of nurses in disasters. The aim of this study was to identify trends and ethical issues among nurses in disasters and how they are related and can be applied in nursing.

Background

Nurses providing health services cannot be separated from ethical problems because nurses directly treat patients and interact with their families.² As health professionals, nurses have a code of ethics requiring preparedness for moral and ethical issues.¹ In addition, ethical competence in nursing practice is related to quality, professionalism, and safety in providing nursing services,⁸ according to a study conducted by Aung et al.⁹ from disaster situations. These differences include ethical problems encountered in unusual and unpredictable conditions during disasters.¹⁰ A more detailed study from Civaner in 2017 explained there are differences in ethical practices related to resource allocation, speed of response, unfamiliar environment, and new colleagues.³ Also, during a disaster, what is considered ethical and unethical can change due to the absence of clear health guidelines, laws, and policies. Besides that, it is also influenced by cultural diversity, conditions of health workers, workload, and personal safety.³

Ideally, disaster response aims to save lives,¹¹ alleviate suffering, and preserve human dignity.¹² Therefore, in a disaster situation, nurses must be able to make complex ethical decisions.^13,14 Ethical issues during a disaster include difficulty determining the limits of responsibility according to competence, violating the victim’s right to privacy, and obtaining consent for action.³ Ethical solutions need to consider and ensure high-quality nursing care⁵ so that nurses can quickly identify ethical problems and make appropriate ethical decisions, ethical sensitivity needs to be applied.¹⁵ According to the findings of Alrahjhi’s study, the nurse’s perspectives on ethics during a disaster include: (1) the experience and ability of nurses regarding disasters play a role in providing efficient care according to ethics, (2) The intensity of the disaster affects nurses in maintaining an ethical practice, and (3) the reality of practice requires nurses to carry out multidisciplinary care.⁴ The study results indicated that ethical guidelines are included in the priority of disaster education.^4,16

The systematic review by Leider et al. in 2017 showed that out of 580 peer-reviewed articles, only 6% or 38 articles mentioned ethics in handling crises and disasters, with the majority discussing triage ethics and focusing more on physicians. Such systematic reviews imply that ethics in health practice should be clearly defined within a predetermined framework considered long before a disaster occurs.¹⁷ Until now, there is no clear framework for nurses related to ethics in disasters. Therefore, there is an urgent need to comprehensively identify trends and ethical issues of nurses in disasters that can be used as a framework for quality improvement and professional development.

Methods

The systematic review identified trends and ethical issues of nursing in disasters. This study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)¹⁸ with PROSPERO: CRD42022350765.

Inclusion and exclusion criteria

Article selection criteria for systematic review used PICO and D (population, intervention/exposure, comparison, outcome, and design)¹⁹ with the following details: Population (P); involving nurse participants who work in hospitals or primary healthcare. Intervention/exposure (I); natural, man-made, or pandemic disasters. There was no comparison component; Outcome (O); in the form of ethical competence, practice, or attitude of nurses; and Design (D); studies with qualitative, quantitative, and mixed methods designs. Studies included were those published from 2012 to 2022, with full text in English. All studies using case study designs, review articles, editorials, and conference presentations were excluded.

Search strategy

Searching used seven journal databases, including PubMed, EBSCO, MEDLINE, SCOPUS, ProQuest, ScienceDirect, and Sage Pub. The authors conducted a discussion about the concept and search keywords. Keywords used were: “Nurses OR Nursing,” “Ethics OR Bioethical Issues,” AND “Disasters OR Pandemic OR natural disaster OR catastrophic.” The keywords used Boolean operators (and) and combined terms from Medical Subject Headings (MeSH) and the thesaurus (Appendix Supplementary 1).

Study selection

We used the Mendeley reference manager to manage the studies. Reporting followed the PRISMA 2020 guidelines.¹⁸ The initial total was 2093, and there were 2050 studies after removing the duplication. Then, these were filtered for the relevant titles and abstracts, and 31 studies were obtained that met the inclusion criteria. However, one study was excluded because it was not full text. Furthermore, all authors read the full texts. There were 15 articles excluded for non-nurse (n = 2), non-disaster (n = 7), inappropriate study design (n = 4), non-English (n = 1), and non-ethical focus (n = 1). Finally, this systematic review included a total of 15 studies (Figure 1)

Figure 1.

Flow diagram used in selecting studies using preferred reporting items for systematic reviews and meta-analyses (PRISMA).¹⁸

Risk of bias and study quality

The authors assessed studies’ quality using The Joanna Briggs Institute (JBI) Critical Appraisal tool for qualitative and cross-sectional^20,21 and the 2018 version of the Mixed Methods Appraisal Tool (MMAT).²² Overall ratings were scored as follows: 75% = good, 50–75% = fair, and <50% = poor.²³

Extraction, analysis, and synthesis of data

The authors independently used one article as a trial. Extracted data included article characteristics (author, country, year of publication, and study design), respondent characteristics (gender, age, marital status, unit/department, length of work, and experience involved in a disaster), type of disaster, measurements, results, and findings. Microsoft Excel was used in PICO, and the synthesis process to define coding and themes and interpret evidence findings. Then, the findings were displayed in tables and frameworks.

Results

Identify study characteristics

In the initial search, we identified 2093 articles, while only 15 studies were included in the review (see Tables 1 and 2).

Table 1.

Characteristics of included studies (n = 15).

Characteristics studies		Number of studies	%
Publication year	2012–2015	2	13.33
	2016–2019	2	13.33
	2020–2022	11	73.33
Country	South Korea	2	13.33
	Palestine	1	6.67
	China	2	13.33
	Canada	1	6.67
	Sweden	3	20.00
	West Africa	1	6.67
	England	1	6.67
	Turkey	1	6.67
	Netherland	1	6.67
	Iran	2	13.33
Design study	Cross-sectional study	4	26.67
	Qualitative study	9	60.00
	Mixed method	2	13.33
Sampling technique	Convenience sampling	4	26.67
	Purposive sampling	3	20.00
	Non-randomized sampling	1	6.67
	N/A	7	46.67
Setting	Public health care	1	6.67
	Hospital	6	40.00
	Hospital and out-of-hospital	8	53.33
Disaster exposure	Pandemic COVID-19	7	46.67
	Infectious disease	4	26.67
	All events disaster	4	26.67
Number of participants	Nurses (891)	8	53.33
Number of participants	Healthcare workers (HCWs) (1078)	7	46.67
Sex	Female (n = 1400)	13	86.67
	Male (n = 481)	13	86.67
	N/A	2	13.33
Age (mean)	20–39 yr (n = 359)	13	86.67
	30–39 yr (n = 743)
	40–49 yr (n = 558)
	50–59 yr (n = 289)
	>60 (n = 6)
	N/A	2	13.33
Marital status	Single (n = 350)	3	20.00
	Married (n = 353)
	Widowed/divorced (n = 32)
	N/A	12	80.00
Department/unit	ICU	11	73.33
	Emergency department
	Others unit
	N/A	4	26.67
Education	Associate degree (n = 177)	6	40.00
	Bachelor’s degree (n = 562)
	Master’s degree (n = 37)
	Doctor’s degree (n = 13)
	N/A	9	60.00
Experience/career	<1 yr (n = 33)	13	86.67
	1–5 yr (n = 460)
	5–10 yr (n = 735)
	≥10 yr (n = 458)
	N/A	2	13.33
Ethical/disaster training	Ethical training (n = 3)	4	26.67
	Disaster training (n = 1)	4	26.67
	N/A	11	73.33

COVID-19: corona virus disease 2019; ICU: intensive care unit; NA: unavailable.

Table 2.

Summary of studies selected and quality of the study (n = 15).

Authors	Country	Focused ethical question and exposure(s)	Settings	Number of participants	Participant characteristics (n (%)							Design and sampling technique	Outcome(s) and measure(s)	Results and Key findings	Quality of study
Authors	Country	Focused ethical question and exposure(s)	Settings	Number of participants	Marital status	Sex (M/F)	Age	Department/Unit	Education (degree)	Experience/career	Ethical/disaster training	Design and sampling technique	Outcome(s) and measure(s)	Results and Key findings	Score (judgment)
Seo & Kim (2022)	South Korea	Organizational ethical climate and ethical sensitivity in COVID-19	Public Health Care	167 nurses	Y: 66 (39.5) N: 101 (60.5)	F: 163 (97.6) M: 4 (2.4)	20–29 yrs: 58 (34.7) 30–39 yrs: 65 (38.9) 40–49 yrs : 24 (14,4) 50–59 yrs : 20(12.0 )	Direct response 73 (43.7) Indirect response 94 (56.3)	College 18 (10.8) Bachelor: 140 (83.3) Master: 9 (5.4)	Clinical career: < 1 yr : 26, 1–5 yr : 73 5–10 yr : 49 10 yr : 19 PHC career :< 1 yr: 7 1–5 yr: 46 5 yr: 45	Ethics education: Y: 54 (32.3) N:154 (92.2)	Cross-sectional, Convenience sampling	1. Demographic 2. Korean Nursing Professional values (K-NPV). 3. the Ethical Climate Questionnaire (ECQ). 4. Ethical sensitivity by Joung	1. Nursing professionalism: significant correlation with organizational ethical climate (r = 0.542, p<0.001) and ethical sensitivity (r=0.356, p<0.001). 2. Organizational ethical significant correlation with ethical sensitivity (r = 0.339, p<0.001). 3. The direct response: infectious disease department affects ethical sensitivity (β = 0.171, p=0.017). 4. Nursing administrators, governments, and hospitals must encourage nurses' protective equipment, protocols, and education.	8/8 (Good)
Maraqa et al. (2021)	Palestine	Ethical dilemmas during COVID-19	In and outside the hospital	Quantitative Physician 156 Nurse 161 Others 40 Qualitative Physician 7 Nurse 6 Laboratory, technician, radiology 2	N/A	Quantitative F: 197 (55.3) M: 159 (44.7) Qualitative F: 9 (60.0) M: 6 (40.0)	Quantitative Mean 36.7 yrs. Qualitative Mean 41 yrs. (range 27–56)	N/A	N/A	Quantitative <10 yrs 154 (43.1) ≥10 yrs 203 (56.9)	N/A	Mixed-Method. Convenience sampling	1. Quantitative: Demographic and assessing stress, attitude, and disappointment level. 2. Qualitative: Perception, concerns, fears, reasons, and motivations.	1. Quantitative: >80% of HCWs (35 years): have a higher willingness to work (p=0.001). Physicians and nurses reported significantly higher willingness to work (p=0.004, Adj. OR = 3.5), lower stress levels (p=0.03), and HCWs with >10 years of experience. 2. Qualitative: Participants feel obligated to work. Stress and disappointment levels can be reduced with better leadership.	5/5 (Good)
Choi & Kim (2018)	South Korea	Ethical issues experienced an outbreak of MERS-CoV 2015	Emergency in six hospitals	169 nurses	Single 142 (84.0) Married 27 (16.0)	F: 169 (100.0)	Mean 28.1 yrs	Participants treated patients who suspected MERS-CoV 105 (62.1)	Associate 79 (46.7) Bachelor and Master 90 (53.3)	Mean clinical career: 5.3 + 5.3 (0.4–25.0) yrs	MERS-CoV education and/or experience Y: 155 N:14	Cross-sectional Study Convenience sampling	1. Demographic 2. Ethical issues. 3. Perceived infection risk: visual analog scale (VAS) 4. Social stigmatization 5. Prevention Guidelines MERS-CoV	1. Ethical problems related to patient avoidance mindset (mean 2.96 of 4) 2. Participants' ethical problems were most affected by social stigmatization (β = 0.360, p<0.001). 3. It is urgent to promote appropriate public awareness, develop and provide relevant systems and policies, and foster ethical leadership, and the organization's	7/8 (Good)
Wang et al. (2022)	China	Nursing ethics during major infectious disease outbreaks	Hospital	Experts I: advanced (49), and specialist nurses (18) Expert II: (26) nursing clinical specialists, educators, managers, and ethicists	N/A	N/A F: 23 (88.4) M: 3 (11.5)	Expert I Mean 52.3 yrs. ranged (30- 75) Expert II 41-50 yrs 3 (11.5) 51-60 yrs 17 (65.3) 61-70 yrs 6 (23.07)	Nurses, educators in nursing ethics and infection,	N/A Associate professor nurses 1, Professor of Ethics 3, Nursing Professor 22 Bachelor 4 Teacher 9 Doctoral 13	> 10 yrs	N/A	Consensus, expert panel method N/A	1. Expert panel: identify ethical and classify statements. 2. Consensus draft construction: based on relevant Ethics for Nurses 3. Expert group: a) writing consensus, b) all the experts meet online.	1. 16 rounds of an online expert. 2. Two rounds of online expert review meetings. \|Chapter 1 General Principles epidemic prevention and control Chapter 2: Responsibilities and rights of nurses Chapter 3: Maintaining a harmonious nurse-patient relationship. Chapter 4: Physician-nurse relationships. 3. It should be convenient for nurses to seek psychological help.	6/10 (Fair)
Peter et al. (2020)	Canada	The ethical responsibilities during the COVID-19	Hospital	24 Nurses	N/A	N/A	N/A	Resource Team 2 Assessment 2 COVID 1 Cardiac Care1 Emergency 4 Internal Medicine 1 Respiratory 1 Child ICU 1	N/A	2–4 yrs: 12 (50.0) 5–9 yrs: 6 (25.0) 10–14 yrs: 2 (8.33) 15–20 yrs: 4 (16.6)	N/A	Qualitative Purposive sampling	1. Using the work of Vanlaere and Gastmans. 2. Semi-structured interviews: the pandemic effects, ethical challenges and sources of stress, and what helps them and influences them.	Four themes to ethical care responsibilities: 1). The challenges of providing good care in response, 2). Tensions between the duty to prevent COVID-19 infection with other moral values 3). Support to foster the capacity of nurses. 4). Maintaining the moral identity of nurses through expressions of gratitude and health. 5) Nurses are provided with safe working conditions.	10/10 (Good)
Slettmir et al. (2022)	Sweden	Nurses' willingness to work in the ICU during COVID-19	Hospital	20 ICU nurses	N/A	F: 15 (75.0) M: 5 (25.0)	F: 27–64 yrs: 15 M: 30 - 56 yrs: 5	ICU	N/A	Treating COVID-19 patients during pandemics in 2020 and 2021	Specialist training in intensive nursing care and anesthesia	A qualitative study with an interpretive design N/A	The theoretical perspective based on Martinsen and Løgstrup's philosophy: (1) the expression of sovereign life, (2) ethical demands (3) interaction relative cultural norms.	1. Naive understanding: participated in unique and historical situations 2. Thematic analysis: - Driven by the situation, - Work effort becomes clear, - Interest and learning as a driving force, -Solidarity -Competence comes with responsibility, - Choice of a profession as a motive, - Significance in helping 3. Comprehensive understanding 4. Nurses respond to ethical demands and care for vulnerable humans while risking their health and lives	10/10 (Good)
Stenlund et al. (2021)	Sweden	Practical and ethical challenges during COVID-19	Hospital	11 ICU nurses	N/A	F: 9 (81.8) M: 2 (18.2)	34–62 yrs (median 49 yrs)	ICU	N/A	4–33 yrs (median: 13 yrs)	N/A	Qualitative descriptive Convenient sampling	Semi-structured interviews: experiences associated with COVID-19 and its practical and ethical challenges	1. ICU nurses seek to meet the needs of COVID-19 patients: protect patients, despite having little experience with interventions given the unknown course of the disease. 2. ICU nurses continually learn new treatment strategies, gain skills, and cope with new ethical dilemmas they face. 3. The attitude of ICU nurses in caring for COVID-19 patients is trying their best. 4. Highlights intensive care work and the impact of COVID-19 care on patients, families, and personnel.	7/10 (Fair)
Jiang et al. (2021)	China	Hospital ethical climate and ethical sensitivity COVID-19	Hospital	399 nurses	Single 107 (26.8) Married 260 (65.2) Divorced 26 (6.5) Widowed 6 (1.5)	F: 337 (84.5) M: 62 (15.5)	Mean 31.53 ± 6.269 yrs	N/A	Certificate (technical school) 7 (1.8) Associate 80 (20.1) Bachelor 293 (73.4) Master 19 (4.8)	5 yrs: 60 (15.0) 6-10 yrs: 179 (44.9) 11-15 yrs: 86 (21.6) 16-20 yrs: 35 (8.8) >20 yrs: 39 (9.8)	Ethics training experience: Y: 304 (76.2) N: 95 (23.8)	Cross-sectional study non-randomized sampling	1. demographics 2. Hospital Ethical Climate Survey (HECS). 3. the Moral Sensitivity Questionnaire (MSQ), 4. Caring Behaviors Inventory-24 (CBI-24)	1. Mean values for HECS (4.43±0.577), MSQ-RCV (45.00±7.085), and CBI-24 (5.34 ±0.661) are relatively high 2. The ethical climate of the hospital showed a significant relationship with the quality of self-evaluation services (r = 0.801, p < 0.01) 3. The mediating of ethical sensitivity is significant in self-evaluated models of quality of care. 4. Improving the hospital's ethical climate and ethical sensitivity can improve the quality of care.	7/8 (Good)
Nichol et al. (2021)	West Africa	The ethical response to emerging infectious disease 2013–2016 EVD Outbreak	Emergency hospital	8 Physician or nurse 7 Leadership roles in emergency medical coordination 1 Served on a legal team	N/A	F: 10 (62.5) M: 6 (37.5)	40–65 yrs	Clinical care 8 Coordinators 7 Legal team 1	N/A	N/A	N/A	Qualitative study N/A	Semi-structured interviews 1. Pre-interview questionnaire 2. Open-ended questions: limited resources, outbreak response, allocation decisions, informed consent experiences, and moral obligations.	1. Common challenges: challenging response situations (81%), frustration, and hopelessness (75%). 2. Ethical decisions: allocating clinical staff time and physical resources: 3. A framework of ethical guiding principles can accelerate access and pilot design and increase community involvement in allocating limited resources.	6/10 (Fair)
Draper & Jenkins (2017)	English	Ethical challenges in Ebola treatment	Emergency hospital	20 respondents; Physician 7 Nurses 6 Others 7	N/A	N/A	N/A	an Ebola treatment unit	N/A	N/A	N/A	Qualitative N/A	Semi-structured interview: perception from receiving a placement order to the end of pre-placement training.	1. Attitudes and motivations for implementation. 2. Perception of “mission” and concern for personal safety. 3. Reaction to the “empty bed”: the ethical challenge is whether the unit should treat more patients 4. Reference point for participant values: where they feel they cannot act on their values	8/10 (Good)
Sevimli et al. (2015)	Turkey	The Value of Ethics in Disaster Treatment (earthquake and non-earthquake)	Emergency hospital	133 respondents: Assistant Professor 4 (2.9) Specialist 19 (14.6) Physician Assistant 11 (8.0) Physician 33 (25.0) Nurse 58 (43.1) and EMT: 8 (5.8)	N/A	F: 58 (42.2) M: 79 (57.7)	Mean 29.88±6.8 yrs <29 yrs: 74 (54.0) 30 yrs: 63 (46.0)	University Hospital 23 (16.8) Ministry of Health Hospital 106 (77.4) Specialty Hospital 8 (5.8)	N/A	Professional career: 0–3 yrs: 65 (47.4) 4–7 yrs: 35 (25,5) 8 yrs: 57 (27.1) In Emergency 0–3 yrs: 90 (65.5) 4–6 yrs: 26 (19.1) 8 yrs: 21 (15.4)	N/A	Quantitative	Two emergency physicians and medical ethicists prepared the questionnaire.	1. 64.2% of HCWs apply Simple Triage and Rapid Treatment (START) 2. 74.5% of participants apply the principles of “not to harm” and “being beneficial”. 3. 67.8% stated that they had always experienced ethical dilemmas and were sensitive to ethical principles. 4. Emergency services professionals have various tendencies in making triage decisions, ethical principles, and legal regulations after natural disasters such as earthquakes, parallel to the current chaotic conditions and environment.	3/8 (Poor)
Donker et al. (2020)	Dutch	Ethical challenges, Ethical climate, COVID-19	ICU Hospital	355 ICU Nurse 41 Intensivist 108 Support Staff	N/A	F: 380 (75.3) M: 124 (24.6)	Mean Nurse 43.64 (11.4) yrs Intensive 45.78 (6.7) yrs Supporting Personnel 40.17 (10.4) yrs	ICU	N/A	< 5 yrs: 114 5–19 yrs: 230 20 yrs: 158	N/A	Quantitative and Qualitative N/A	1. Measure of Moral Distress for Healthcare Professionals (MMD-HP) 2. The ethical decision-making climate questionnaire (EDMCQ) 3. Questionnaire: 20 items related explicitly to the COVID-19 pandemic.	1. The level of moral distress of nurses is higher than that of support staff (mean=2.97(2.06)) 2. All professions rated the most positive ethical climate regarding a culture of mutual respect, ethical awareness, and support 3. The overall moral distress score of the original MMD-HP was significantly lower in ICU nurses and intensivists compared to the historical control group one year before COVID-19. 4. Leaders must provide a supportive environment, communicate clearly, and encourage group reflective debriefing to cope with moral stress.	4/5 (Good)
Gustavsson et al. (2022)	Sweden	Moral challenges among disaster healthcare responders	In and outside the hospital	7 Nurses 5 Physicians	N/A	Nurse F: 5 M: 2 Physician F: 3 M: 2	Mean 48 yrs ranged (from 35 to 64)	N/A	N/A	9 to 35 yrs	N/A	Qualitative N/A	Focus group discussions: 1. Opening questions: (moral) 2. Main question: the situation's causes, consequences, their daily life at home, and their support level. 3. Recommendations and suggestions	Five themes represent 16 categories and 81 subcategories. Five themes: 1) Types and 2) Managing difficult situations, 3) Tools and support, 4) Involvement as a protective factor, and 5) Work environment as a risk factor. Provides perceptions of disaster responders' about moral challenges concerning their well-being, which can be integrated into organizational support structures for responders before, during, and after deployment.	9/10 (Good)
Ghanbari et al. (2021)	Iran	Ethical decision-making in disaster triage	In and outside the hospital	30 participants: - Triage nurses (6) - anesthesiologists (4) - EMT (5) -Physicians and nurses from the Iranian Red Crescent (6) -Clerics (4) - medical ethicists (5)	N/A	F: 27 M: 3	Mean 40.3 (SD = 10.7 yrs)	Prehospital, Emergency departments (ED) ICU.	N/A	Mean 12.6 yrs (SD = 5 yrs) ranged (3 - 17)	N/A	Descriptive qualitative N/A	Participants triage experiences: 1. challenges prioritizing patients 2. exploratory questions: Face moral challenges when prioritizing victims 3. criteria to prioritize victims	Two main categories and nine subcategories: 1. Efficient and effective triage: Urgent need for intervention effectiveness. 2. Priority-oriented triage: Particular attention to patient vulnerabilities and prioritizing saving more years of life. Productive lives and social efficiency. Prioritizing based on service delivery possibilities. Non-preferential priority. They are evaluating the application of these principles to achieve the greatest good for the most significant number of disaster triage.	10/10 (Good)
Aliakbari et al. (2015)	Iran	Ethical and legal issues in disasters	In and outside the hospital	35 nurses	N/A	F: 5 M: 30	Mean 37.5 yrs	N/A	Bachelor 35 (100.0)	Ranged 7–28 yrs > 10 yrs experience in disaster	N/A	Descriptive qualitative study Purposive sampling	Semi-structured interviews: nurses' experience working in a disaster	1. Professional responsibility and adherence to ethics 2. Familiarity and compliance with legal requirements 3. Important issues such as legal standards of care, fairness and equity, patient consent and autonomy, expansion of the scope of disaster nursing practice, and the ethical responsibility of nurses to care are addressed first as part of an education program.	7/10 (Fair)

Note: Y: Yes, N: No, M: Male, F: Female, N/A: Not available

The majority (73.3%) were published from 2020 to 2022^24–34 The study designs were cross-sectional (4/25, 26.6%),^24,30,35,36 qualitative (9/15, 60.0%),^{26–29,31,33,34,37,38} and mixed methods (2/15, 13.3%).^25,32 Eight studies were conducted in-hospital and out-of-hospital (53.3%).^{25–27,31,33,34,37,38} Exposure to disasters included the following: COVID–19 pandemic (46.6%),^{24,25,27–30,32} infectious diseases (26.6%),^26,31,35,37 and all types of disaster events (26, 6%).^33,34,36,38 Of all studies, the number of participants was 1969 people, including the following: involved nurses only (8/15, 53.3%),^{24,26–30,35,38} involved nurses, and other healthcare workers (HCWs) (7/15, 46.6%).^{25,31–34,36,37} There were 13 studies (86.6%) that mentioned the sex/gender of the participants, with the majority being female (74.4%).^{24,25,28–35} The ages of the participants ranged between 20 and over 60 years (13/15, 86.6%). Participants’ professional experience ranged from 5 to 10 years (13/15, 86.67%). Three studies (20.0%) reported training on ethics^24,28,30 and only one study (6.6%) was on disaster training.³⁵

Assessment of risk of bias and study quality

The JBI Critical Appraisal tool used for the qualitative study resulted in five articles rated as good and four as fair. In addition, for the cross-sectional study: three considered good, and one was poor. Furthermore, two studies were rated good in the MMAT (see Table 2).

Findings from synthesis analysis

The synthesis of 15 studies identified five themes that were related to trends and issues of ethical practice in disaster situations (Appendix Supplementary 2): (1) ethical issues in disasters have the potential to address ethical dilemmas, (2) factors applying nursing ethics to support ethical decision-making in disasters, (3) strategies for applying ethics and dealing with ethical issues in disasters, and (4) the impact of applying ethics in disasters.

Ethical issues in disasters have the potential to address ethical dilemmas

This theme consists of two sub-themes; first, vulnerabilities^{25,26,29,31–33,35–38} is a sub-theme that refers to the condition of being vulnerable to the emergence of ethical issues while providing care. The studies identified in this vulnerabilities sub-theme discussed nurses’ safety and well-being risks.^25,32,35,37 Then, further study was conducted regarding various professional competences among HCWs^29,31–33 and the ethical issues of confidentiality and privacy.^26,29,36,38 The second sub-theme is the obligation to care.^{25–33,35–38} Nurses as HCWs provide burdensome and care that may be risky for themselves personally, which can lead to ethical issues during a disaster.

This literature identified the commitment^{25–32,35,37,38} of nurses and HCWs to their professional responsibilities in providing services. In addition, this sub-theme also presents issues related to limited resources,^{27,31–33,36} increased workload^27,32,37 as well as policies and communication^{25,27,29,32,33} in disaster situations.

Most studies mention^{25,26,31,34,36} that dilemmas and ethical issues use similar and related terms. For example, ethical issues can become ethical dilemmas when faced with limited choices and extreme situations. We revealed that various issues lead to the dilemma of nurses during a disaster.

Factors applying nursing ethics to support ethical decision-making in disasters

This theme consists of two sub-themes as the main factors impacting the application of ethics and ethical decision-making. The first sub-theme is external factors^{24,26,27,30–32,36–38} that consist of ethical codes^{24,26,31,36–38} as the professional principles of nurses. Then, law and ethics factors^27,36,38 must be considered when making ethical decisions during a disaster. In addition, organizational climates and their characteristics identified in several studies^30,32,37 influence nurses’ attitudes toward ethical issues and decisions. The second sub-theme is personal factors^{24,25,28–30,33,36,37} that support nurses in making ethical decisions, including ethical sensitivity, which helps identify ethical issues and practice ethical behavior during disasters.^24,29,30 In addition, there are personal characteristics factors highlighted in several studies,^{24,25,28,29,32,33,36,37} for example, nurses with experience, knowledge, and competence influence ethical practice and comprehensive ethical decision-making during disaster situations. In the findings of this systematic review of the literature, the most difficult ethical decision is regarding the principle of disaster triage because it requires nurses to allocate limited resources to save patients in a short time and sometimes decide on the fate of the patients due to the lack of time and limited available resources.^29,32,34,36

Strategies for applying ethics and dealing with ethical issues in disasters

This literature found several strategies for dealing with ethical issues and implementing ethical practices in disaster situations consisting of two sub-themes, namely, support for nurses^{25–28,30,32,33,35} and engagement of nurses.^{20–23,25–29,31–34} The sub-theme of support for nurses includes two aspects. The first is psychological support, for example, counseling sessions intended to increase or reduce the pressure in disasters.^{25,26,30,32,33} Furthermore, it includes social support and encouragement from colleagues for nurses and HCWs to remain committed to providing care in disaster.^{26–28,32,33,35} The second sub-theme reveals strategies for involving nurses in policymaking,^{24–27,32,35} then engaging them in the training and education^{24,26,29,30,32,33,35–38} related to disasters ethics, and creating clear guidelines for nurses regarding ethical practice in disaster situations.^29,31,35

The impact of applying ethics in disasters

This review also revealed the impact of ethical practices in disaster that identified two sub-themes: impact on quality of care^{25–27,29–34,36} and impact on HCWs.^{25,26,28,29,31–35,37} Several studies reported that ethical practice by nurses could improve the quality and safety of patient care^{25,27,29–32,36} and provide adequate care during disasters.^26,32,34 However, it also causes physical and psychological impacts on nurses and HCWs, such as fatigue, frustration, anxiety, stress, and burnout when dealing with ethical issues in disasters.^{25,26,28,29,31–35,37}

Discussion

In this systematic review, 11 of the 15 articles selected were published in the 2020–2022 range regarding infectious (4/15, 26.6%) outbreaks and COVID-19 (7/15, 46.6%), while 4 other articles focused on earthquake disasters (1/15, 6.66%) and unspecified disasters (3/15, 20%). These results showed a significant publication trend during the COVID-19 pandemic.^39,40 The COVID-19 pandemic has created many ethical challenges that require HCWs to find the “right way or best method” to manage it.^41,42 Several studies have revealed differences in the trend of ethical issues related to willingness to work during disasters. Most HCWs are generally less willing to work during pandemic events or infectious outbreaks because of concerns about the risk of transmission and the harmful social stigma caused in society compared to work during natural disasters.^43,44 (Figure 2)

Figure 2.

Framework for describing nurses’ ethical practice in disasters.

During a disaster, complex ethical issues will arise, which have the potential to cause ethical dilemmas. An ethical dilemma is a conflict when choosing between two equally essential choices. Understanding ethical issues and dilemmas will determine the application of ethics, which is influenced by external factors and the nurses’ personal decision-making during a disaster. We found the ethical issues that are widely discussed are triage with the principle of helping as many patients as possible with the challenging situation. Therefore, a specific strategy is needed to effectively resolve ethical dilemmas or difficult decisions so that the impact of applying ethics in a disaster situation can be evaluated.

We identified that ethical issues have the potential to cause ethical dilemmas in disasters. In some literature, the terms dilemma and issues are interrelated.^{25,26,30,31,36} This result was similar to the study by Molewijk et al., which explained ethical challenges, in general, are described using words such as ethical issues, ethical dilemmas, and ethical problems.⁴⁵ Most of the ethical issues are due to the obligation to care and occur when HCWs continue to work^{25–32,35,37,38} under challenging situations with a large number of patients but limited resources.^{27,31–33,36} Accordingly, the workload increases^27,32,37 and moreover there is an increase in vulnerabilities as a result of disasters such as risks to the safety of nurses.^25,32,35,37 It is supported by several studies that reported unusual situations with ethical issues related to public health ethics.^3,9,10,16

This systematic review showed that two related factors apply to nursing ethics: external factors^{24,26,27,30–32,36–38} influence nurses’ views on ethical issues and ethical decision-making during disasters. These are supported by the personal factors of nurses^{24,25,28–30,33,36,37} in the application of ethical practices and decisions. The findings of this study are in line with the study conducted by Nora, who argued that analyzing nursing actions is based on multidimensional elements consisting of elements of the nurse’s external context (organizational characteristics) and aspects of personal context (personal characteristics, knowledge) in ethical decision-making.⁴⁶ As one of the external factors, a code of ethics functions as a guiding principle in nursing practice.^{24,26,31,36–38} Several studies reveal that the code of ethics serves as a guide for nurses in recognizing ethical problems and making ethical decisions.^47–49 In addition, it also explained the relationship between an excellent organizational ethical climate which can increase ethical sensitivity and support HCWs in making correct ethical decisions.^24,30 According to a study conducted by Cerit and Özveren, the findings explained that creating an organizational ethical climate will result in high ethical sensitivity in providing health services.⁵⁰

Ethical decision-making during a disaster leads to applying triage principles.^29,32,34,36 Disaster triage is more challenging because ethical decision-making is needed to prioritize treating many victims with limited resources. Ethical practice during a disaster is based on utilitarian principles: doing the maximum good for the most significant number of people through the most efficient use of resources.⁵¹

Strategies for implementing ethics in disasters are needed for ethical decision-making and overcoming difficult ethical issues. Another study explains that nurses need to use various strategies to foster sensitivity, ability, and wise ethical decisions during the challenging ethical issues they are experiencing.⁴⁶ The social support provided to HCWs by family, colleagues, or organizational management can reduce psychological stress and help nurses overcome many physical and environmental challenges resulting from disasters.^52,53

In addition, this study revealed that nurses are rarely involved in decision-making, so policies in the field are not followed, which ultimately creates ethical issues.^27,29,32 The involvement of nurses in policymaking can contribute to service quality because nurses are more familiar with existing policies.^16,54,55 In this review, nurses’ training and education are also considered to improve disaster ethics competence in nurses.^{24,26,29,30,32,33,35–38} Organizations must develop disaster training and legal guidelines to improve ethical competence.¹⁰ Mitrović et al. revealed that in disaster situations, there are few practical guidelines or training.⁵⁶ Therefore, a study by Al Harthi recommended continuing education for nursing staff on ethical and legal issues.¹⁶

The final theme is regarding the impact of ethical practices during a disaster. This impact can be evaluated if the strategy used is clear and measurable. Overall, the effect we identified was related to the quality of care.^{25–27,29–34,36} According to Moradi’s study, nurses who provide the best care for patients have applied ethical practices because they know and are sensitive to cultural differences during a disaster.⁵ This review also highlights the physical (fatigue, illness, and difficulty sleeping) and psychological (stress, fear, frustration, and burnout) impacts that HCWs feel on the ethical issues they face during disasters.^{25,26,28,29,31–35,37} Kang et al. revealed that HCWs who face difficult situations such as pandemic disasters experience considerable mental pressure to influence the quality of interactions with patients.⁵⁷ Even so, positive psychological impacts are obtained during disaster situations, such as increasing self-confidence, emotional maturity, and compassion in responding to victims who experience difficulties.⁵⁸

Limitations of the systematic review

Studies were limited to English, and no searches were conducted in the gray literature. However, we ensured that the articles obtained from the 6 journal databases are sufficiently representative, while the concept to discuss nursing ethics in disaster is still limited.

Conclusions

Most of the recent ethical studies are related to ethics in the COVID-19 pandemic. There are differences in nurses’ perceptions and attitudes in dealing with infectious versus natural disasters. Ethical issues arise from the vulnerabilities and the obligation to care. This can potentially cause ethical dilemmas that affect nurses in making decisions. Overall, ethical issues in disasters include safety and well-being risk, professional competence, confidentiality and privacy, commitment, limited resources, workload, security, policy, and communication. Applying ethical nursing in disasters is influenced by external and personal factors. This framework can describe ethical nursing in a disaster as a guideline aimed at helping nurses, nursing educators, and policy makers to develop schematics or possible scenarios of ethical issues that achieve the critical thinking skills needed for responsible ethical decisions in disasters.

Supplemental Material

Supplemental Material - Trends and ethical issues in nursing during disasters: A systematic review

Supplemental Material for Trends and ethical issues in nursing during disasters: A systematic review by Yayu N Fithriyyah, Atikah K Alda and Haryani Haryani in Nursing Ethics

Footnotes

Author contributions

YNF contributed to the data’s conception, design, and analysis. YNF and AKA was responsible for the data collection and preparation of the manuscript. HH critically process data collection and supervised the content manuscript. All authors approved the final version for submission.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Yayu N Fithriyyah

Supplemental Material

Supplemental material for this article is available online

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