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

Aims

The aim of this study was to better understand how nurses who care for patients with COVID-19 experience ethical issues. We addressed this aim by conducting a thorough systematic review of qualitative evidence appearing in the literature.

Design

We conducted a systematic review of qualitative evidence using the Cochrane Qualitative and Implementation Methods Group Guidance Series. ³² Because ethical data were included, we used the Preferred Reporting Items for Systematic Reviews and Meta-analyses on Ethical literature (PRISMA-Ethics) ³³ to appropriately discuss and report the ethical content evaluated in this review.

Search strategies

Four strategies were used to discover relevant literature ³² : (1) manual search of previously published articles, (2) systematic search of six well-known literature databases, (3) articles identified via authors’ expertise, and (4) citation and reference tracking. These strategies are discussed in detail below.

Firstly, we performed exploratory manual searches of previously published articles and reviews to identify possible keywords and terms to build provisional search string(s) for database searches. As for the terms regarding ‘ethical issues’, two premises were established; ‘ethics’ has been used as ‘moral’ interchangeably in nursing research ³⁴ and the terms ‘ethical issues’ can be expressed by problems ³⁴ or sensitive situations. ²¹ Also, we reflected on this literature and on nursing ethical issues, in general, to add to and finalise the search strings to be used.

Secondly, we conducted systematic searches of six databases: PubMed, Embase, Cinahl, Web of Science, Philosopher's Index, and Scopus (Additional file 1). The most appropriate search string for each database was used for searching. Keywords were revised when necessary. Since our review was not concerned with results from intervention programmes, we used a Population, Exposure of interest, Outcome or Response (PEO) approach to separate the search string rather than the traditional approach in which population, interventions, comparators, and outcomes (PICO) are used. ³⁵ A PEO research approach focuses on non-numerical data in which relationships and associations are explored. Thus, for our systematic review, the string consisted of three groups of search terms: (1) the population comprised nurses caring for patients with COVID-19; (2) the exposure of interest were terms referring to COVID-19; and (3) the outcome was terms about ethical issues. Search ‘hits’ were exported and stored in EndNote™ X9 reference management software (The EndNote™ Team, 2013).

Thirdly, additional candidate articles were identified through the researchers' expertise. Fourthly, we performed citation and reference tracking until no additional publications were found. ³⁶ Figure 1 outlines the entire search process, which was guided by PRISMA-Ethics. ³³ OPEN IN VIEWER

In the identification phase, the first author (Y.O.) carried out the literature search to ensure that all relevant articles would be identified (Figure 1). The search produced a total of 1,534 articles. Duplicates were removed before manually screening both titles and abstracts for inclusion (957). Candidate articles were screened by title. Titles that both researchers agreed were irrelevant to the aim of this review were excluded. All other articles (652) that seemed to be relevant to the topic or for those that no consensus between the authors was reached were forwarded to the next phase. In the screening phase, both researchers evaluated all abstracts of the articles selected during the identification phase by reading them and checking whether they met the inclusion criteria. Again, all studies that met the criteria were forwarded to the next phase of the search process. If no consensus was reached for a particular article, the article was also forwarded to the next phase. All other studies (313) were excluded. In the eligibility phase, a total of 74 articles that were passed on from the screening phase were read and compared with the inclusion criteria. Of these, articles with text irrelevant to the study (59) were excluded, as the article did not focus on nurses or ethical aspects. Quantitative studies or articles not published in English were excluded as well. Through reference and citation tracking, the reference lists of all 15 articles produced four additional articles. A number of 19 articles were included in the initial search. Afterwards, we updated our initial search results conducted in April 2022 with a complementary database search in January 2023 to reflect recently published articles which could meet our inclusion criteria. Finally, 26 articles were decided to be included (Figure 1).

Inclusion and exclusion criteria

Using pre-specified inclusion and exclusion criteria, one researcher (Y.O.) screened titles, abstracts, and full texts of candidate publications identified in the database search. For questionable candidate articles, the first author (Y.O.) and the second author (C.G.) discussed the article until a consensus was reached on whether it should be included. The following selection criteria were used throughout the entire search and evaluation process. Since the WHO first declared COVID-19 as a pandemic disease in March 2020, ¹ we included journal articles published between March 1, 2020 and December 31, 2022 that reported on primary empirical research with a well-defined qualitative methodology.

The database search was conducted on April 10, 2022. Inclusion/exclusion of an article depended on the following factors: (1) type of the study, or studies, reported in the article, (2) types of participants in the study, and (3) outcomes measured in the study (Table 1). We updated our initial search results with a complementary database search, performed on January 14, 2023. Hence, in the end, we included pertinent journal articles published between March 1, 2020 and December 31, 2022.

OPEN IN VIEWER

Table 1.

Inclusion and exclusion criteria for selection of articles on ethical issues experienced by nurses who care for patients with COVID-19.

	Inclusion	Exclusion
Types of the study reported on	• Published qualitative and mixed-method studies	• Reviews, dissertations, case studies, books, book chapters, theoretical or conceptual papers, guidelines, conference papers, or grey literature (e.g. opinions, perspectives, or discussion papers)
	• Publication language is English
	• Studies have been published since the declaration of the COVID-19 pandemic by WHO (March 12, 2020)
Types of participants in the study	• Nurses caring for patients with COVID-19	• Nurses not caring for patients with COVID-19
	• Practising nurses in studies sampling their encountered ethical issues alone	• Studies in which only the ethical issues encountered by non-nurses (e.g. physicians, students, or other healthcare workers) were sampled
	• Practising nurses in studies sampling their encountered ethical issues combined with physicians, students, or other healthcare workers if nurses` data could be separately extracted
Outcome measures in the study reported on	• Ethical issues experienced by nurses caring for patients with COVID-19	• No relevant research topics
		• Studies in which only the issues encountered by nurses in the COVID-19 pandemic without ethical aspects
		• Research findings that have hardly any ethical aspects despite the ethical issues being described

Quality appraisal

The quality of the included articles was assessed using the quality assessment tool described in Appendix D of Hawker et al. ³⁷ Rigour was judged by evaluating the clarity of the narratives presented in the nine parts/aspects of each article (abstract and title, introduction and aims, methods and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalisability, and implications and usefulness), which correspond to the nine questions of Hawker et al.’s assessment tool. ³⁷ Each question assesses the clarity of one part of an article as ‘good’, ‘fair’, ‘poor’ or ‘very poor’. While Hawker et al. ³⁷ did not suggest cut-off scores for a total quality rating of articles, other researchers who used their tool developed a numerical scoring system for overall quality.^38,39 In the present review, we used the scoring scheme of Lorenc et al. ³⁸ : good quality = 4 points; fair quality = 3 points; poor quality = 2 points; and very poor quality = 1 point. A total score for each included article was then computed by summing each of the ‘nine question scores’; total scores ranged from 9 points to 36 points. Next, we grouped the articles into three categories according to their overall quality scores: high quality = 30–36 points; medium quality = 24–29 points; and low quality = 9–23 points. ³⁸

Data extraction and synthesis

To become familiar with the data, we closely and thoroughly evaluated the included articles several times. This enabled us to eventually build summary tables of the characteristics of how nurses who care for COVID-19 patients experience ethically sensitive issues (Additional file 2 and 3). Data analysis was guided partly by the Qualitative Analysis Guide of Leuven (QUAGOL), which comprises two rounds of analyses composed of five stages each. ⁴⁰ The first round prepares the data for the coding process. In the first stage, the first author (Y.O) read and re-read the selected articles thoroughly to understand each of them holistically and to capture their essence. In the second stage, authors typically construct a brief abstract of the key storylines of an article. Although most key storylines of the selected articles were agreed upon between two researchers, a few of these key storylines reached consensus through our discussion. In the third stage, we formulated the conceptual schemes based on the key storylines of each article derived from stage 2. In the fourth stage, we adapted, completed, or refined our conceptual schemes. In the fifth stage, we tested the conceptual schemes and verified them by repeatedly comparing them through forward-backwards ‘movement’ between within-case and across-case analyses.

All researchers carefully checked that the conceptual schemes fairly and accurately characterised what was stated or implied in the article being analysed. The conceptual schemes focused on answering our research question: ‘How do nurses who care for COVID-19 patients experience ethically sensitive issues’? Hence, if our conceptual schemes or interpretations differed from what the original authors described in their articles, the research team discussed these concepts or interpretations until consensus was reached. ⁴¹

The second round of analysis consisted of three of the five second-round analysis stages of QUAGOL (i.e. stages 6–8), in which we coded the conceptual schemes derived from the first round of analysis. For coding, we used NVivo® 12 software (Lumivero, Denver, CO, USA). In the first stage of this round (stage 6), we created a common list of concepts, and then input these concepts into NVivo 12. We did not hierarchise or link any of the concepts at this point. In the second stage (stage 7), we analysed and defined the concepts through across-case analysis. This enabled us to reach an overall characterisation of the main recurring themes and higher-level abstract concepts. During this process, emerging themes grounded in the data were constantly compared with the higher-level concepts. In the third and final stage (stage 8), we described the concepts, their meanings, and their characteristics. All researchers discussed each concept's meaning until a consensus was reached.

Study characteristics

We identified 26 relevant articles for inclusion (Additional file 2 and 3). The studies occurred in various care settings: ICU (n = 31); general wards (n = 7); designated care settings for patients with COVID-19 (n = 9); acute or emergency care (n = 7); and ‘other’ care settings (n = 2). Studies were conducted in Iran (n = 6); Sweden (n = 4); Turkey (n = 3); USA (n = 2); Canada (n = 2); China (n = 2); Indonesia (n = 1); Italy (n = 1); South Korea (n = 1); Jordan (n = 1); Greece (n = 1); and Spain (n = 1); one study combined data from eight European countries (n = 1). Four types of qualitative research designs were used: descriptive (n = 16); phenomenological (n = 8); interpretive (n = 1); and narrative (n = 1). Data were collected through interviews (n = 22); answers to open-ended questions (n = 3); or through a combination of interviews and focus groups (n = 1).

Methodological quality

The 26 included studies had the following overall quality grades: high (n = 14); medium (n = 9); and low (n = 3) (Additional file 4 and Quality appraisal section above). No studies were excluded because of methodological weaknesses. Most studies clearly stated their aims and findings; all studies obtained ethical approval from their institutional review boards. For most of the studies, the rigour of conducting qualitative research was good, because sampling methods and trustworthiness were presented clearly. However, some included articles failed to clearly define the main themes or sub-themes of their study, or misunderstood some of the ethical issues. This situation can weaken confidence in the transferability or generalisability of the results. For instance, some of the authors’ interpretations of the participants’ statements published from interview data were unconvincing in our opinion.

Main results

We distinguished two components in our synthesis. These components explained the essence of the ethical experiences of nurses who care for patients with COVID-19. The first component characterised the moral character of nurses as a willingness to respond to vulnerable human beings. The second component characterises ethical issues nurses faced. These ethical issues sometimes became barriers that impeded nurses from responding to vulnerable persons’ requests for dignified care. These components are described in detail next.

Ambivalent emotions

Nurses’ own emotions sometimes were at odds with how they felt about their patients. This ambivalence was layered on top of and sometimes mixed with clear ethical issues related to personal and professional principles. First, most nurses reported feeling compassion towards their patients’ sense of crisis and vulnerability, especially about how they struggled with daily health threats and their diminishing well-being. After witnessing the intense suffering of these patients, nurses expressed great concern about their patients’ fragility, as their very existence was threatened. Nurses were concerned about their patients’ gradual health deterioration,^16,43,44 sense of isolation,^22,24,45 fear of death,^22,23,46 despair of dying alone,^{16,23–25,43,47} and the risk of possibly having an indecent funeral.^43,48

Such concerns led nurses to imagine and reflect on how distressed their patients and families must be as the disease progressed. These reflections moved nurses to express compassionate attitudes.^{14,22–24,43,45,49} In particular, driven by moral imagination, their emotions helped nurses to arrange situations in which patients and their families could ‘connect’ and share precious moments together.^{14,23,24,45,49} Such compassion facilitated by moral imagination stimulated one of their professional duties, that is, the intense ethical responsibility to respond to vulnerable human persons' appeals and to protect and improve patients’ dignity.^23,50–52

On the other hand, although nurses were compassionate towards their patients’ suffering, they also felt vulnerable and anxious about the uncertainty surrounding this unprecedented health crisis. This nervousness and unease were felt at professional and personal levels. Nurses reported feeling vulnerable and alone, and they sometimes questioned whether their knowledge and skills were sufficient to stave off their patients’ deteriorating health. They also felt anxious about possible impacts of their nursing care on the patients’ health outcomes, and they were deeply concerned about providing adequate care in the face of scarce evidence-based nursing for this unprecedented crisis.^46,53 As a result of such concerns, some nurses became increasingly afraid and were obsessed with the possibility that their care might actually harm their patients’ safety.^16,54 Some nurses criticising and questioning their professional identity experienced demoralisation and distress.^25,43,55,56 Although they remained professionally devoted and compassionate, nurses also reported feeling despair, powerless, and helpless, and even linked their experiences to a traumatic psychological event that accelerated and amplified their vulnerability.^16,25,42,43

As people with real feelings and fears, nurses also reported feeling vulnerable when caring for patients with COVID-19. Continuously working in a dangerous healthcare environment in the midst of a highly contagious virus with high transmission probability has added to nurses’ heightened feelings of vulnerability, causing them to fear for their own health and safety.^{15,16,25,42,43,47,48,50,52–54,57} They also reported experiencing work-related physical effects of this prolonged distress like fatigue and insomnia.^43,57,58 Some nurses also needed emotional support, such as scheduled time to focus on their self-care.^{15,25,42,46,58} Their fear was amplified by the unprecedented nature of the work environment during the pandemic: Nurses had to keep working as they witnessed their nurse colleagues being infected by their patients or as they watched, over and over again, patients dying in pain from the consequences of COVID-19.^{16,43,50,53,54,57}

Nurses were also concerned about infecting others beyond the immediate care context, like the possibility of infecting their loved ones or anyone else they might come in contact with.^{16,25,43,48,51–54,57} These life-and-death health and safety concerns caused them to be afraid of coming in close contact with own family, leading to feelings of emotional isolation, loneliness, and familial separation.

Professional commitment motivated by a two-fold sense of ethical responsibility

Nurses’ professional commitment was motivated by their strong bond to the ethical responsibilities of healthcare professionals to care for people in medical need. The pandemic’s unusual circumstances led nurses to come to a better understanding of their role as a moral agent, one with two types of ethical responsibility. One was characterised by altruism and the other by the duty to embody and express the professional values of nursing. Providing professional nursing care in a public health crisis is a prime nursing responsibility.

How was the altruistic ethical responsibility of nurses manifested? First, nurses felt the obligatory responsibility to help patients willingly and selflessly. This was manifested by their being ever mindful that their patients were completely dependent on them and that they needed their help.^23,50,51 Encountering patients’ distressed-looking faces and fragile bodies during daily care pushed this responsibility to the fore. For example, while repositioning a patient in bed – even slight repositioning – and witnessing their rapidly deteriorating condition, nurses soon understood patients’ extreme fragility and need for extraordinary professional care.^16,46,52,54 When checking for a quarantined patient’s vital signs, nurses said they could not avoid the anxious and fearful looks on young patients’ faces, alone and separated from their parents.^23,52 One nurse vividly recalled ⁵² :

‘I felt that I had really touched their lives, because it was different […] Patients see you (a nurse) as their only hope. You open the door, and they are waiting for you. You are the only one who can go in and be with them, that's why it feels so different’.

Listening to patients' unique stories also pushed nurses to feel like they were the only person in the world who could respond to their patients’ needs and appeals; this realisation renewed and bolstered their commitment to selflessly help without hesitation.^{24,45,47,52,58} As families were prohibited from visiting their loved ones, they were forced to communicate with them by video calls. When nurses witnessed these tearful and heart-wrenching video calls, they gained a deeper understanding of the patients' distress and isolation; this experience heightened the importance of the responsibility to be altruistic.^{16,22,24,45,47,59} Through these experiences, nurses became fully aware of their role in advocating and protecting patients’ dignity.^{22,24,45,54,59}

How was nurses’ embodiment of professional nursing duty manifested? Despite the dangerous and extreme work environment, nurses willingly cared for patients, sticking tenaciously to their professional ethics as the norm, regardless of their personal feelings about the pandemic and the highly charged political environment. When the pandemic emerged, nurses reflected on their roles and dutiful contributions to society as nurses and healthcare professionals.^{14,45,46,50,57,58}

The pandemic and resulting crisis even stimulated nurses to promptly and unhesitatingly carry out their professional ethical responsibilities.^50,51 Interviewed nurses said their professional feeling of duty spontaneously intensified as a result of the pandemic and caring for COVID-19 patients. From their nursing education and through self-reflection of their ethical responsibility in their practice, they learnt what to do and how to do it well in a crisis.^15,48,50 They also reported reflecting on the sacred ‘calling’ from neighbours, people in need of help, society, and their nation.^{14,45,46,50,57,58} Some authors termed nurses’ responses to the emergency crisis of public health as ‘the nurse inside me’. ⁵⁰ Some nurses instinctively understood their role as patient advocates.^14,45,57

Ethical problems threatening the dignity of human beings

All 26 studies identified ethical problems that nurses experienced as threatening the dignity of patients or themselves.

Ethical dilemmas about prioritising care among vulnerable humans

Some studies reported in the 26 articles discussed ethical dilemmas that arose when execution of incompatible duties clashed, necessitating nurses to prioritise some duties over others.

Nurses have a professional duty to care for patients; simultaneously, they have a right to protect their own health and safety.^{13–15,25,43,52,55} Nurses experienced ethical dilemmas when the exercise of these two rights conflicted. In the end, most nurses said that they prioritised their professional duties over their right to protect themselves. Some nurses even believed that carrying out their social responsibility came first: being willing to ‘sacrifice’ themselves in a public health crisis.^50,52,53,58 Other nurses said they felt like they were ‘frontline soldiers’ who must fight metaphorically on a health-crisis ‘battlefield’.^14,15,46,52 This willingness, however, ended when their own, or their colleagues’, health and safety were threatened.

Nurses’ adherence to their professional commitment was tested when working in an unsafe environment,^{13,15,48,50,51} when the probability of virus transmission from patients to nurses was high,^13,25,50,51 and when the public refused to use simple preventive measures or were wilfully ignorant of the severity of the disease.^43,51 The following situation faced by one nurse illustrates how priority was given to a medical doctor’s wishes over her right to protect her own health and safety ⁴⁷ :

‘An MD decided to cancel a [patient’s] pending COVID-19 swab because she didn’t “feel” like they had COVID-19. And then later on, that patient …[was] swabbed, and [it] came back positive, meaning that [the] staff who [were excused] from working with COVID-19 patients (for medical exemption reasons) have been put at risk’.

So, this nurse was not only put into an unsafe work environment but also her dignity was threatened by being unnecessarily exposed to the coronavirus because of the doctor’s unreasonable prioritisation.

Some nurses working in COVID-19 ICUs reported feeling conflicted by their dual responsibilities to sufficiently train newly dispatched nurses, on the one hand, and to simultaneously protect ICU nurses’ well-being, on the other hand, by not imposing heavy workloads.^{15,25,42,51,55} ICU nurses explained that they aimed to protect patients’ safety, while also wanting to be loyal to their colleagues.^15,25,42 Most ICU nurses viewed dispatched nurses as vulnerable persons ‘thrown’ into an extremely challenging environment rather than nurses with a lack of knowledge or skills.^42,55 However, this training was an added burden to ICU nurses who already had a heavy workload; this threatened their well-being and dignity. Being overworked was associated with low-quality care and possibly nursing errors; ICU nurses insisted on the need for self-care, which would improve the quality of overall nursing care.^15,25,42,46

Uncertainty about ethical issues

Some studies reported experiences related to uncertainty that arose when nurses were unsure or unaware of what the ethical problems were in a health crisis situation.^{44,47,49,52,54,56} Some nurses did not state what was ethically wrong, although they were frustrated by a sense of ‘something feeling wrong’. Particularly, nurses felt uncomfortable when they were required to carry out what were clearly the physicians' professional duties, like providing doctor-related medical treatments.^44,47,52,54 The physicians shirked their responsibilities in some cases and asked nurses to carry them out, because they wanted to avoid direct contact with the infected patient. However, nurses failed to or barely recognised these situations as ethical problems; rather, they simply viewed them as negative experiences of the nurse-physician relationship, or as a consequence of role confusion.^44,47,52,54

Detailed discussion of dual ethical themes and their moderators

The two-fold nature of nurses’ moral character revealed a selfless attitude expressed not only towards COVID-19 patients and their families but also towards themselves and their fellow nurses. Nurses recognised ethical issues when they encountered barriers to providing care for vulnerable persons stricken with COVID-19.

During the COVID-19 pandemic, nurses’ willing attitude to respond was initially blunted by other emotions. Early on, nurses felt conflicted between expressing compassion towards vulnerable others and feeling anxious about the unexpected impact of their nursing care on patients and on themselves. However, they realised later on that the vulnerabilities associated with having COVID-19 were different than any vulnerabilities experienced in the past, and this caused a shift in their character: Compassion ‘won out’ over anxiety, moving the nurses to concentrate on caring for their patients. This finding is consistent with conclusions reached in previous literature reviews on nursing attitudes during the COVID-19 pandemic,^17,29,60,61 in which nurses were able to re-focus more on caring for others.

Nurses’ connectedness with the patient’s suffering led them to empathise with others’ suffering, frustrations, and emotions in new ways when faced with the unique and critical situations prompted by COVID-19. This finding can be linked to the ‘virtue ethics’ approach in nursing. The importance of virtue or moral character is an essential aspect of nursing education,^18,62 and this was evident in how nurses’ altruistic ethical responsibility was manifested: They felt a tenacious responsibility to willingly and selflessly help patients by coming to understand that their COVID-19 patients completely depended on them and needed their help.^23,50,51 To be virtuous entails more than just making rational decisions.^18,63 The nature of nursing is intimately intertwined with ethics, and ethics is linked to nursing in the profession’s moral character. ⁶⁴ A nurse’s moral character is developed by cultivating good habits like moral imagination or emotions that can sustain them when confronting ethical challenges. ⁶⁴ Nortvedt ⁶⁵ argued that a nurse needs to respond sensitively to a patient’s appeal through personal emotional interpretation and moral imagination in the caring process of human-to-human interaction. We previously highlighted the importance of cultivating and expressing emotions in the practice of virtuous nursing, because when practised, it allows nurses to be receptive to the needs of others. ¹⁸ This is consistent with the two key themes that emerged in our analyses. The emotional faculties of nurses enable them to detect ethical problems and express their emotions, which can be significant in an ethical and caring relationship.^18,63 Thus, for nurses, moral acts arising from one’s good moral character should be cultivated. This moral character is vital to protect citizens’ well-being in a public health crisis, like what unfolded in the COVID-19 pandemic.

Our thematic analyses showed that nurses’ professional commitment was motivated early on by a strong sense of altruistic and professional responsibility. The altruistic responsibility grew when seeing others’ faces in distress and understanding each patient’s unique story. The nurses’ sense of responsibility triggered ethical behaviours, namely caring acts towards their patients. However, they struggled with the responsibility for protecting and improving a person’s dignity through their nursing care advocacy. Our findings are consistent with other reviews on nurses’ responsible behaviours during the COVID-19 pandemic.^27,29,30,60 The study of Peter et al., ⁶⁰ for example, revealed that nurses endeavoured to fulfil their caring responsibilities as moral agents through face-to-face caring relationships. Rony et al. ²⁹ highlighted that frontline nurses felt it was their professional obligation to be by the critical patients’ side. Ours’ and others’ findings can be explained by our previously expressed view that nurses’ responsibility should also include integral human responsibility, that is, becoming deeply involved in what happens to the patient in a particular caring context. ²⁰ Given this ethical foundation, the review of Peter et al. ⁶⁰ pointed out that only a few empirical studies have actually reported on integral human responsibility. In essence, they concluded that certain common challenges and unique COVID-19 pandemic-related ones held back nurses from being able to meet their ethical responsibilities of care.

In our analyses of qualitative evidence, three ethical issues stood out in which nurses faced barriers to responding to vulnerable persons’ appeals. First, ethical problems mainly occurred in situations where threats to human beings’ dignity arose, both to patients and nurses themselves. Concerning patients’ dignity, nurses were concerned about ethical problems arising because of dehumanising and unsafe care originating from external constraints. These constraints were organisational in nature, such as lack of necessary resources, dispatch nurses’ COVID care-related incompetence, blanket visitor-restriction policies, and extended use of PPE. These situations eroded nurses’ ethical identity, leading to moral distress. Thus, nurses had no choice but to experience several situations where the dignity of patients and families was ignored; in other words, they received undignified nursing care.

Dignified nursing care is recognised as person-centred care, which is characterised by responses to individual appeals and meeting personal needs through interpretative dialogue in the caring relationship. ²¹ However, that kind of care was scarcely provided due to organisational limitations during the COVID-19 pandemic. Our finding is aligned with previous reviews that concluded that those constraints caused substandard care, leading to ethical problems^27,28,60,66 and abuse of patients’ and families’ rights and autonomy.^26,28,30,60 Fundamentally, such constraints are linked to ethical concerns about human dignity. Enhancing a person’s dignity is the normative standard at the core of care ethics and the ultimate goal of nursing.^21,67,68 Also, upholding human dignity is the responsibility of nurses in the code of ethics in nursing.^67,69 The systems and policies that enable nurses to provide individualised care need to be established and continually supported so that nurses can protect and promote the dignity of patients and their families, rather than provide substandard care to appease bureaucratic goals.

Organisational constraints also hurt nurses’ dignity. Scarce resources especially damaged their dignity. The daily lives of nurses were also disrupted by public prejudice, which manifested as stigmatisation or discrimination against them. In addition, nurses’ health and safety were threatened because of working in unsafe work environments (e.g. heavy workloads or physical and psychological discomfort from extended use of PPE), which barely improved with time. As with previous reviews,^27,28,30,60 our findings supported their conclusions that ethical problems lead to abuse of nurses’ dignity. Attempts by organisations to resolve this problem through unilateral administrative order and support was deemed impractical and ineffective.^28,60 Conversely, the review of Rony et al. ²⁹ reported that the leadership of nurse leaders or organisational support to resolve ethical difficulties was effective and helpful to nurses. The review of Luo et al. ⁶¹ discussed positive viewpoints of nurses growing professionally or reaching personal achievement through nurses’ caring experiences during the pandemic.

Nevertheless, when nurses’ sense of dignity is threatened, they struggle to maintain self-respect. As respect has a mutuality attribute, their capacity to show respect towards others can diminish.^70,71 On the one hand, achieving a sense of dignity results in a feeling of power, a positive self-perception, and elevated self-esteem.^72,73 On the other hand, threatening or violating dignity leads to a perceived lack of authority, less feeling of significance, erosion of humanity, and emotional responses like rage, anxiety, shame, and embarrassment.^74,75 These outcomes pose greater intricacies within the nursing profession, as they subsequently affect turnover and the entirety of the healthcare system.^74,76 Therefore, organisations and leaders would do well to establish and support practical measures to protect and promote nurses’ dignity by listening to them and by thoroughly evaluating the effects of instituting these measures by conducting research.

The second ethical issue that inhibited nurses from responding to vulnerable persons’ appeals mainly occurred in situations where incompatible duties and care obligations to different parties clashed. Both parties were vulnerable and needed help, but incompatible ethical responsibilities set up an ethical dilemma. Along with the professional duty to care for others, nurses had a basic right to protect their own health and safety from an extremely infectious and life-threatening disease. This second finding is aligned with nursing scholars’ arguments about establishing a balance between the obligations of beneficence and duty to care for patients and nurses’ rights and their duty to protect themselves and their loved ones.^6,77 McKenna ⁷⁷ highlighted the unfairness that results when society expects nurses to simultaneously take on the duty to care in the face of personal health and safety threats. Morley et al. ⁶ explained that the rationale is based on the relational dimension existing in all human caring activities. By ensuring nurses’ health and safety, nurses can provide longer-term and good-quality nursing care and can maintain their own well-being. This is true because nurses' personal and professional lives are often grounded in interdependent relationships of responsibility and care. Thus, healthcare policymakers and system leaders do well to acknowledge and respect relational accounts of care and apply them to current practice realities.

The third ethical issue that hindered nurses from responding to vulnerable persons’ appeals was related to ethical uncertainty that sometimes arose when nurses were unsure what ethical principles or values were relevant or even what ethical problems were present. In situations where unexpected ethical problems occurred, some nurses could barely distinguish management problems from ethical problems, or were confused about the nature or scope of these two domains. Others criticised ethical problems that arose without offering appropriate or convincing ethical reasoning. Their behaviours might originate from a lack of basic ethical knowledge or unclear ethical guidance originating from their organisations. Previous research supports our interpretation that nurses barely applied good ethical reasoning; instead, they tended to conflate personal convictions or expectations of others with ethical principles, leading to ethical uncertainty.^11,78 Previous studies emphasised two basic reasons for this confused state: Ethical knowledge that should have been instilled during nursing education was too superficial and sparse, leading to ethical uncertainty,^79,80 or nurses’ lack of clear ethical guidance from their organisations amplified ethical uncertainty among nurses. ⁸ Moreover, ethical uncertainty can influence nurses’ job sustainability and quality of care.^8,11,81 Therefore, our results led us to recommend that healthcare organisations should provide clear and detailed ethical guidance, and that further research should be conducted on development programmes aimed at improving ethical competence in nurses, including efforts to teach solid ethical knowledge. Most importantly, organisations must act ethically in relation to nurses so that nurses can share and follow their ethical guidance.

Limitations and Implications

Our study has some limitations. In the data synthesis process, our research team soon realised that some of the main themes or sub-themes identified by certain studies’ authors were less than convincing and unsupported; thus, we thoroughly reinterpreted and synthesised new themes. The quality of some included studies was relatively weak in terms of transferability or generalisability because their authors seemed to misunderstand certain ethical terms (e.g. ethical problems, ethical dilemmas, and moral distress) or failed to provide standard, widely accepted definitions of these terms as they described their themes. For this reason, we thoroughly and repeatedly discussed these kinds of cases for development and integration into our emerging themes. This reinterpretation is not unusual. Such limitations of studies dealing with ethical issues among nurses have been reported in other reviews^31,60 and have been pointed out by nursing scholars as well.^11,82 To avoid such reanalyses, it is recommended that researchers seek to more clearly understand and define the ethical concepts they use so that their future findings can contribute to the nursing ethics knowledge base.

Meanwhile, we used a well-developed search strategy, clear inclusion and exclusion criteria and compact specific periods. It enabled us to identify qualitative studies conducted on various continents and yield a nearly exhaustive representation of the literature’s participants, allowing us to discover unique ethical issues common to nurses caring for patients with COVID-19. It can contribute to shedding light on the sense of dignity not only among patients but nurses as well and help healthcare policymakers establish a supportive system and management concerning ethical issues experienced by nurses.