key: cord-1049860-hp0rnwq3 authors: Firouzkouhi, Mohammadreza; Alimohammadi, Nasrollah; Kako, Mayumi; Abdollahimohammad, Abdolghani; Bagheri, Gholamreza; Nouraie, Morteza title: Ethical challenges of nurses related covid-19 pandemic in inpatient wards: an integrative review date: 2021-04-12 journal: Ethics Med Public Health DOI: 10.1016/j.jemep.2021.100669 sha: 058df9f5bc5e1d7bade79c747cf59d1885f93ecd doc_id: 1049860 cord_uid: hp0rnwq3 Introduction: The COVID-19 pandemic is a social problem. Nurses face ethical challenges in providing care activities related to COVID-19. Aim: Therefore, this study aimed to explore the ethical challenges of nurses in COVID-19 pandemic. Method: This is an integrative review study conducted from 2007 to 2020. Databases of PubMed, Google Scholar, Scopus, Web of Science were searched. The results of the eligible studies (12 cases) were analyzed. Results: A total of 228 articles satisfied the inclusion criteria, and 12 articles were selected for analysis. The study units showed that the ethical challenges of nurses in caring for patients with COVID-19 consisted of three areas, including nursing; patient and family; and treatment equipment and facilities. Conclusion: Providing care for patients with COVID 19 pandemic has increased nurses’ ethical challenges. Therefore, nurses need to pay more attention to not face psychological problems and premature burnout. The covid-19 pandemic has so far infected nearly 100 million people worldwide and killed more than 2 million people in the world [1] . Nurses are one of the health professional groups in providing health care continuously and globally under this pandemic. They play a critical role in prevention and pandemic care [2] . According to the World Health Organization, there are about 28 million nurses working in the world. Meanwhile, the world still faces a shortage of about 5.9 million nurses to 2018. These deficiencies are more prevalent in African countries, South-East Asia, the Eastern Mediterranean region, and Latin America. It is also estimated that the number of nurses will reach 36 million by 2030. Studies in 37 countries also show that the death toll among health care workers between July 22 and August 15, 2020, 100000 per population is 0.05 percent. Also, The International Council of Nurses' latest analysis in August 2020 shows that the number of nurses who have died after contracting COVID-19 in 44 countries is 1,500 in August [3, 4] . In China, for example, nurses make up 68% of medical staff as primary caregivers for COVID-19 clients [5] . The outcome of treatment decisions during the COVID-19 pandemic is uncertain for clients and even medical staff [6, 7] . Clients with COVID-19 face many ethical challenges when receiving care. Ethical challenges mainly refer to moral dilemmas and conflicts, and other scenarios under challenging situations, which may not be solvable by nurses or other treatment teams. Ethical conflicts arise when a person is aware of the need for the right actions. However, some internal or external factors may have difficulty taking appropriate actions [6, 7] . Thus, it highlights many of the difficult ethical issues that healthcare professionals face in caring for patients and families [2] . The studies have shown that nurses in clinical practice face serious ethical challenges in several ways, especially when caring for COVID-19 patients. Nurses may face ethical challenges due to, exposure to new illnesses, and lack of experience in new situations. The challenges may lead to mental health problems such as anxiety, fear, stress, insomnia, or irritability [5, 8] . The inherent nature of nursing is respect for human rights [9] . Violation of individuals' rights, such as poor access to information, education, and care, increases individuals' basic vulnerabilities to COVID-19 disease. Reducing this vulnerability requires actions that enable individuals and communities to make effective decisions for their life. The code of ethics in the COVID 19 pandemic is not responsive and has caused nurses to face many ethical dilemmas. Therefore, administering ethical guidelines will lead to fewer challenges, more patient satisfaction, and the quality of care [10] . Besides, ethical challenges have increased in health care systems due to the enormous hospitalized patients with COVID-19 in intensive care units, lack of nursing staff, high expectations for delivering the best care for the patients, and overlooking the nursing staff services. We conducted integrative review to identify nurses' ethical challenges in the COVID-19 pandemic. To identify discrepancies in various studies related to nurses' activities. The integrative review approach is particularly well-suited for reviewing a topic across diverse research designs and methodologies to provide a more comprehensive understanding of the phenomenon under study [11] . This study's question: What are the ethical challenges that nurses face in COVID-19 pandemic in inpatient wards? This is an integrative study conducted by the Ganong approach. Integrative review study is a method that collects and synthesizes the knowledge generated by analyzing the results extracted in the studies selected for review [12] . This study was conducted in the following steps: Setting a research question; sampling or selecting studies for review; representation of the reviewed studies; analysis of selected studies; Interpretation of results and final report [12] . In the COVID-19 pandemic, ethical challenges were observed in the nursing work. Therefore, including AND and OR were also used in the search. The article was published in languages other than English were excluded. To fully comply with this integrative review's ethical aspects, a thorough review of the databases was implemented to include all eligible articles. Two researchers independently conducted quality assessments, and if necessary, the differences were resolved through discussion with a third researcher to avoid bias selection. Search strings used in PubMed based on the MeSH keywords: Of 228 extracted articles, 12 were eligible. Duplicate articles were excluded. The selection of articles continued with the reading of titles and abstracts. When in doubt about the inclusion or omission of any article, the article's full-text was read. Finally, the eligible articles were analyzed ( Figure 1 ). The selection process followed the PRISMA guidelines and recommendations for identification, selection, eligibility and inclusion [13] . Data analysis in an integrative review proceeds in a number of steps in order to sort, categorize and summarize data into a meaningful whole, facilitating the drawing of sound conclusions from the synthesis.. In order to analyse the articles, evidence of the nurses' ethical challenges was highlighted and coded. Then, categories and subcategories were formed. Finally, the results of the integrative review were interpreted and prepared for the report [8] . 8 In this study, 12 articles met the inclusion criteria. Table I shows the selected studies by title, year and country, type of study, the purpose of the study, and the results. The reviewed studies' main results were about three areas: nurses, patients with COVID-19 and their families, and inpatient wards' facilities and medical equipment. Ethical challenges for nurses were including the safety of nurses, colleagues and families, shortage of nurses, lack of concentration due to mental fatigue, life-threatening, a large number of patients, lack of definitive treatment, performing nursing procedures in dangerous situations, importance giving the system to protect the lives of nurses, the rules and regulations that cause contact between nurses and companions, and physical and psychological injuries and lack of protective equipment [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] . Ethical challenges centred on the patient and the family were the challenge of treatment decisions, family visits with the patient, patients' excessive anxiety and fear, research on patients and the risk of disclosing patients' identities, patients' expectations, family requests about their patients Informing patients about death and other news related to the family, communicating with the patient from behind a mask and protective clothing, ensuring the patient's rights, researching patients, respecting the patient's dignity and behaviour, and anger and restlessness of families It was about what happened to their patients [14, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] . Ethical challenges focused on medical facilities and equipment included coordination to address the shortage of medical equipment and facilities, stability in emergency decision making under pressure to allocate equipment, allocation of sufficient resources through supply units, disruption of supply chain equipment and personnel [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] . As the study's results showed, nurses' ethical challenges in the COVID 19 pandemic revolve around three areas, nurses, patients and their families, and medical equipment and facilities. In the field of nurses, ethical challenges include the safety of nurses, colleagues and families, shortage of nurses, lack of concentration due to mental fatigue, life-threatening disease, a large number of patients, performing nursing actions in dangerous conditions, giving importance to the system nurses' survival was challenged, as well as physical and psychological injuries and a lack of protective equipment. The results showed that nurses in normal conditions and intensive care units connected with critically ill patients face a shortage of human resources or equipment, and there are ethical challenges for nurses in this area. When the number of patients suddenly increases, the equipment and forces will no longer be responsive, new problems will arise, and the moral challenges will be much more significant. These conditions are much more visible in the COVID-19 pandemic [26] . Nurses' safety is one of the most critical aspects of the health systems, threatening them in the COVID-19 pandemic. Nurses take care of patients during the pandemic and cannot morally withdraw despite being aware of the potential dangers [26] . Besides, health systems must provide safety for nurses in preserving their lives in the COVID-19 pandemic. Maintaining human resources is necessary for the health system to provide services for more patients. The COVID-19 pandemic is associated with nurses' moral and psychological challenges. They must be prepared to meet the challenges and uncertainties. If nurses are infected with COVID-19, they will face moral challenges to transfer the disease to their family. Inadequate protective equipment against the disease exposes the nurses to risk [27] . Moreover, rules and regulations put nurses in conflict with the family of patients. The families expect to visit their loved ones, but the rules have not allowed a normal visiting. So, conflicts arise between nurses and the families of patients. The annoyed families do not understand the rules and endanger nurses and their lives at risk. Nurses face the problem of having companions with COVID-19 disease. When die, informing the family leads to conflict when patients died from COVID-19 [28] . The number of patients in need of intensive care is increasing. Nurses' moral problems also increase when they cannot offer all necessary care due to personnel shortages [29] . Nurses also use protective equipment for a long time to care for COVID-19 patients, which can cause scars on their faces. Wearing protective clothes for a long time increases the body's temperature, leading to intolerance and losing concentration on tasks. Burdens of work, increasing the work shifts and critically ill patients, and deaths, and how to overcome these burdens occupy the nurses' minds, which increases ethical challenges for nurses in this area [30] . Stressors and other factors in the intensive care unit cause fatigue in nurses who lose control of the existing conditions and face moral challenges [31] . Another result of the studies is a challenge for the patient and the family's axis. The patient and family challenges and moral issues are, including decision making, meeting families with patients, patients' excessive anxiety and fear, research on patients and the risk of disclosing patients' identities, patients' expectations, family requests for their patients, notification of death and other outcomes, communicating with the patient from behind a mask and protective clothing, ensuring the patient's rights, respecting the dignity and behaviour of the patient, families' irritability, insulting and distrusting to the treatment team, and the patient's conflicting demands and the family from their treatment team can cause these conditions. The study results showed that caring for patients with secure dress poses an ethical challenge. The COVID-19 patients see nurses only behind masks, face shields, and gowns, making it difficult for communication. This requires empathetic communication and attention to patients' psychological concerns and needs. Besides, according to the hospital's conditions, families were not allowed to visit the patients. Emotional distress and physical problems aggravate in patients who do not have a visitor [32] . As there is no specific treatment or prevention for the COVID-19, another challenge arises for nurses. Researchers frequently visit the patients and their families for research purposes, in which conscious patients and the families of unconscious patients are concerned about the confidentiality of giving information. The risk of disclosing patients' identities and social stigma is important for some people, creating ethical challenges for nurses [33, 34] . Patients' death is another challenge that nurses face when the patient's family is distressed. In some cases, there is even a conflict between the nurse and the family. The deaths of patients sadden nurses, and their colleagues' psychological support is also important to them. Among these problems, nurses face the moral challenge of behaving not to face moral problems [35] . Another challenge for nurses about patients' families is meeting families with a loved one who is critical in the intensive care unit. The visits are also very upsetting for families and nurses in intensive care. During the COVID-19 pandemic, the duration of visits is short. The distance between visits is long, and the emotional pressure on the family and the patient increases, which is a moral challenge for nurses [36] . Besides, disagreement between nurses and patients' families regarding patient care is an important source of nurses' moral distress [37] . Another result of the current study is on the equipment. This includes coordination problems to address the shortage of equipment and medical facilities, stability in emergency decision making under pressure to allocate equipment, allocation of sufficient resources through supply units, disruption of the supply chain of equipment. The equipment and facilities were not distributed equally in all regions of a country during the COVID-19 pandemic. Shortage of intensive care unit beds, staff, drugs, and equipment are the resource constraints in this epidemic. Following the increase in the number of patients in the COVID-19 pandemic, there are serious discussions about determining the criteria for allocating medical equipment in different countries. Nevertheless, in practice, nurses have to adjust the available equipment in the wards according to the patients' needs so that no problem arises [38] [39] [40] [41] . Also, the decision to allocate resources for the patients is a big challenge for nurses, making it difficult for nurses to make decisions [42] . Countries are different in terms of medical facilities. In less developed countries, the number of patients with COVID-19 is high due to cultural and health issues. The facilities and equipment are lacking. The medical facilities have not equally distributed in all country regions based on the number of critically ill patients. This is a challenge that increases for medical staff, especially nurses who spend most of their time with the patients [43] . Besides, the pandemic COVID-19 has significant problems in the health supply chains in five dimensions, including drugs, personal protective equipment, medical equipment, medical facilities, and blood. Medical equipment shortages and a large number of patients influence the distribution cycle of equipment promptly. They have become a challenge for nurses in many countries [44] . Another study results also show that it is difficult to predict demand due to the changeability, prevalence, and spread of the Covid-19. However, equipment shortages are costly and have a limited capacity to replace and distribute them. Supplying and replacing them is a problem for all countries, and equipment shortages are a significant challenge for nurses [45] . Pandemic is a global challenge that infected and died many people in communities. One of the strengths of this review study is that it was performed during the COVID-19 pandemic, which can help nurses. In addition, selected studies are from countries with high patient rates, and the results are objective. One of the weaknesses of this study is the use of review studies and a letter to the editor. Because it has no research aspect, and their results are not the views of research examples. It conveys the opinions of the authors. But overall, their results can be informative for managers. 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