Ethical problems among nurses during pandemics: A study from Turkey

Abstract

Background

Fighting Covid 19 at the forefront, increased the risk of infection and scarcity of resources have caused the ethical problems among nurses. It was planned to examine the ethical problems faced by nurses caring for Covid-19 patients and how they overcame the outcomes of these problems.

Methodology

This qualitative study was conducted with 20 nurses who caring Covid 19 patients in Turkey. Data were collected between January 24 and February 21, 2021. Purposive sampling was used in the study and a qualitative content analysis was performed.

Results

The research findings were discussed under two main themes as ethical problems and outcomes of ethical problems faced by nurses working in Covid-19 units. Then, 4 sub-categories for the theme of ethical problems (institutional problems, lack of knowledge and experience in nurses’ new place of duty, enforcing nurses to do doctors’ duties, problems encountered while caring for patients) and 2 sub-categories (emotions felt by nurses, coping strategies) for the theme of outcomes of ethical problems faced by nurses were defined.

Conclusion

The findings emphasize that nurses face ethical problems while giving care to Covid 19 problems. The nature of health services requires an ethical perspective to protect and improve human health, especially in uncertain, difficult and risky situations. Nurses should be supported to provide the ethical perspective in the best way.

Pandemics are health events in world history that lead to life changes and have a global impact [1]. Coronavirus (Covid-19) has become the most important health problem of the 21st century due to being highly contagious and having a poor clinical prognosis, particularly in patients aged 65 and over [2]. The World Health Organization (WHO) reported 146 million confirmed cases and 3 million deaths globally to date. Almost 5 million confirmed cases and 40 thousand deaths have been recorded in Turkey so far according to WHO statistics [3].

With the onset of the Covid-19 pandemic, all healthcare professionals around the world have entered a period that is very difficult in every respect [4]. Nurses make up the largest global health workforce during this pandemic [5]. Nurses working at the forefront of the Covid-19 pandemic have had to make difficult ethical decisions in the face of situations and ethical problems they have not experienced before [6].

An ethical problem is a situation in which it is hard to choose the right solution for various reasons [7]. Ethical problems are complex situations that require moral judgment and choice. These problems have no easy and precise solutions that can be defined as absolute right and wrong [8]. The pandemic has raised ethical issues concerning the need for sufficient intensive care units, personal protective equipment (PPE), healthcare personnel, and other resources [9]. The obligation of nurses to choose which patient to care for while protecting both patients and themselves brings them face to face with an ethical dilemma [10].

The three common ethical issues that will affect nurses are the safety of nurses, patients, colleagues and their families, the allocation of scarce resources, and the changing nature of nurses’ relationships with patients and families [11]. Ethical dilemmas, along with the duty of care in the pandemic, result in serious moral and emotional distress for nurses [12]. Nurses undertake many responsibilities such as identifying and diagnosing patients, saving lives, educating themselves and society about preventive measures, as well as caring for those who are not infected. Nurses work hard and face unpleasant and complex ethical problems, moral conflicts, patient deaths, and long working hours in practice [13], [14].

The ethical issues faced by nurses and other healthcare professionals in the current pandemic are complex and require multidisciplinary thinking, policies, and strategies to guide future nursing practice and education. Few studies deal with the ethical problems faced by nurses during the pandemic. As this study will show the experiences of nurses from Turkey regarding the pandemic, which has similarly affected nurses all around the world, it is thought that it will make an important contribution to the literature. This study aimed to examine the ethical problems faced by nurses caring for Covid-19 patients and how they overcame these problems and dealt with the consequences.

Materials and methods

Research type and location

This study was conducted as a phenomenological pattern study in clinics treating Covid-19 patients at Firat University Hospital and Fethi Sekin City Hospital in Elazig, which is located in the East Anatolia region of Turkey between 24 January and 21 February 2021.

Participants

The population of the study consisted of nurses working in the Covid-19 clinics of two large hospitals in Elazig and who provided patient care. The study used purposive sampling and the sample size was determined with the aim of repeating the data and reaching data saturation. The inclusion criteria applied to the purposive sampling are volunteering to participate in the study and having experienced ethical problems. The snowball and maximum variation sampling methods were used to select the participants. The purpose of snowball sampling is to recruit samples required for the study by asking people in the population who have the most information about the subject. To this end, the nurses who could be participants were determined by interviewing the head nurses at the pandemic clinics. After interviewing the head nurses at the pandemic clinics, the study's purpose and method were explained to the potential participants and those who agreed to participate in the study were interviewed. In addition to the head nurses at the pandemic clinic, the participants who agreed to be interviewed were asked the question “Do you know anyone who has information about this subject?” The maximum sampling method attempts to reveal different aspects of the subject by ensuring diversity among the individuals who may be involved in the subject being studied. In-depth interviews were conducted with a total of 20 nurses working at the state-owned hospital (11 nurses) and the university hospital (nine nurses) to provide maximum diversity in terms of the characteristics of the health institution where the nurses worked. After interviewing 18 participants, the researchers thought that data saturation had been reached. Two more participants were interviewed for control and data saturation was reached. The study was then conducted.

Data collection

The research data were collected using a “Personal Information Form” and a “Semi-Structured Interview Form.” The personal information form consisted of seven questions to ascertain the sociodemographic characteristics of the nurses. The semi-structured interview form included questions and problems designed to explore the ethical problems, feelings, experiences, and indecision faced by nurses while working in Covid-19 units.

Individual interviews, used to obtain descriptive data from the participants in their own words, were carried out by asking questions face to face to obtain information. The researchers chose this method to obtain information about the lives of the participants and predict how they viewed their lives [15]. As this study aimed to acquire data regarding the ethical problems experienced by nurses, the data were collected through phone calls with 14 participants and online video interviews with six participants, all of whom had signed a voluntary participation form and agreed to participate in the study. The telephone calls were recorded on tape, and online calls made via the Google Meet application were recorded on video, with verbal and written consent. The interviews lasted a minimum of 15 minutes 39 seconds and a maximum of 36 minutes 57 seconds.

The interviews were planned with the participants in advance over the phone and were held when they were available in quiet environments where the interviews would not be interrupted. Individual in-depth interviews were held with the participants. When asking the interview questions, the necessary changes were made according to the flow of the conversation and the questions were asked in a chat-like style and in an encouraging way, and feedback was given. In addition, depth was added to the interviews by asking questions such as “Did you say that…?” and “Should I understand this from what you said?” to increase the validity of the study. The participants’ answers to the questions, their expressions, and the questions that they hesitated to answer were all noted by the researcher. The recorded interviews were transcribed by the researchers, and the participants’ statements were quoted verbatim. The records were listened to repeatedly and checked for accuracy against the data in the written text.

Data analyses

The research data were analyzed using the MaxQda 2020 package program. Inductive qualitative content analysis was performed when analyzing the data to create the themes and codes covered by the study. Inductive content analysis reveals the underlying concepts of the data and the relationship between these concepts through coding. The steps of coding the data, finding themes, arranging the codes and themes, and interpreting the findings were followed respectively when analyzing the data. First, open coding was done; second, these codes were categorized, and finally, themes were created. After the themes were created, the findings were interpreted and made into a report. The report included direct quotes and a description of the phenomenon within the framework of the concepts and themes.

Ethical considerations

This study was approved by the Ethics Committee for Non-Interventional Studies of Firat University (No. 2021/04 - 02). Written consent was obtained from all of the participants and all of them were informed about the aim of the study. Participants were told that the recorded data will be used for research purposes only and that the records will not be shared with anybody.

Results

A total of 20 nurses working in the Covid-19 units of two hospitals participated in the study. The mean age of the nurses in the study was 28.42 ± 6.30 and their average work experience was 6.25 ± 6.84 years; 65% of the nurses were single and 95% were women (Table 1 ).

Table 1.

Socio-demographic characteristics of the participants.

Characteristics	n (%)
Marital Status
Married	7 (35)
Single	13 (65)
Education
Bachelor degree	17 (85)
Master degree	3 (15)
Gender
Female	19 (95)
Male	1 (5)
Hospital
Public	11 (55)
University	9 (45)
Position
Nurse	19 (95)
Nurse executive	1 (5)
Clinics
Covid–Emergency	2 (10)
Covid–Unit	7 (35)
Covid–Intensive Care	11 (55)

The research findings were discussed under two main themes, namely, the ethical problems faced by the nurses working in Covid-19 units and the consequences of these ethical problems. The theme of ethical problems faced by nurses was further divided into four categories and the theme of consequences of ethical problems faced by nurses was divided into two categories. The themes and categories are shown in Fig. 1

Figure 1.

The hierarchical code-subcode model of the first theme.

Theme 1: Ethical problems faced by nurses

The four categories determined in light of the comments made by the participants were institutional problems, nurses’ lack of knowledge and experience, doctors’ neglection of duties, and ethical problems encountered while providing care to patients.

Category 1:Institutional problems

Subcategory 1: Lack of medical devices and PPE

Most of the participants mentioned that due to the rapid increase in the number of patients at the start of the pandemic, devices such as ventilators, monitors, and nebulizers and the amount of PPE remained insufficient. They stated that the lack of medical devices, in particular, negatively affected patient care. They also stated that some clinics had problems due to broken or malfunctioning devices, so they had to choose among patients whose condition worsened to allocate the available resources.

There were broken monitors, we couldn’t decide who to monitor when several patients got worse at the same time. Doctors decided based on the patients’ overall condition, age, and saturation (N9).

Due to the lack of ventilators, we continued to provide respiratory support with Ambu (resuscitators) to some patients for a while. We sometimes used a portable ventilator (with a maximum duration of use of 4 or 5 hours) (N18).

While we could not find any surgical masks, doctors had N95. We started to think about where they came from and why we were not given any. We felt like a distinction was being made among healthcare professionals (N5).

We experienced problems in procuring PPE, especially in the early stages of the pandemic. We were not able to change dirty and wet overalls as there was not enough PPE. There were days when we worked with three masks or just one mask a day. However, this problem was solved later (N11).

Subcategory 2: Staff shortage

There were cases where there was a shortage of both nurses and other staff (doctor and medical secretary) due to overcrowding in some clinics, particularly the emergency units of hospitals. This situation further increased the workload of nurses whose working conditions were already difficult due to the pandemic. The nurses also reported that they had to fulfill tasks other than their duties and responsibilities to address patients’ grievances, and that this adversely affected their motivation and patient care.

The number of nurses in the emergency unit could not meet the increasing number of patients, and therefore patients in the yellow area were kept waiting while patients in the red area were given care (N13).

For example, we sometimes had to do some computer operations that the secretary is supposed to do. Sometimes, we asked for the medications that the doctor should have asked for. The patient had a fever and medication had to be provided. It was our duty and responsibility to provide treatment and care. We did both the secretary's job and the doctor's job (N8).

Category 2:Lack of knowledge and experience in nurses’ new place of duty

Those nurses who had been in contact with patients for the longest time during the pandemic stated that they experienced ethical problems due to the lack of experience and knowledge about the clinic they worked in. Nurses transferred in from other clinics due to the pandemic stated that they did not have time to adapt to the unfamiliar environment and conditions and therefore they constantly felt anxious.

I have never worked in intensive care before because it requires a lot of experience and knowledge. I was very nervous at first. For example, a nasogastric tube was placed in a patient, I had never done that before (N19).

While I was preparing the drugs, there were drugs I was seeing for the first time. There were many times when I had a dilemma because of questions such as what should I pay attention to in treatment (N7)?

We did not have time to learn about the differences in treatment and care in the new work environment. We worked by watching the other nurses and asking questions from time to time (N2).

Category 3:Forcing nurses to do doctors’ duties

The nurses in the study frequently stressed that doctors did not want to do their job during the Covid-19 pandemic. It has been reported that doctors are trying to transfer their duties to nurses to reduce contact with patients infected with Covid, and there were arguments when the nurses did not agree to this, and communication within the health team was disrupted. This situation was interpreted by the nurses as doctor-led bullying.

I told the doctor that a patient had Covid-19 symptoms and that a PCR test should be done. The doctor did not administer the test, saying that he did not think the patient was Covid-19 positive. When the same patient was tested two days later, it turned out to be positive (N19).

Doctors tell you do the PCR test, for example. When I stated that I would not do it, he asked me to take blood from the patient. This was unnecessary because the patient was stable and the blood test had just been done (N18).

For example, four assistants were staying at home one night shift when the patients worsened. I called and said you need to come. One of the doctors said no I can’t come, it's not my turn, it's his turn (N20).

I have witnessed many times when the doctor asked about the patient's condition over the phone and did not want to come and see the patient in the unit (N15).

Category 4: Problems encountered while caring for patients

Subcategory 1: Being unwilling to intervene

Most of the nurses stated that they did not hinder patient care, although they sometimes felt reluctant to provide care due to the risk of infection while providing care to patients during the pandemic. They stated that they experienced some problems due to patients having little awareness about wearing masks during the first period of the pandemic. In addition, the presence of nurses who acted without taking pre-intervention protective measures in emergencies was another problem.

There were times that I didn’t want to do. But you do it because it is your duty. It does not prevent me from performing my duty (N2).

Sometimes patients didn’t care about us either. They were coughing into our faces, not wearing their masks. When we were going to do a procedure, it was really hard to convince the patient (N5).

Even though I take care not to go near the patient without wearing a gown, a friend of mine runs immediately with one mask and one glove to take the patient's blood and attach an oxygen mask so that the patient is not aggrieved (N10).

Subcategory 2: Excessive empathy

Most of the nurses stated that despite the uncertainty and fear they experienced while caring for patients, they sometimes showed excessive empathy and acted by putting the well-being of the patients before their own. They also stated that there were moments in which they showed excessive empathy Toward patients because the pandemic did not allow patients’ relatives to visit them. As a result, while trying to help patients meet their physiological needs and give them time to express their feelings, nurses’ contact with patients increased.

I could have been in his place; he could have been a member of my family. Whenever this occurred to me, I suddenly felt guilty. He was alone and was not doing well (N3).

While caring for COVID-19 patients, we have the right not to enter without PPE, even if the patient is in arrest. But I remember wearing an N95 and going inside many times, sometimes without even wearing a gown (N6).

Fig. 2shows the hierarchical code-subcode model of the first theme. In this model, the frequency of the codes belonging to the first theme is seen.

Figure 2.

The hierarchical code-subcode model of the second theme.

Theme 2: Consequences of the ethical problems faced by nurses

Category 1: Emotions felt by nurses

The nurses stated that they experienced worthlessness, fatigue, and burnout due to the problems they experienced during the Covid-19 pandemic.

Subcategory 1: Feeling of worthlessness

The nurses said they felt worthless due to reasons such as positive discrimination in favor of doctors in PPE distribution, constant rotation of clinics they work in, and newcomers to the profession often working in different places, while experienced nurses mostly work in the same place.

Even in the distribution of masks, there were different practices between us and the doctors. We felt quite worthless (N12).

As we are new graduates, they can have us do everything until we become seniors. I do everything. I have experienced this a lot, so I felt very bad. I have experienced this feeling of worthlessness many times (N16).

Subcategory 2: Fatigue-burnout

The nurses stated they felt emotionally tired due to the fear and anxiety created by the pandemic, and that the uncertainty and changing working conditions pushed them to burnout. Having Covid-19 patients among family members, not being able to see their loved ones (such as spouse and child, mother), and having to live in quarantine caused them to experience these feelings more.

I had to go to work more often during the pandemic as some of my teammates were Covid-19 positive. We frequently witnessed deaths due to Covid-19 while working, it was very tiring in every sense (N3).

The first periods of the pandemic, in particular, were very intense and we started to take care of patients directly without any training. Think about it, you are just starting out in the profession, you witness one, two deaths every day, and even more deaths on some days (N17).

Category 2: Coping strategies

Subcategory 1: Getting support

The nurses stated that they resorted to various support mechanisms to cope with the heavy workload, being infected with Covid-19, losing their friends, and other problems during the pandemic. One of the coping methods is getting professional support. The nurses stated that they and their teammates often tried to support each other as they could not get social support from their relatives.

Yes, I get professional support. Since I can no longer tolerate what I have experienced myself, I try to feel good somehow with medication (N5).

My friends from work and I were comforting each other (N17).

It felt good for me to spend time outdoors with my close friends and sometimes with my family, paying attention to social distancing (N1).

Subcategory 2: Praying and other methods

The nurses stated that the emotions experienced and the need for relief that emerged as a result of these emotions continued throughout the pandemic and that they frequently prayed as a means of relaxation. In addition, they tried to find solutions themselves to cope with the problems, and they used such methods as reading books and doing various activities at home.

I always tried to relax by praying by myself a lot and asking for God's help (N8).

I tried doing different activities that would make me feel good when I was at home (N5).

When I came home, I tried to read books regularly every day because it both relieved my stress and relaxed me. Other than that, I took care to sleep for at least six hours (N18).

Subcategory 3: Considering quitting the profession

The nurses stated that they felt burnout due to the risks they were exposed to, the intense workload, and the emotional stress experienced as a result of losing patients, and that they were thinking about resigning as a solution.

Yes, I considered quitting many times but it was prohibited (N5).

At first, I really considered quitting because we were working very intensely and under a lot of stress. Too many patients were coming in and testing positive (N6).

Fig. 3 shows the hierarchical code-subcode model of the second theme. In this model, the frequency of the codes belonging to the second theme is seen.

Figure 3.

The hierarchical code-subcode model of the second theme

The code cloud is shown in Fig. 4 . The codes written in large fonts in the code cloud are the most frequently expressed codes throughout the study. The codes written in the small font are the codes that are expressed less frequently throughout the study. For example, the Lack of Knowledge and Experience in Nurses’ New Place of Duty category is the most intensely expressed category in the entire study.

Figure 4.

Themes and sub-themes.

Discussion

Ethical challenges are common in clinical nursing practice, and a contagious environment can more easily confront nurses with ethical challenges [16], [17]. In the study, nurses who cared for Covid-19 patients under difficult conditions encountered many different ethical problems, experienced negative emotions along with these problems, and tried to use their own coping strategies.

Ethical problems faced by nurses

According to the literature, nurses, who are at the forefront of the fight against Covid-19, experience ethical problems in many issues such as the obligation to provide care despite being at risk of infection, patient priority, and allocation of resources [18], [19]. These problems have made the management of care more complicated, especially during the pandemic [20], [21]. One of the most important and common ethical problems experienced by the nurses in this study during the pandemic is “having to select patients due to the lack of medical devices for patients and personal protective equipment for nurses as a result of the uncontrolled increase in the number of patients and their use of scarce medical devices.” The nurses emphasized that this situation negatively affected patient care. Similarly, the nurses caring for Covid-19 patients stated they are victimized in many areas such as access to personal protective equipment, infection control measures, clinical knowledge, and skills training in infectious diseases, environmental control, and inequalities, thus leading to ethical problems [22]. The ethical problems that other studies revealed were neglect; patients dying with no dignity and alone; taking into account old age, disability, weakness, sex, and ethnicity when allocating limited medical devices, not prioritizing the care of the elderly, and seeing deaths as less important during the Covid-19 pandemic [16], [17], [22]. In one study addressing ethical dilemmas during the pandemic, one-third of nurses reported that they were afraid of going to work due to inadequate protection and possible infection, and 40.9% of them were afraid of caring for Covid-19 patients. In another, 81.4% of the nurses stated that the maximum age to be allocated scarce resources should be 84 when there are insufficient supplies, but they believed that each patient had the right to receive optimal treatment regardless of age and medical history. Meanwhile, 74.7% stated that they did not believe that they had the right to refuse to treat certain patients [18]. In such ethical dilemmas, nurses find it hard to make and implement decisions for themselves and their patients.

The study also saw that the number of nurses and other healthcare workers was insufficient due to the high number of Covid-19 patients and that this increased the workload under already difficult working conditions with nurses performing tasks other than their duties. This resulted in a decrease in the nurses’ performance and the quality of care they gave. In healthcare areas, nurses are the closest to patients and constantly communicate and interact with them. Since care is a continuous process, nurses spend more time with patients than other healthcare professionals do [23], [24]. Therefore, of all the healthcare professionals, there is a noticeable need for nurses. Any lack of healthcare professionals is likely to lead to ethical problems related to failure or delay in the care and treatment of patients or medical errors. A related study revealed the inadequate response of a limited number of healthcare workers to urgent needs to reduce the risk of infection and the decrease in their sense of responsibility and performance with increasing burnout as problems related to professional ethics [25]. Another problem that emerged in the study was that nurses working in different units were transferred to pandemic units with a high care burden due to patient overcrowding, and this change made in a short time caused anxiety due to the lack of experience and knowledge. Considering the average work experience (6.25 years) of the nurses in the study, it is inevitable, according to the literature, that care will be affected due to insufficient knowledge, skills, and experience [16], [23], [26]. Similarly, one qualitative study conducted during the Covid-19 pandemic reported that nurses could not adapt to the new work environment and job responsibilities and they could not complete their role change in a short time, and they lacked knowledge and skills [16]. As in many parts of the world, existing clinics in Turkey, too, were closed and pandemic clinics and hospitals were established to meet the need to hospitalize Covid-19 patients and provide intensive care. Nurses were assigned to pandemic clinics, emergency services, and intensive care units at this time, and there was serious patient overcrowding in these clinics [26]. Young, dynamic, and newly graduated nurses usually work in the Covid-19 clinics and intensive care units in Turkey [23]. The average work experience time of the nurses participating in this study is also low. It is stated in the literature that it is mainly these nurses who face ethical problems and this may be due to lack of information and lack of self-confidence [26].

In the study, it was observed that doctors tried to transfer their duties to nurses to reduce contact with Covid-19 patients, and when the nurses did not agree to this, there were conflicts and interpersonal relations were negatively affected. This situation can be considered an ethical violation for nurses in defiance of the principle of justice and equality. Similarly, one qualitative study reported that nurses caring for Covid-19 patients were exposed to the infectious environment much more than doctors, that they were disturbed by the ambiguity and inequality between them and doctors, and that doctors tried to boss nurses and put their own responsibilities on them [16]. Furthermore, Crisham (1981) stated that institutional policies for nurses that contradict their own concepts of justice, being forced to obey the physician, and uncertainties regarding authority and responsibilities all create pressure when making decisions in the face of ethical problems. This indicates that another ethical problem may arise by preventing the adequate and timely delivery of care given to patients [27].

According to the statements of the nurses in the study, the patients did not take care to wear masks, the nurses behaved timidly when providing care due to the risk of infection, and had to practice without taking protective measures, especially in emergencies. This points to another ethical problem in which the nurse tries to be of use to the patient, even though he/she is often faced with a health risk. In the nursing care process, there can be times when the patient's values and expectations come into conflict with the professional values of the nurse and what is expected of him/her. Studies have stated that some decisions made by nurses in such situations can cause moral distress, that is, they feel that they know the right thing to do but cannot do this for personal or professional reasons [17].

The study revealed that nurses provided care by overly empathizing and putting the well-being of the patients before themselves, and the nurses needed more support because they were not accepted as companions. While it is not wrong for nurses to approach patients who are lonely and often close to death with empathy, it is thought that excessive empathy imposes an emotional burden on nurses and can negatively affect the care of other patients by reducing motivation. According to other studies, nurses reflect their values, life experiences, cognitive skills, moral sensitivity, and judgment in the care they give and the ethical decision-making process while they are under the influence of many environmental factors and pressures [[28], [29]]. The important thing here is to exercise restraint in empathy and to balance psychological well-being to be of use to patients. Logic and feelings must be in harmony when making ethical decisions [30].

Outcomes of ethical problems faced by nurses

According to the nurses’ statements, the distribution of personal protective equipment in favor of the doctors and the frequent rotations of the clinics where newcomers were working caused nurses to feel worthless. This distribution of resources within the healthcare team is an ethical issue that goes against the principle of justice and equality. This principle emphasizes the fair distribution of resources and the distribution of harm as well as benefit, without regard for personal benefit, while providing healthcare services [30]. Since all healthcare professionals need to be highly motivated during the pandemic, this sensitive problem, which could negatively affect communication and interaction within the team, must be addressed and resolved in favor of the nurses who are the injured parties. It is thought that the constant rotations of the clinics where the nurses work will decrease the working performance in parallel with the failure to adapt to the clinic and this will affect the patient care negatively. A study conducted in parallel with this determined that moral distress was higher in nurses whose working environment had changed [28]. In the study, some nurses stated that they experienced emotional fatigue due to long-term anxiety, uncertainty, and burnout as a result of changing working conditions during the pandemic. Nurses working in conditions that they had not experienced before in the pandemic were also deprived of their families, which could be the most effective source of support in coping with these difficulties. Other studies have reported that caregivers who bear the burden of a collapsing health system in the Covid-19 pandemic experience various degrees of emotions and reactions such as guilt, fear, burnout, or intense stress [29]. In addition, studies have reported that nurses were disappointed when they could not provide the necessary care for their patients, they felt ineffectual due to constant worries that they could not treat chronic patients, and though that they might endanger their health and that of their colleagues. Encountering too many deaths, patients dying in isolation and alone, fear of being infected themselves, the lack of protective equipment, infecting colleagues, families, friends due to lack of protective equipment or established protocols all threaten emotional and psychological well-being [31]. Nurses need information about Covid-19, healthcare ethics, nursing skills and psychological resilience strategies, ethical support, coping tools, and even therapy to prevent or alleviate the negative effects of these traumas on their psychosocial health, or to increase psychological resilience. Organizations must provide these resources to ensure the well-being of healthcare workers during and after the pandemic [32].

When the statements of the nurses in the study regarding coping methods were considered, it was seen that some received professional support, tried to get support from their teammates, prayed, read books, did various home activities, or tried to find solutions on their own. As can be seen, nurses have resorted to different ways of coping with ethical problems individually or collectively. It is thought that this situation either isolates nurses or compels them to seek collective support. Instead, it may be beneficial if the institutions they work for establish social support units for healthcare professionals immediately and operate them effectively, follow up nurses’ social and psychological needs and situations, support ethical care and psychological resilience, in particular, and integrate supportive practices such as yoga, meditation, music therapy, and psychotherapy into the working environment. Similar results were obtained in another qualitative study conducted with nurses caring for Covid-19 patients [16], [33]. These methods of coping with all ethical problems can be attributed to the nurses’ religious beliefs, individual characteristics, cultural backgrounds, and work experience. Studies indicate that religion and culture can influence ethical decision-making [34]. The religion of Islam, which is the religion of the majority of Turkish society, emphasizes the sanctity of life, mercy, and gaining strength by asking from God. The study revealed that coping strategies during the pandemic process did not work on some nurses and they considered quitting their jobs. In a different study, nurses said that they were not considering quitting the profession despite the stress, risks, emotional burden, insufficient support, and protection at work. They reported that this was due to their strong commitment to care, but they needed a supportive environment for their needs and ethical concerns [18]. This difference may be due to nurses’ different personal and professional values, psychosocial and economic status, and working conditions.

Limitations

Our study has several limitations. This was the first study to investigate the ethical problems faced by nurses during the pandemic in Turkey. In addition, many nurses had concerns about the research topic because it would not be nice for hospital administrators to share some situations (limited resources and broken devices) with us. The nurses thought that what they were going to say would create a disadvantage for them. Due to this concern, the nurses who participated were mostly young. Furthermore, the results of our study may vary by geographical regions.

Conclusion

The nature of health services requires an ethical perspective to protect and improve human health, especially in uncertain, difficult, and risky situations [20], [21]. The ethical problems faced by nurses are listed as the problems stemming from the institution they work in and the new work environment, the problems experienced due to the doctors’ unwillingness to fulfill their duties, and the problems encountered while providing patient care. To overcome the negative emotions experienced as a result of these problems, they resorted to getting support, prayer, and other methods. There were even those who considered quitting the profession. Regardless of the type of the healthcare institution, any PPE and medical device support should be provided by the government in full. Action plans and policies should be prepared against similar epidemic situations. Hospital administrations should make arrangements to provide nurses with professional support so they can cope with negative emotions. The health status of nurses, who play the most important role among health professionals in protecting public health and providing care, should be addressed from all aspects.

Author contributions

P.S. designed the study and helped oversee it; O.D.Y and M.U. contributed to data collection and data analysis; F.E and N.B. contributed to the transcripts.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Disclosure of interest

The authors declare that they have no competing interest.