Nurses’ Moral Distress in Caring for COVID-19 Patients

Due to the epidemic of Coronavirus Disease 2019 (COVID-19), numerous patients have been hospitalized in the Intensive Care Unit (ICU) and some have expired in Iran and around the world. COVID-19 highlighted various difficult ethical issues encountered by healthcare providers in caring for patients and families. Nurses, as frontline healthcare workers, spend most of their time with patients; therefore, it is essential to address the ethical concerns they face [1].


Use your device to scan and read the article online
Dear Editor romoting the principles of professional practice is an approach to build trust among individuals concerning the medical profession. Individuals' trust in nurses plays a crucial role in patient care; thus, is of significant importance. The main cornerstone in nursing care is the existence of nurses with professional ethics.
Due to the epidemic of Coronavirus Disease 2019 (COVID-19), numerous patients have been hospitalized in the Intensive Care Unit (ICU) and some have expired in Iran and around the world. COVID-19 highlighted various difficult ethical issues encountered by healthcare providers in caring for patients and families. Nurses, as frontline healthcare workers, spend most of their time with patients; therefore, it is essential to address the ethical concerns they face [1].

Attention to safety in nurses
In the fight against COVID-19, ensuring the safety of nurses and other forefront healthcare workers is an important ethical concern. Nurses have to work under conditions that pose fundamental and uncertain risks to their health. Although nurses often voluntarily care for patients in high-risk situations, deficiencies and inappro-priate conditions (e.g. the lack of protective facilities), prolonged presence in the wards to compensate for staff shortages, and patient care threaten their health; accordingly, such conditions jeopardize more effective patient care. Due to these limitations, nurses cannot provide effective care and experience moral distress, psychological distress, and Post-Traumatic Stress Disorder (PTSD) [2].

Providing healthcare resources for patients
COVID-19-induced conditions have necessitated more serious (and ethical) attention to the prioritization of care and resources in different care units. Making the right decision about the patient is among the ethical aspects that nurses encounter in special wards; it imposes a great moral burden on the healthcare staff. Nurses must provide care, justice, transparency, and protection in a way that does not incur legal and conscientious responsibilities. Patients with COVID-19 are admitted to hospital wards with different care needs. They require adequate medical care, beds, ventilators and oxygen therapy, medicine, and so on. When nurses are unable to provide effective care due to a large number of hospitalized patients and the lack of facilities, they face moral contradictions. Even in the UK, due to a large number of patients, the situation changed; normally, in the ICU, the ratio of nurses to patients was 1: 1, i.e., altered to 1: 6. Consequently, it affected care and caused ethical P problems among nurses. Accordingly, they could not properly meet the care needs of patients. They were also forced to use inexperienced and unskilled service personnel who had not even received the necessary training in the waste disposal and equipment cleaning. This created a moral dilemma for nurses, which may increase the transmission of infection, as well as non-specialist personnel becoming infected with the coronavirus and increasing mortality [3,4].

Nurses' communication with patients and their families
During the COVID-19 epidemic, nurses had to communicate with patients while wearing masks and protective clothing to care for patients. Under these conditions, sympathy with the patient and the part of the care that provides the patient morale remains inadequate. Patients with unstable vital conditions require further comfort from nurses, i.e., not done well with these conditions [5]. Families' communication with the ward to meet with patients is limited to face-to-face and telephone visits; in the event of a patient's death, families feel unpleasant [4] and may have bitter memories of the hospital for the rest of their lives. Nurses need to morally understand the patient's family to prevent them from negative feelings if losing their loved ones. During the patient's hospitalization, conditions should be created to allowing for face-to-face or video contact between the patient and the family. Such measures can help the patient recover and increase the patient's mood and problems of separation from the ventilator [6].
The challenge for nurses and other healthcare workers is to manage these scenarios potentially humbly with innovative solutions. The patient and the family need the support of nurses, which must also be considered. The effects of COVID-19 on nurses and other healthcare workers might be long-lasting in post-COVID-19.
Healthcare systems must identify these factors to reduce nurses' moral distress. This is because assisting nurses is effective in caring for patients.
Other support services and programs for nurses, such as providing equipment and facilities, psychological services, and audio-visual services to better communicate the patient with the family to address psychological distress problems or other concerns may arise in the future.
The COVID-19 pandemic is a lesson for humanity. Thus, health officials and policymakers are suggested to provide better services to healthcare workers and patients through effective planning.

Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.