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Abstract
Background:
Whenever there has been a worldwide contagious disease outbreak, there have been reports of infection and death of healthcare workers. Particularly because emergency nurses have contact with patients on the front line, they experience ethical problems in nursing while struggling with infectious diseases in an unfavorable environment.
Objective:
The objective of this study was to explore emergency nurses’ ethical problems and to identify factors influencing these problems during the outbreak of Middle East respiratory syndrome–coronavirus in Korea.
Design and sample:
For this cross-sectional study, a questionnaire survey was conducted with emergency nurses working in six hospitals selected through convenience sampling from the hospitals designated for Middle East respiratory syndrome–coronavirus patients in the capital area.
Ethical considerations:
This research was approved by the Institutional Review Board of G University in Korea.
Results:
The findings of this study suggest that during the Middle East respiratory syndrome–coronavirus outbreak, emergency nurses experienced ethical problems tied to a mind-set of avoiding patients. Three factors were found to influence emergency nurses’ ethical problems (in order of influence): cognition of social stigmatization, level of agreement with infection control measures, and perceived risk.
Conclusion:
Through this study, we obtained information on emergency nurses’ ethical problems during the Middle East respiratory syndrome–coronavirus outbreak and identified the factors that influence them. As found in this study, nurses’ ethical problems were influenced most by cognitions of social stigmatization. Accordingly, to support nurses confidently care for people during future health disasters, it is most urgent to promote appropriate public consciousness that encourages healthcare workers.
Introduction
The first patient of Middle East respiratory syndrome–coronavirus (MERS-CoV) was discovered in Korea on 20 May 2015. This discovery was followed by the rapid spread of the disease, and 186 patients were diagnosed with the disease within a month.1 Of these patients, 89 (47.8%) were found to be infected in an emergency department (ED), showing that MERS-CoV was transmitted mainly through EDs in Korea.2 This situation occurred because most of the patients presenting a high fever and cough visited or were referred to an ED in order to be examined for MERS-CoV infection, but they were not isolated while they stayed at length in the ED without definite diagnoses.2,3
As MERS-CoV spread through the hospitals, 41 healthcare workers (22.0%) were infected with the virus.4 With the worldwide emergence of novel infectious diseases, such as MERS-CoV, severe acute respiratory syndrome (SARS), and avian influenza I (H5N1), in the last 15 years, healthcare workers have been at high risk of infection from such diseases while caring for patients.5 In particular, nurses are most likely to have immediate contact with patients; therefore, they are easily exposed to the risk of infection. According to one study, more than 50% of healthcare workers infected with MERS-CoV were nurses.6 In 2003, during the worldwide pandemic of SARS, a highly contagious infection with respiratory distress similar to MERS-CoV, ED doctors and nurses experienced ethical conflicts and severe stress as they had to face the disease on the front line of defense in the battle against this new and potentially fatal contagion.7–9 Additionally, during the SARS catastrophes in Taiwan, Toronto, and Singapore, many nurses and doctors in EDs experienced psychological discomfort due to situations where they cared for patients with highly contagious diseases.7–9
These previous cases, in which healthcare workers were exposed to the risk of fatal infection from a pandemic disease such as SARS, raised a pressing issue regarding healthcare workers’ ethical problems in caring for patients who place them at risk of newly emerging infectious diseases.10,11 According to the study by Maunder et al.,8 prominent psychological problems experienced by healthcare workers during the outbreak of SARS were fear, anxiety, anger, and frustration. During the SARS outbreak, many healthcare workers experienced ethical conflicts between the fear of infection, anxiety, and excessive workload and professional obligation or responsibility to care.8,9 Based on the literature review, during the outbreaks of respiratory transmitted diseases, nurses experienced ethical problems between nursing professionalism and the risk of contagion when providing nursing care to patients. Moreover, during the outbreak of MERS-CoV, reported to be high in infectiousness and fatality, emergency nurses who had contact with patients in the front line of care would experience more ethical problems in providing nursing care to patients.
Literature reviews have also reported possible variables that might influence the ethical problems experienced by nurses providing patient care during pandemic situations. Tzeng12 found that nurses’ levels of agreement with general SARS infection control measures were a significant predictor of nurses’ fulfilling their professional care obligations. Furthermore, according to a study on nurses’ fear of avian influenza (H5N1) and their professional obligations,13 nurses’ perceptions of the sufficiency of their hospitals’ infection control measures and equipment were significantly correlated with their willingness to care for infected patients. According to previous studies, what is more, nurses’ ethical problems during a pandemic might be affected by perceived risk and cognitions of social stigmatization.8,9
Previous studies have explored ethical conflicts and problems experienced by nurses in clinical environments such as emergency care, end-of-life care, and critical care.14–17 However, there are few previous studies analyzing the ethical problems experienced by emergency nurses on the front line of patient care during an outbreak of a contagious disease. In particular, there is no study on emergency nurses’ ethical problems during the latest MERS-CoV outbreak in Korea. Thus, this study reviewed literature in this context8,9,12,13 and constructed a theoretical conceptual framework looking at how four variables (perceived risk, cognition of social stigmatization, the level of agreement with infection control measures, and the perception of hospital measures against MERS-CoV) may have influenced emergency nurses’ ethical problems in caring for patients during the MERS-CoV outbreak.
Aims
The aim of this study was to explore nurses’ ethical problems and to identify factors influencing these problems during the 2015 outbreak of MERS-CoV in Korea. The ultimate purpose of this study was to enhance the understanding of nurses’ ethical problems and to expand the knowledge of ethical problems in nursing care to patients with contagious diseases, especially in pandemic situations.
Method
Design
This was a quantitative research design study conducted using a cross-sectional, descriptive survey to identify factors influencing emergency nurses’ ethical problems during the MERS-CoV outbreak in Korea. The study was conducted in two phases. First, a pilot study was conducted to test the feasibility and reliability of the measuring tools. After the pilot study’s completion, the main survey was conducted to investigate factors influencing emergency nurses’ ethical problems during the MERS-CoV outbreak.
Participants
For this study, emergency nurses were selected through convenience sampling from EDs of six hospitals. During the outbreak of MERS-CoV in Korea, 15 hospitals throughout the country were designated to accommodate MERS-CoV patients. Of them, the researchers selected six hospitals located in the capital area including Seoul, Incheon, and Gyeonggi-do and studied 180 nurses working at the EDs of those hospitals.
For parametric statistics, we calculated the sample size assuming an effect size of 0.15 with an alpha level of 0.05 at a power of 0.80, with five predictors using the G*power 3.1 program.18 According to this calculation, 146 participants were needed to conduct linear multiple regression, but the survey was actually conducted with 180 emergency nurses from the six hospitals. In additions, by analyzing 169 questionnaires as the final valid data, this study satisfied the requirement of the minimum sample size for linear multiple regression, which was 146.
Ethical considerations
This research was approved by the Institutional Review Board of G University in Korea (no. 1044396-201508-HR-041-01). The study’s purpose was explained by the researcher to the head ED nurses of the six selected hospitals, and after their consent was obtained, the questionnaires were delivered. In order to protect participants’ privacy and maintain confidentiality, a research assistant distributed the sealed envelopes and collected the questionnaires after the participants voluntarily signed the informed consent form.
Data collection
Six hospitals were randomly selected by the researcher from the 15 hospitals designated for MERS-CoV patients in Seoul, Incheon, and Gyeonggi-do, where most of the MERS-CoV patients were concentrated. Next, the researcher explained the purposes of this study to the Nursing Department of each hospital by phone and obtained permission for data collection. The questionnaires were distributed to 180 nurses who were sampled from the six hospitals and agreed to participate in the research in anticipation of attrition in August 2015, before the cessation of the outbreak. A total of 172 questionnaires (95.6% response rate) were returned. Of these, 169 were used in the final analysis; three incomplete questionnaires were excluded.
Measures
The survey questionnaire consisted of one demographic section and five measuring variables sections: (a) ethical problems in nursing care with patients during the MERS-CoV outbreak (nine items), (b) perceived risk of MERS-CoV infection (one item), (c) cognition of social stigmatization regarding disadvantage due to caring for patients during the MERS-CoV outbreak (three items), (c) agreement with infection control measures in caring for patients with fever or suffering from MERS-CoV (six items), and (e) perception of hospital measures against MERS-CoV (three items).
Demographics
The 13 questions concerning general characteristics included participant age, gender, marital status, religious affiliation, level of education, hospital scale, length of employment, salary, position, and whether they had any MERS-CoV education or MERS-CoV nursing experience, as well as whether they had a child or lived with family members.
Ethical problems in caring for patients
The researchers developed the scale for ethical problems experienced in caring for patients during the outbreak of MERS-CoV by extracting 10 items from a review of previous studies and the researcher’s clinical experiences.9,12,13 However, one item was removed because of its low relevancy, as indicated in the preliminary survey, and nine items were used in the main survey. The content validity (CVI) of this scale was rated (1: “Not relevant”; 4: “Very relevant”) by two infection control nurse practitioners, one nursing professor, and an ED head nurse. When calculated with the ratio of the number of items given 3 or 4 points to the total number of items assessed by four experts, the CVI was 0.90.
Each item was answered on a 4-point scale (1: “Not at all”; 4: “Absolutely yes”). The reliability (Cronbach’s α) of the scale was 0.78 in the preliminary survey with 15 emergency nurses and 0.83 in the main survey.
Perceived risk of infection
In order to measure the perceived risk of MERS-CoV infection, a visual analogue scale (VAS) was used. To the statement “I worry about being infected with MERS,” the respondent answered by marking the scale, which ranged from 0 to 10 cm. The marked position was measured to one decimal place. A high score denotes a highly perceived risk of acquiring MERS-CoV.
Cognitions of social stigmatization
The researchers composed four items using a 4-point scale primarily through a review of previous studies.7–9 The CVI of this scale was rated (1: “Not relevant”; 4: “Very relevant”) by two infection control nurse practitioners, one nursing professor, and an ED head nurse. One item, assessed with 1 or 2 points, was removed, and the restructured scale of three items was used in a preliminary survey with 15 emergency nurses, where ambiguous phrases and words were corrected. The final CVI (calculated with the ratio of the number of items given 3 or 4 points to the total number of items assessed by four experts) of the scale was 0.75, and its reliability (Cronbach’s α) was 0.79 in the preliminary survey and 0.85 in the main survey. A high score signifies that the nurse perceives that he or she will be ostracized or suffer disadvantage if people know he or she works in a hospital during the outbreak of MERS-CoV.
Agreement with infection control measures
In order to measure the level of agreement with infection control measures, the researchers prepared six items using a 4-point scale (1: “Never do”; 4: “Always do”) based on the Infection Prevention Guidelines for Healthcare Workers in the MERS-CoV Response Guideline provided by the Korea Center for Disease Control and Prevention (KCDC).19 A high score indicates that the participant performs MERS-CoV infection prevention measures well. The reliability (Cronbach’s α) of the scale was 0.81 in the preliminary survey with 15 emergency nurses and 0.93 in the main survey.
Perceptions of hospital’s measures against MERS-CoV
To measure how the nurses perceived the hospital’s measures against MERS-CoV, the researchers prepared three items on a 4-point scale through a review of prior studies.13 The CVI of this scale was rated (1: “Not relevant”; 4: “Very relevant”) by two infection control nurse practitioners, one nursing professor, and an ED head nurse. The CVI (calculated with the ratio of the number of items given 3 or 4 points to the total number of items assessed by four experts) of the scale was 0.83. The reliability (Cronbach’s α) of the scale was 0.80 in the preliminary survey with 15 emergency nurses and 0.91 in the main survey. A high score signifies that the participant perceives that the hospital is taking proper preventive measures against MERS-CoV infection.
Data analysis
Collected data were analyzed using SPSS/WIN 21.0, and the normal distribution of the major variables was confirmed before analysis. The participants’ general characteristics, ethical problems, perceived risk, cognitions of social stigmatization, levels of agreement with infection control measures, and perceptions of hospital’s measures against MERS-CoV were analyzed using frequencies, percentages, means, and standard deviations. The reliability of related variables was assessed using Cronbach’s α. The validity of emergency nurses’ ethical problems for patient care during the MERS-CoV outbreak was assessed using factor analysis. In order to identify factors influencing ethical problems, the enter method of multiple regression analysis was performed. The Durbin–Watson statistic was used to test for the presence of serial correlation among the residuals, and multicollinearity was detected by examining the tolerance for each independent variable.
Results
Participants’ demographics
The demographics of the 169 participants were as follows: the average age of the participants was 28.1 years and all of them were female. They had an average total clinical career duration of 5.3 years. The majority (53.3%) of the participants had a bachelor’s or master’s degree, and 84.0% of the participants were staff nurses. Almost all of the participants (91.7%) had attended MERS-CoV education, and 62.1% of the participants had cared for suspected MERS-CoV patients (Table 1).
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Table 1. Participant characteristics (N = 169).
Ethical problems in caring for patients during the MERS-CoV outbreak
The mean for ethical problems in nursing was 2.32 out of 4. The item “It will be stressful for me to take care of MERS-CoV patients” attained the highest mean score (2.96) followed by “If I have to choose between MERS-CoV patients and other kinds of patients, I will care for the other kinds of patients” (2.75; Table 2).
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Table 2. Ethical problems in caring for patients during the MERS-CoV outbreak (N = 169).
Main variable characteristics
The mean perceived risk of infection score was 6.42 out of 10. The mean for cognition of social stigmatization was 2.37 out of 4. The participants’ mean scores were 3.61 out of 4 on agreement with infection control measures, and emergency nurses’ agreement with infection control measures was relatively high. The participants’ mean scores were 2.88 out of 4 for perceived hospital’s measures against MERS-CoV (Table 3).
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Table 3. Participants’ main variable characteristics (N = 169).
Factors influencing ED nurses’ ethical problems in nursing during the MERS-CoV outbreak
In order to determine the factors influencing emergency nurses’ ethical problems, this study entered the main variables (perceived risk of infection, cognition of social stigmatization, level of agreement with infection control measures, and perception of hospital’s measures against MERS-CoV) into a regression analysis, controlling for the participants’ characteristics.
According to the results of linear multiple regression analysis using the enter method, the participants’ ethical problems were most affected by cognitions of social stigmatization (β = 0.360, p < 0.001). The participants’ ethical problems were also high when there was low agreement with infection control measures (β = −0.224, p < 0.01) and high perceived risk of infection (β = 0.157, p < 0.05). In addition, these variables explained 23.1% of variance in ethical problems during the MERS-CoV outbreak (Table 4).
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Table 4. Linear regression analysis predicting ethical problems with MERS-CoV (N = 169).
However, the Durbin–Watson statistic was 1.632 in the error autocorrelation test for regression analysis, indicating that there was no autocorrelation. Tolerance for testing multicollinearity was 0.319–0.915, higher than 0.1, and the variance inflation factor was 1.080–6.856, lower than the reference level of 10. Thus, there was no problem with multicollinearity.
Discussion
Until the appearance of the first patient, MERS-CoV was a disease totally unknown to Koreans. Contrary to expectation, the number of infected people increased rapidly, and the whole country was enveloped in anxiety, leading to a socioeconomic depression.19 As a measure against the spread of MERS-CoV, the government designated hospitals for MERS-CoV patients and urged suspected patients to visit those specified hospitals to be diagnosed and treated.1
This study purposed to survey ethical problems that might be experienced by emergency nurses at the designated MERS-CoV hospitals during the outbreak and to identify factors influencing those problems. Since SARS broke out in 2003, a number of articles have reported a high rate of infection among healthcare workers and have raised ethical issues related to their professional obligation or duty to provide clinical care under the risk of infection.7–13 Since the outbreak of SARS, emerging infectious diseases such as MERS-CoV, Ebola, and avian influenza (H5N1) have been developing one after another, but healthcare workers are still at high risk of acquiring emerging infectious diseases.5 During the outbreak of MERS-CoV in Korea, the ED medical staff experience ethical problems between fear and stress from the risk of MERS-CoV infection and their professional obligations working on the front line of patient care, despite insufficient personnel, poor facilities, and inadequate emergency patient management systems.2
According to the results of this study, the most common ethical problem experienced by emergency nurses during the outbreak of MERS-CoV was having a mind-set of patient avoidance. The items showing the mind-set issue were as follows: “It will be stressful for me to take care of MERS-CoV patients” scored the highest followed by “If I have to choose between MERS-CoV patients and other kinds of patients, I will care for other kinds of patients.”
In addition, the factor that most influenced emergency nurses’ ethical problems in nursing was their cognitions of social stigmatization. During the outbreak of SARS, there was also a social phenomenon of people avoiding not only hospital healthcare workers but also their families in fear of infection.7–10,20 In Korea, it was reported that the children of nurses and doctors working at a hospital with MERS-CoV patients were not allowed to attend their kindergartens and schools, and the government initiated strong measures, including judicial punishment, against such a practice.21 According to Koh et al.,9 there was a significant relationship between healthcare workers’ stress during the outbreak of SARS and their cognitions of social stigmatization. Moreover, in the study of Maunder et al.,8 social stigmatization was a prominent theme, not only for SARS-infected patients but also for healthcare workers.
The results of previous studies8,9 and this one suggest the need for social support to encourage medical care workers and help them stay committed to patient care while struggling with infectious diseases in an adverse environment. First, in order to prevent vague public fear stemming from ignorance of newly emerging infectious diseases, the government and public institutions should provide people with accurate information on the diseases and educate them about prevention. What is more, news media, which may provide leading reports that unnecessarily frighten the public, should distinguish between the level of risk and the level of precaution contingent on affected or unaffected areas. If the risk of a disease is reported without the classification of severity, it will scare people, and the fear of infection will aggravate their misunderstanding and prejudice against healthcare workers. The emergence of infectious diseases will continue in the future. Thus, the formation of a mature public consciousness against disease disasters will help us cope with such diseases more efficiently.
The second most influential factor for emergency nurses’ ethical problems during the outbreak of MERS-CoV was the level of agreement with infection control measures. In other words, the participants’ ethical problems were significantly lower when the precautionary behavior against MERS-CoV was high. Consistent with this result, Tzeng12 also reported that nurses’ levels of agreement with infection control measures were a significant predictor of their willingness to provide care for SARS patients. This finding may provide a very useful clinical implication. That is, on the outbreak of a contagious disease, if the government and hospitals establish a protocol for precautions against the infectious disease and educate nurses to reinforce their infection prevention behavior, such efforts will minimize nurses’ ethical problems in caring for patients. Moreover, nursing administrators will play important roles as executors in isolating nurses from health disaster situations, such as SARS and MERS-CoV, and managing their internal conflicts.21 Thus, nurses’ ethical problems will be reduced if nursing administrators support nurses’ precautions by providing guidelines and monitoring for infection prevention behavior.
Another influential factor for emergency nurses’ ethical problems during the outbreak of MERS-CoV was perceived risk of infection. During the outbreak of SARS, most healthcare workers perceived a great personal risk of falling ill with SARS, and the most remarkable psychological impact was fear of contagion.8,9 According to a survey on avian flu (H5N1),22 however, healthcare workers replied that they would participate in patient care if they were given appropriate protective equipment and provided with prevention guidelines and education. In situations of caring for patients who place them at risk, nurses may experience ethical problems, but it is not easy for them to abandon their professional obligation. Yet, there should first be structural devices and policies for nurses to care for patients in safe environments, followed by an emphasis on nurses’ professional obligations.
According to one study,23 nurses’ willingness to care for SARS patients during an outbreak was affected more by their organizational commitment than by their professional commitment, and compensation for extra efforts had a significant effect on the nurses’ willingness to accept assigned precarious jobs during the outbreak of SARS. Rather than only emphasizing nurses’ sacrifices and obligations, we should support them with sufficient compensation for the sacrifice. Shabanowitz and Reardon22 found that during a pandemic, healthcare workers wanted to decide their level of participation by themselves, and 79% of the respondents replied that they would participate voluntarily. Thus, instead of demanding or forcing nurses to provide care for patients who place them at risk, we need to respect their autonomy and provide sufficient compensation and safety mechanisms to facilitate their participation in patient care.
Limitations
The limitation of this study is the generalizability of its results because it was conducted with a small number of hospital emergency nurses selected through convenience sampling during the outbreak of MERS-CoV in Korea. Based on the results of the literature review, the study analyzed only four variables that might influence emergency nurses’ ethical problems, but there may be influencing variables other than these. Accordingly, further research is required to analyze influencing factors other than the general characteristics and variables used in this study.
Conclusion
This study purposed to understand ethical problems experienced by emergency nurses, who are required to have front line contact with patients, in a critical situation caused by an emerging infectious disease, such as the outbreak of MERS-CoV in Korea, and to identify factors influencing their ethical problems. The findings suggest that the most common ethical problem experienced by emergency nurses during the outbreak of MERS-CoV was having a mind-set of patient avoidance. The study finding indicates that the participants’ ethical problems were most affected by cognitions of social stigmatization. Accordingly, to support nurses as they confidently provide care for people during future health disasters, it is most urgent to promote appropriate public consciousness that encourages healthcare workers. The second factor influencing participants’ ethical problems was agreement with infection control measures. These results suggest that nursing administrators need to encourage nurses in the field to actively take precautions against infection, and the government and hospitals need to provide nurses with protective equipment, protocols, and education so that nurses may care for patients in safe environments. The findings of this study may provide useful information in emergency nurses’ ethical problems during future outbreaks of contagious diseases similar to MERS-CoV.
Acknowledgements
The authors would like to thank the nurses who participated in this study, and they appreciate the nurses’ efforts against MERS-CoV.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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