Nurses’ Experiences of their Ethical Responsibilities during Coronavirus Outbreaks: A Scoping Review

Globally, nurses have experienced changes to the moral conditions of their work during coronavirus outbreaks. To identify the challenges and sources of support in nurses’ efforts to meet their ethical responsibilities during SARS, MERS, and COVID-19 outbreaks a scoping review design was chosen. A search was conducted for eligible studies in Ovid MEDLINE, Ovid Embase and Embase Classic, EBSCO CINAHL Plus, OVID APA PsycInfo, ProQuest ASSIA, and ProQuest Sociological Abstracts on August 19, 2020 and November 9, 2020. The PRISMA-ScR checklist was used to ensure rigor. A total of 5204 records were identified of which 41 studies were included. Three themes were identified related challenges in meeting ethical responsibilities: 1) substandard care, 2) impeded relationships, 3) organizational and system responses and six themes relating to sources of support: 1) team and supervisor relationships, 2) organizational change leading to improved patient care, 3) speaking out, 4) finding meaning, 5) responses by patients and the public, 6) self-care strategies.Our review revealed how substandard care and public health measures resulted in nurses not being fully able to meet their ethical responsibilities of care. These included the visitation policies that impeded the support of patients by nurses and families, particularly with respect to face-to-face relationships. Organizational and system responses to the evolving outbreaks, such as inadequate staffing, also contributed to these challenges. Supportive relationships with colleagues and supervisors, however, were very beneficial, along with positive responses from patients and the public


Background
Currently 90% of National Nursing Associations have reported that they are concerned with heavy workloads, a lack of resources, and increasing numbers of nurses experiencing stress and burnout as a result of caring for patients during the COVID-19 pandemic (International Council of Nurses [ICN], 2021a). Several literature reviews have described the severe psychological impacts on healthcare workers during recent epidemics and pandemics (Carmassi et al., 2020;Preti et al., 2020;Shaukat et al., 2020). Joo and Liu (2021) have also conducted a literature review that has revealed the barriers that nurses have encountered when caring for COVID-19 patients related to limited and constantly changing information, unpredictable responsibilities, a lack of support, concerns about the safety of their own families, and psychological stress. However, much less attention has been paid to the moral conditions of nurses' work during the COVID-19 pandemic and previous Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks. Several recent studies (Iheduru-Anderson, 2021;Lapum et al., 2021;Rezee et al., 2020;Sperling, 2021) have reported nurses' ethical concerns about shifts in the standard of nursing practice, including patients dying in isolation, and have examined nurses' viewpoints regarding resource allocation during the COVID-19 pandemic. No literature review to date, however, has synthesized and appraised the growing empirical evidence on how previous coronavirus outbreaks and the current pandemic have impacted the capacity of nurses to meet their ethical responsibilities. In addition, no review of the literature has explored what has helped nurses sustain their efforts in the contexts of major shifts in practice because of  Nurses are morally responsible to their patients and communities: to promote health, to prevent illness, to restore health and to alleviate suffering and promote a dignified death" (ICN, 2021b, p. 2). Theorists, such as Vanlaere and Gastmans (2011), have further delineated what nurses' ethical responsibilities are using a theoretical lens of care. Care involves both an attitude of 'caring about' that entails nurses' emotional and attentive response to patients and 'caring for' that requires nurses to take responsibility in engaging in caring activities to meet the needs of their patients often in the context of a face-to-face interaction (Vanlaere & Gastmans, 2011). As an ethical responsibility, care must be other-regarding in that attention must turn to the needs of others (Vanlaere & Gastmans, 2011). From a care perspective, moral emotions are elicited in those who care (Vanlaere & Gastmans, 2011), which have been defined as "those emotions that are linked to the interests or welfare either of society as a whole or at least of persons other than the judge or agent" (Haidt, 2003, p. 853).
Meeting the ethical responsibility to care for others requires that nurses are also cared for and have their needs met so that they can temporarily ignore their own goals and concerns to recognize and attend to the needs of others (Tronto, 1993). Not only are patients dependent on nurses to meet their needs, nurses are also dependent on patients to maintain their moral identity. Through expressing gratitude and displaying improvement in their health or wellbeing, patients enable nurses to develop a sense that they are good nurses (Peter et al., 2018;Vanlaere & Gastmans, 2011). Ultimately, through caregiving nurses can find life fulfillment and meaning, but with limited close contact with patients, nurses often experience stress because of their compromised abilities to fulfill the responsibilities of care (Vanlaere & Gastmans, 2011).

Purpose
The purpose of this scoping review was to identify the challenges and sources of support in nurses' efforts to meet their ethical responsibilities during the SARS, MERS, and COVID-19 outbreaks. We chose to examine the findings of studies conducted involving SARS and MERS, along with those during the COVID-19 pandemic, because nurses' experiences during these outbreaks may follow similar patterns, they all are the result of potentially lethal coronaviruses with a comparable mode of viral transmission, and each yielded a widespread public health response. The following research questions guided our review: 1. What challenges did nurses experience fulfilling their ethical responsibilities of care during the SARS, MERS, and COVID-19 outbreaks? 2. What fostered nurses' capacity to fulfill these responsibilities during the SARS, MERS, and COVID-19 outbreaks?

Design
We chose a scoping review to allow a mapping of the broad range and extent of research occurring related to nurses' responsibilities and moral emotions during the COVID-19 pandemic and previous coronavirus disease outbreaks (Arksey & O;alley, 2005). Specifically, this review was guided by the methodological framework initially proposed by Arksey and O'Malley (2005), and advanced by Levac et al. (2010). The framework consisted of five stages, including identifying research questions, searching for relevant studies, study selection, charting data, and analysing and reporting the data. To improve rigor in the methodology and process, steps outlined by Tricco et al. (2018) in the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR)' were followed.

560
ProQuest Sociological Abstracts ((MAINSUBJECT.EXACT("Midwifery") OR MAINSUBJECT.EXACT("Nurses")) OR noft(nurse* or nursing or midwif* or midwiv* or personal support worker* or healthcare aid* or health care aide*)) AND noft(coronavirus* or corona virus* or ncov* or cov or covid* or mers or middle east respiratory syndrome* or sars* or severe acute respiratory syndrome*) reference list of all the sources that met the inclusion criteria and past literature reviews were hand-searched to identify additional sources ( Figure 1). No further searches were conducted for reasons of feasibility. Initial title and abstract screening were conducted by two team members (EP and CV). The inclusion and exclusion criteria (Table 2) were refined during the early stages of the screening process (Levac et al., 2010). These were chosen to identity empirical studies of nurses or midwives who had provided direct care to patients with SARS, MERS or COVID-19 and had expressed concerns in the form of moral emotions, i.e., stress or distress, which is consistent with Vanlaere and Gastmans (2011)'s articulation of 'caring about' which includes attentiveness and emotions expressed for the other. Each article was tagged as 'include', 'maybe' and 'exclude' in Covidence™. Full-text screening of studies marked 'include' and 'maybe' were conducted independently by two team members (EP and CV). Discrepancies in the screening process were resolved by rereading articles and collaborating with the team (Levac et al., 2010).

Search outcomes
Our review yielded a total of 41studies from 16 countries, including five quantitative and 36 qualitative studies

Cross-sectional qualitative survey
To explore perceptions of the most salient sources of stress in the early stages of the COVID-19 pandemic in a sample of U.S. nurses 455 nurses (registered nurses and advanced practice registered nurses)

Azoulay et al. (2020)
France Cross-sectional quantitative survey To assess the prevalence and determinants of symptoms of anxiety, depression, and peritraumatic dissociation in critical care healthcare providers exposed to COVID-19 1058 participants (nurses, physicians, allied health professionals etc.)

Bahramnezhad and
Asgari (2020) Iran Qualitative (phenomenology) To explain the lived experiences of nurses in the care of patients with COVID-19 to create a comprehensive description of this care and to understand the intrinsic structure of this phenomenon

nurses
Blanco-Donoso et al.    Figure 1). Of these studies 29 were about the COVID-19 pandemic, 10 about SARS outbreaks, and two about MERS outbreaks. Most studies involved nurses exclusively (29), while others had participants from other healthcare professions and occasionally family members as well (12).
When results pertained to another professional group or family members exclusively, we did not include that material in our extractions or findings.

Quality appraisal
A formal appraisal of reviewed papers is not a requirement for a scoping review (Levac et al., 2010) and therefore, will not be reported.

Data abstraction
Data abstraction and charting were an iterative process, that allowed the team to become familiar with the sources and provide a summary of the articles included in the study (Peters et al., 2020). Key information about the source of evidence from the included articles was recorded in a tabular form. The extracted information included author(s), year of publication, country of origin, type of coronavirus, aims/ purpose, participants, research design, sources of concern and stress, and preventive and supportive elements. (Table 3)

Synthesis
The abstracted data was then collated and summarized by identifying themes that describe and synthesize key patterns and narratives in the literature (Arksey & O;alley, 2005). To supplement our thematic analysis, we also carefully considered how the data fit the theorization of ethical responsibilities of care to identify both sources of challenge and support in the chosen studies.

Results
We found three themes related to challenges in meeting ethical responsibilities: 1) substandard care, 2) impeded relationships, 3) organizational and system responses and six themes relating to sources of support that helped nurses to meet their ethical responsibilities: 1) team and supervisor relationships, 2) organizational change leading to improved patient care, 3) speaking out, 4) finding meaning, 5) responses by patients and the public, and 6) self-care strategies.

Challenges in meeting ethical responsibilities
Substandard care. Nurses experienced intense feelings of helplessness and perceptions of futility when caring for patients during coronavirus outbreaks. Nurses expressed concern when the usual standards of care could not be met (Butler et al., 2020;Gagnon & Perron, 2020;Iheduru-Anderson, 2021;Kackin et al., 2021;Schroeder et al., 2020;Shih et al., 2007). Certain studies specified the nature of substandard care, such as when poor infection control measures could have led to the spread of the virus to patients, (Gagnon & Perron, 2020;Iheduru-Anderson, 2021;Kim, 2018), a hospital bed could not be supplied upon admission (Tan et al., 2020), patients did not receive life-saving treatments or adequate attention (Butler et al., 2020;Iheduru-Anderson, 2021;Liu et al., 2020a), COVID screening and time needed to don and doff personal protective equipment (PPE) led to delays in treatment and care (Hou et al., 2020;Jia et al., 2021;Kates et al., 2021), or home visits were limited (Digby et al., 2021;Kackin et al., 2021). Substandard care related to end of life of care was also reported, such as when end-of-life decision-making occurred too quickly (Azoulay et al., 2020) or end-of-life care was not dignified (Lee et al., 2020). Facilitating the proper treatment of dead bodies and assisting with funerals and other ceremonies related to death and dying were also identified as part of participants' responsibilities that could not be fulfilled adequately (Galehdar et al., 2020;Leong et al., 2004). Specifically, Iheduru-Anderson (2021) reported how nurses struggled with "the ethics of working below the accepted standard of care" (p. 9). Other studies (Archer et al., 2020;Digby et al., 2021;Jia et al., 2021;Leong et al., 2004) identified the prioritization of COVID-19 patients led to the withdrawal and the restriction of treatment options for non-COVID-19 patients as a source of concern.
Nurses' reports of substandard patient care because of coronavirus measures were accentuated by the redeployment of nurses to practice areas, such as intensive care, in which they did not have confidence in their abilities (Arnetz et al., 2020;Catania et al., 2021;Digby et al., 2021;He et al., 2021;Jia et al., 2021;Lee et al., 2020;Liu et al., 2020aLiu et al., , 2020b. For instance, Catania et al. (2021) reported how new graduates often became the most senior professionals on COVID units despite their lack of experience. Impeded relationships. Nurses expressed a serious concern that they could not form adequate caring and humanizing relationships with patients given the barriers presented by the need to wear PPE and to limit direct contact (Bahramnezhad & Asgari, 2020;Bournes & Ferguson-Paré, 2005;Butler et al., 2020;Hall et al., 2003;Karimi et al., 2020;Koller et al., 2006;Leong et al., 2004;Sun et al., 2020). For example, Bournes and Ferguson-Paré (2005) spoke of PPE "smothering connectedness" (p. 328) because compassionate facial expressions were difficult to convey as the result of wearing a mask, making the demonstration of compassion and responsiveness, two of nurses' core values (ICN, 2021b), difficult. Similarly, Leong et al. (2004) described how PPE requirements resulted in the unrecognizability of healthcare professionals and the taboo of touching patients without gloves, bringing about a disruption in connectedness.
Organizational and system responses. Organizational and system responses to the evolving pandemic contributed to contexts in which nurses could not meet their ethical responsibilities. Frequently cited were the shortage of PPE to protect patients (Arnetz et al., 2020;Blanco-Donoso et al., 2021;Karimi et al., 2020), and the lack of equipment (Butler et al., 2020;Karimi et al., 2020;Lee et al., 2005), adequate training (Arnetz et al., 2020;Góes et al., 2020;Karimi et al., 2020;Liu & Liehr, 2009), staff (Ardebili et al., 2020;Blanco-Donoso et al., 2021;Butler et al., 2020;Catania et al., 2021;Gagnon & Perron, 2020;Góes et al., 2020;Kackin et al., 2021;Karimi et al., 2020;Liu et al., 2020aLiu et al., , 2020bSarabia-Cobo et al., 2020;Shih et al., 2009;Tan et al., 2020;Travers et al., 2020) and clarity of responsibilities . Other researchers also reported team dysfunction, including the avoidance of infected patients Chiang et al., 2007;Shih et al., 2007), as difficult. With these shortcomings, nurses could not provide an adequate standard of care in the context of an outbreak. Gagnon & Perron (2020); Iheduru-Anderson (2021), and Karimi et al. (2020) highlighted the problem of ill-prepared local healthcare systems. Gagnon and Perron (2020) used the words "deplorable" (p. 112) and "systemic negligence" (p. 112) to describe the working environment in which nurses experienced inadequate staffing, mandatory overtime, and poor communication while trying to care for COVID-19 patients. In one American study, (Arnetz et al., 2020), nurses experienced constraints in their ability to voice their perspectives regarding public health measures, even while at work, because the pandemic had become so politicized, and nurses who worked through the SARS epidemic in Taiwan criticized the government for the lack of a good SARS response, expressing the importance of their participation as core decision makers in any future health crisis planning at the local and national levels (Shih et al., 2007).
Organizational change leading to improved patient care. A small number of studies described how a coronavirus outbreak led to active measures on the behalf of front-line nurses to improve the standard of care such as leading organizational change to improve patient care, (Hou et al., 2020;Jia et al., 2021;Liu & Liehr, 2009;Shih et al., 2007;Travers et al., 2020) including a shift to virtual care (Archer et al., 2020;Digby et al., 2021). Shih et al. (2009) reported that nurses repeatedly asked for additional equipment and more human resources, such as extra staffing, to cope with changes to practice. Jia et al. (2021) described 'active control and planning' (p. 7) which led nurses to find ways to raise the standard of care through efforts such as developing nursing specific plans of care and sharing transferable knowledge from patient cases.
Speaking out. The Gagnon and Perron (2020) and Hall et al. (2003) studies were unique in that they used news stories to illustrate nurses' experiences and to recognize the individual and collective voices of nurses. Gagnon and Perron (2020) described how nurses providing direct care expressed their concerns to the media regarding substandard care to the public, while Hall et al. (2003) reported on nurses' speaking out about visitation policies and nurse leaders' efforts to make changes to the healthcare system.

Finding meaning in work
Despite the hardships experienced in their work, nurses spoke of developing strength and resilience by finding meaning and expressing pride in their work (Chiang et al., 2007;Lee et al., 2020;Liu et al., 2020ab;Sheng et al., 2020;Shih et al., 2009;Sun et al., 2020;Tan et al., 2020). More specifically, some spoke of fulfilling their professional duties and oaths (Ardebili et al., 2020), affirming their commitment to God (Ardebili et al., 2020), obtaining a divine sense of purpose Shih et al., 2009), and coming to terms with their own mortality (Chiang et al., 2007) as ways of finding meaning.

Discussion
The results of our scoping review revealed numerous challenges to nurses' efforts to meet their ethical responsibilities during previous coronavirus outbreaks and the COVID-19 pandemic. These were structural in origin because they were related to the lack of clinical, financial, informational, and supportive resources and the impact of public health measures on nursing practice and the standard of nursing care. As healthcare professionals, nurses are responsible and accountable for their nursing practice (ICN, 2021b), yet because nurses working during SARS, MERS, and COVID-19 were often without adequate resources, such as appropriate staffing and equipment, and were working under strict public health measures, they often could not fully meet all their ethical responsibilities of care simultaneously.
The infection control measures, such as visitation policies and PPE, limited the relational work of nurses, especially with respect to face-to-face interactions. The inability of family members to be physically present with patients, particularly at the end of life, was a significant source of concern for nurses. While literature in public health ethics speaks to the ethical tension of balancing the rights of individuals with that of the collective good when making decisions regarding public health measures (Smith & Upshur, 2019), such as visitation policies and decisions to ration healthcare resources during public health emergencies, these issues are discussed assuming that the reader or moral agent is in the position to make these decisions. In this review, however, the nurses did not express concern as a result of decision-making or moral dilemmas, but in contrast, expressed concern as a result of not being able to meet their caring responsibilities in everyday work. Decision-making regarding resources and public health measures had already occurred at a higher level of public health officials and organizational leaders, who may not have had direct links to nurses in frontline practice or understand the forces that compel nurses to ethically respond to those under their direct care.
In their classic work, Lützén et al. (2003) explain how nurses who provide direct care are accountable for the standard of care they provide but they are not often involved in the policies that structure their work. Moreover, they argue that policies generally reflect utilitarian principles that are oriented to maximizing benefit for broader groups and populations, while nurses generally are focused on individual patients' needs and are acutely aware of their vulnerability and best interests. The results of our study are aligned with the analysis of Lützén et al. (2003) because the impact of organizations on nurses' day-to-day work came to the forefront as problematic for nurses with respect to their caring efforts. We argue that the intended ethical dimensions of policies, such as infection control and staffing measures, often do not reflect or take into consideration nurses direct moral experiences of these policies and the implications of these measures on their work in close proximity to patients.
We also observed that many (75) publications that we deemed eligible for full-text review were excluded because there was no clear evidence that nurses were experiencing moral emotions or could not fullfil their ethical responsibilities related to their concerns regarding patients and patient care. Instead, the emotions described in these papers were mainly about nurses' anxiety of becoming infected themselves or infecting their family members. This excluded group of the literature may not have employed data collection techniques that elicited responses about patient care concerns or nurses in these studies, despite the difficult working conditions, were able to provide good nursing care. Alternatively, these studies may reflect nurses' inability to experience moral emotions and put their own needs aside temporarily when their own health and safety needs are not being met. In essence, it is possible that these nurses were not adequately cared for themselves to be able to be attentive to and care for others adequately.
A variety of self-care strategies were reported including receiving support from family and friends, along with practices related to mindfulness, including meditation, prayer, and yoga. These strategies are relevant to nurses' caring capacity because nurses require care themselves to provide care for others (Vanlaere & Gastmans, 2011), and they can help nurses build moral resilience in the face of moral distress (Rushton, 2016). Along with self-care strategies, nurses found that their relationships with the healthcare team, especially nurse colleagues, to be very helpful. Other work by Traudt et al. (2016) has also found that the presence of a moral community, in which nurses can openly discuss and gain support with their moral concerns, can be an excellent source of support for nurses to continue to practice ethically. Finding meaning in their work and receiving the responses of patients and the public were also identified by many reviewed papers as supportive which is in keeping with the work of Vanlaere andGastmans (2011) andPeter et al. (2018) who have described the importance of patients' and the public's reactions in sustaining nurses' moral identities as people who care for others and can make a difference in their lives. It may also be that these experiences help nurses to reflect on their moral responsibilities in a pandemic from a broader perspective, helping to place their work into a context that recognizes the realistic expectations for patient care during the constraints of a public health emergency.
Our scoping review did not find many studies that showed nurses' efforts to directly address the underlying challenges they encountered in their efforts to meet their ethical responsibilities of care, such as speaking out about their working conditions or engaging in political advocacy. Only eight studies (Archer et al., 2020;Digby et al., 2021;Hou et al., 2020;Jia et al., 2021;Liu & Liehr, 2009;Shih et al., 2007;Shih et al., 2009;Travers et al., 2020) demonstrated ways in which nurses influenced organizations to improve the standard of care, and only one study (Hall et al., 2003) reported that staff nurses voiced their concerns regarding visitation policies. These types of active responses are critical because they can directly influence or eliminate sources of these challenges, such as substandard care and impeded relationships. It is possible that these efforts did exist, but the nature of the research studies could not capture this data. Future inquiry might examine nurses' opportunities to change the conditions of their work to fulfill their moral responsibilities and whether organizations are more open to hearing their voices.
It is essential to recognize that substandard care not only has an immediate deleterious impact on patients, it also erodes the moral identity of nurses in such a way that it could have a cascading impact on their ability to provide ethical care for future patients. As the COVID-19 pandemic continues, and other future health crises emerge, the need for a sustainable nursing workforce that can meet its moral responsibilities is apparent. Governments and administrators plan and provide care environments that make it possible for nurses to offer ethically good care.

Limitations
This scoping review included studies that had been published up until November 2020. As a result, it did not capture many studies related to nursing ethics during the COVID-19 pandemic that have been published since that time. Moreover, because most of the studies we examined did not mention ethics explicitly, we needed to infer the ethical struggles that these nurses encountered. In addition, in some instances, participants in the reviewed studies included healthcare providers other than nurses which may have slightly impacted our findings.

Conclusions
Our review revealed how common challenges such as substandard care, as well as unique ones related to public health measures, resulted in nurses not being fully able to meet their ethical responsibilities of care. The former included organizational and system responses to the evolving outbreaks, such as inadequate staffing, and the latter included the visitation policies and the barriers presented by PPE which impeded the support of patients by nurses and families, particularly with respect to face-to-face relationships.
These findings point to the direct impact of public health policies across multiple areas of nursing practice, including acute care and long-term care. The need for healthcare organizations, which are often tasked with translating broader public health policies into local practice requirements, to formally involve front-line nurses in this process is essential to promote transparency, accountability, and opportunities for feedback. Nurses providing direct care also need to be included in decisions regarding the prioritization of patients, as they have insight into how these decisions will impact direct patient care.

Declaration of Conflicting Interests
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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Toronto COVID-19 Action Initiative,