Design
The qualitative study with content analysis approach was conducted to explain the lived-experiences of healthcare professionals of ethical challenges, from July to October 2020.
Participants
Key participants were 18 healthcare professionals working in educational medical centers and hospitals of the public or private sectors, in Tehran, capital of Iran. Sampling was conducted by purposive and snowball methods. The participants were purposefully selected among expert and experienced professionals involved in the management and care of COVID-19 patients. First, 12 experienced people was selected and interviewed. Then, interviews were continued with 6 people who introduced by them. Totally, 18 participants entered into the study whom their characteristics represented in Table 1. To observe maximum variation in sampling, participants with diversity in terms of age (28–55 years), gender, expertise and work experience recruited into the study, and some of them simultaneously were working in private sector.
Data collection
Data were collected through semi-structured in-depth interviews from July to October 2020. 22 interviews were done with 18 participants which lasted 30 to 70 minutes and stopped after theoretical saturation. Interviews were done with participants who met inclusion criteria and started with the open question: "What ethical challenges did you experience during COVID-19 pandemic?” In order to deepen the interviews, some probing questions such as “what did you experience while taking care of the patients?”, “what did you feel?”, and etc. were asked.
The interviews were conducted in the preferred time and place of the participants both in-person and by telephone by the first and last researcher. 18 interviews were conducted by voice call via cell-phone or WhatsApp application and 4 interviews were conducted in-person due to the desire of some participants, in compliance with health protocols. The interviews were recorded with the permission of participants.
Data analysis
Data were analyzed by Graneheim and Lundman approach(18). Immediately after each interview, the recorded interviews were listened by the researchers and transcribed verbatim. After reading the text several times, semantic units and open codes were extracted. The open codes were then compared and categorized into more abstract subcategories and categories based on their similarities and differences. MAXQDA 10 software was used to facilitate data analysis process.
Table1: Demographic characteristics of the participants
Participant
Number
|
Specialty
|
Degree
|
Gender
|
Work place
|
work experience (Year)
|
P1
|
Nursing
|
MSc
|
female
|
Educational hospital
|
7
|
P2
|
Nursing
|
BSc
|
male
|
Educational hospital
|
17
|
P3
|
Nursing
|
BSc
|
female
|
Educational hospital
|
10
|
P4
|
Nursing
|
PhD
|
female
|
Educational hospital
|
13
|
P5
|
Nursing
|
BSc
|
female
|
Educational hospital
|
15
|
P6
|
Nursing
|
BSc
|
female
|
Educational hospital
|
10
|
P7
|
Nursing
|
BSc
|
female
|
Educational hospital
|
5
|
P8
|
Physician
|
Resident
|
female
|
Educational hospital
|
1
|
P9
|
Physician
|
Sub-specialist
|
female
|
Educational hospital
|
14
|
P10
|
Physician
|
Resident
|
female
|
Educational hospital
|
1
|
P11
|
Nursing
|
BSc
|
female
|
Educational hospital
|
17
|
P12
|
Nursing
|
BSc
|
female
|
Educational hospital
|
16
|
P13
|
Nursing
|
BSc
|
male
|
Educational hospital
|
13
|
P14
|
Medical ethics
|
MD, PhD
|
Male
|
Private hospital
|
17
|
P15
|
Medical ethics
|
MD, PhD
|
male
|
Educational hospital
|
13
|
P16
|
Nursing
|
BSc
|
male
|
Educational hospital
|
4
|
P17
|
Nursing
|
BSc
|
female
|
Educational hospital
|
19
|
P18
|
Medical ethics
|
MD, PhD
|
male
|
Private hospital
|
25
|
Rigor
long-term engagement and peer check were used to increase credibility of data. The leader researcher also resided in a coronavirus medical center for one week and observed the management and care processes. Regarding member check strategy, two participants were asked to confirm the labels and codes. To develop dependability, moreover peer checking, the experiences of some participants were directly quoted. Bracketing, peer check and member check were observed to make sure about reliability. variation of expertise and increasing auditability by reporting step by step were ways to incline possible transferability of the findings.
Ethical considerations
This research was licensed by the Ethics Committee [IR.SBMU.RETECH.REC.1399.359] from the Vice Chancellor for Technology and Research of Shahid Beheshti University of Medical Sciences. After explaining the research objectives and emphasizing on the confidentiality and anonymity of information, the verbal consent was obtained from the participants.
Findings
The ethical challenges were categorized into 4 categories and 11 sub-categories (Table 2).
Table 2- Categories and sub-categories
Main
Challenges
|
Category
|
Sub-category
|
Poor professional care
|
Disrupted communication;
Ambiguity of nurses’ role;
Uncompassionate care
|
Preference of public interests over individual care
|
Ignorance of family-centered care;
Lack of mourning care
|
Difficult decision-making
|
Ambiguity in standards of care;
Forced to choose
|
Moral distress
|
High workload and negative attitudes;
Concerns about Coronavirus transmission to family members;
Uncertain ethical climate;
Emotional fatigue
|
Category I: Poor professional care
Most participants acknowledged that wearing personal protective equipment (PPE) and fear of COVID-19 infection interfered in communicating with patients. This category is made up of 3 sub-categories.
Disrupted communication
Most participants experienced communication problems with patients:
“The doctor covers himself so much and distances from the patient, so that he did not hear what the patient is saying and did not communicate with the patient.”(P7)
Ambiguity of nurses’ role
Most nurses experienced ambiguity in their role and over-demand by physicians:
“I called the physician to report him the emergency situation of the patient. Instead of coming to visit the patient, he wanted me to give him history. When family member of the patient wanted to talk with physician, they designated this task to the nurses.”(P6)
Uncompassionate care
Most participants perceived that sometimes the care provided by healthcare professionals was uncompassionate:
“Disappointment in patients raised increasingly, I think these patients should be given more psychological care than just treatment, because they have the view that there is no cure and they will die. Sometimes, for example, the patient asks the physician and he says, 'I don't know! - sometimes clerics came and talked with patients and calm them down”. She continued: “Some physicians or even nurses do not take care of patients with COVID-19 who are affected by other underlying diseases like cancer, it does not matter the patients are young or aged. This is annoying.”(P7)
Category II: Preference of public interests over individual care
Most of the participants stated while there was need to psycho-spiritual support and presence of the patient family, the presence of a companion with the patient was prohibited and it was not possible for the family to say goodbye to the deceased patient. This category contains 2 sub-categories.
Ignorance of family-centered care
For most participants, the Family Absence Act was a challenge:
“Today I had an elderly Turkish-speaking patient with whom I could not communicate in any way. But his companion talks to him and provides their needs and psychological support.”(P4)
Lack of mourning care
Most participants experienced the emotional needs of patients' families to say goodbye to their patient during mourning or after the sudden death:
“Patients were in good health, suddenly they needed to resuscitation but families really could not believe that their patients had died or connected to the ventilator; they could not accept and say, 'Oh, it is impossible!' They became angry and fight with staff.”(P16)
“We had trouble regarding to visiting end-stage patients by their family members. The families were begging us to let them see their patients for the last time; we were in situation whether the family could see him or not.”(P5)
Category III: Difficult decision-making
Most participants experienced difficulty in decision-making situations due to complexity of the coronavirus, as well as a lack of resources. This category consists of two sub-categories.
Ambiguous standards of care
The experiences of most participants indicated the difficulty and ambiguity in diagnosis and treatment of the patients with COVID-19:
“In the early phases, the guidelines were written without considering diabetic patients, prioritization of patients to receive services, and how the mourning process; One challenge was to impose the burden of decision-making for intubation on professionals due to a lack of a clear protocol and insufficient skills and tools.”(P15)
“Nurse Manager, and anesthesia assistant asked us what should we do now? Whether there is indication for resuscitation of this patient or not?”(P1)
Forced to choose
Most participants experienced the challenge of being forced to choose between patients:
“Another challenge that bothered me a lot was choosing between bad and worse; which patient had to be chosen to connect to ventilator?”(P4)
"Most of the time, we had to make decision about which patient has to stay alive or not.”(P8)
Category Ⅳ: Moral distress
Most participants experienced heavy workload that caused them fatigue and distressed. This category consists of 4 sub-categories:
High workload and negative attitudes
Most participants experienced high workload and negative emotions:
“My relatives and friends became less in touch with me, when they find out I work in where patients with COVID-19 were hospitalized.”(P2)
“I witnessed many nurses were working by heart, they ignored their rest time. But someone says that nurses receive money, it is their duty, hearing these, upset us more.”(P7)
Concerns about Coronavirus transmission to the family members
Most participants experienced stress due to fear and anxiety about transmission the infection to their family members:
“We were more worried about our family members. I was really worried about affecting my father with COVID-19 because he has an underlying illness.” (P8)
“Staff constantly considered the patient as a threat. I am more worried because my wife is pregnant and I have a double stress."(P13)
Uncertain ethical climate
Most participants believed that COVID-19 pandemic as an unexpected circumstance, undermined the ethical climate:
“I tell the emergency unit, I'm busy now, I'm intubating the patient, don't send a patient towards us, they did not listen me at all.”(P4)
“Some doctors look at the patient as a mean, they come quickly for visits and write hasty orders."(P7)
"Because of crowding of the patients in emergency unit and leaving the doors open for proper air circulation and ventilation, their privacy was not fully observed." (P14)
“Some physicians in ICU wards desire to give an alternative drug and evaluate its effect. They prescribed the drugs without patient's consent because the patient was unconscious, there was no companion with patients, and there was no supervision by ethics committee.”(P15)
Emotional fatigue
Most participants experienced emotional exhaustion because of that their colleagues or patients were affecting or dying of COVID-19, unexpectedly:
“One of the worst things we experienced was that we witnessed many deaths during a work day. We got depressed, the patient was dying, we were crying with their family - I really felt a burnout in some situation, and I wanted to resign of work.”(P1)
“It was very hard to see the death of 10 patients together one day, and it was harder when all of them died at the same time. I still have a nightmare. We became like people coming back from the war. We really need psychiatric counseling.”(P8)