This study targeted Chinese anti-pandemic nurses who directly cared for COVID-19 patients.
It showed that these nurses reported high average scores for hospital ethical climate, ethical sensitivity, and self-evaluated quality of care for COVID-19 patients.
This study also found that among anti-pandemic nurses, the perceived strength of the hospital ethical climate was associated with high self-evaluated care quality directly, as well as indirectly through the mediation effect of ethical sensitivity.
Anti-pandemic nurses in our study perceived a high degree of strength in the hospital ethical climate. The average scores for this measurement were higher than those reported by nurses using the same study instrument in acute-care hospitals in Canada in 2009 [14]; in care settings for older people in Finland in 2015 [40]; and in cancer care settings in Greece and Cyprus in 2019 [41] —although the difference might be due to differences in working settings, cultural backgrounds, and situational contexts. An organization’s values and goals could reflect the strength of the ethical climate in that organization [42], which provides the context in which ethical behavior and decision-making occurs. Thus, if nurses have a deep understanding of the hospital ethical climate, they can judge and adjust their behaviors to be consistent with the hospital’s values. During the COVID-19 outbreak, the rapidly evolving pandemic threatened the health and lives of the public. In that critical period, making people’s lives and health the priority and making all-out efforts to prevent and control the contagion was society’s common goal [43–44]. China coped with the rapid spread of the COVID-19 pandemic by building two temporary hospitals in two weeks (Leishenshan and Huoshenshan), and transforming exhibition halls, stadiums, hotels and college dormitories into places to isolate the patients diagnosed with mild symptoms [44]. Even though nurses were at risk of infection, they experienced a professional obligation not to withdraw from participating in the anti-pandemic efforts. However, we should note that these data were collected from March through April 2020, when the nurses had only worked in the isolated wards for a couple of months. Some negative factors such as burnout that affect nurses’ perceptions of hospital ethical climate were likely not yet obvious or severe.
In addition, our study also showed that nurses perceived more positive relationships with managers and peers than with physicians in terms of agreement on hospital ethical climate, which was consistent with previous studies [14, 34, 40]. On the one hand, the nursing profession traditionally requires obedience to hospital managers and a high level of cooperation with peers. On the other hand, the long-standing affiliation in seniority hierarchies between physicians and nurses may have been a cause of the relatively low score on relationships with physicians as perceived by nurses [40]. During the pandemic, different work shifts and tasks for physicians and for nurses might further reduce their contact. For example, the general isolation hospital wards or mobile cabin hospital wards were mainly under the charge of nurses, and the physicians had a more consultative role. Therefore, strengthening physician-nurse cooperation on empirical clinical work is crucial to improve the hospital ethical climate.
Our study indicated the anti-pandemic nurses demonstrated a higher level of ethical sensitivity than those reported by nurses working in the psychiatric department in Sweden in 2009 [26, 45], and nurses working in tertiary and secondary hospitals in China in 2018 and 2014[46–47]. According to Huang et al. [34] ethical sensitivity includes moral responsibility and strength, and moral burden dimensions. As the positive dimension of ethical sensitivity, moral responsibility and strength play an important role in nurses’ cognition and judgment when facing ethical issues in daily work. In contrast, moral burden is considered to be the negative dimension, evoked by a problem or situation. In our study, we have strong reason to believe the anti-pandemic nurses’ moral responsibility and strength, and moral burden were both higher than in previous studies [34, 46]. On the one hand, anti-pandemic nurses volunteered to go to the frontline and thus could have had high professional commitment and compassion [17, 48–49], which could explain our results showing high moral responsibility and strength. But anti-pandemic nurses could also easily encounter conditions that could lead to a high level of moral burden, such as the challenges of excessive psychological pressure, the lack of experience in dealing with the new disease, insufficient supplies of protective gear, overload of facilities, and the high risk of infection [5, 17, 48, 50–51]. The high ethical sensitivity demonstrated by nurses in this study suggests that they were shaped by the institutional mission of the anti-pandemic hospitals, and were actively trying to address the ethical burdens they faced on the frontlines. Future research should examine how supportive services—such as the psychological counseling, aid for daily necessities, and short work shifts available to the nurses in this study—can continue to be improved during responses to public health emergencies, to help alleviate the moral burden dimension of ethical sensitivity.
The anti-pandemic nurses reported a high level of self-evaluated care quality in this study, which was against the general assumption that care quality could not be guaranteed due to the high requirements for occupational precautions. A recent qualitative study showed that anti-pandemic nurses felt proud that they had the opportunity to serve and fulfill their professional duties during the COVID-19 outbreak in China [52]. The feeling of being needed by their country and people encouraged them to join the anti-pandemic task without hesitation [53]. Because of the national call to respond to COVID-19, nurses in studies and news reports appeared to experience the pandemic response not only as a professional duty but also an ethical imperative. Notably, the subscale titled “commitment” showed a relatively lower score than other sub-scales on the self-evaluated care quality scores, and the item “spending time with the patient” gained the lowest score. These findings may be a result of the requirements for nurses to distance themselves from patients and take additional occupational precautions to prevent the spread of infection. Other research shows that wearing medical protective masks, disposable protective suits, and disposable latex gloves during the pandemic response reduced the sensory stimulation of anti-pandemic nurses and even caused sensory deprivation [54], which could have also affected communication and connection with patients. However, intrinsic motivation of nurses helped them to make great efforts to adhere to professional values [17, 55], which might have been a cause of the overall high level of self-evaluated care quality.
Similar to previous studies [56–57], our study revealed that the perceived hospital ethical climate, ethical sensitivity, and self-evaluated care quality were positively correlated with each other and that ethical sensitivity partly mediated the relationship between hospital ethical climate and self-evaluated care quality. Nurses played a crucial role in the treatment and care of COVID-19 patients, and ethical sensitivity was essential for nurses to provide high-quality care. A high ethical sensitivity level could help nurses feel confident in justifying ethical decisions, feel prepared to deal with ethical issues, and feel confident in fulfilling professional responsibilities [58–59]. Some studies [34–35] have translated and localized the hospital ethical climate and ethical sensitivity survey tools for Chinese culture. Therefore, future studies can develop training programs in China and other countries to improve the hospital ethical climate and ethical sensitivity of healthcare woekers, especially for public health nurses, to equip them with the ethical capacity to perform well during public health emergencies.
There are several limitations to this study. First, data were collected through an online survey and reported by the nurses themselves, raising the possibility of information bias. Second, the participants were not randomly selected due to the urgent situation, which might lead to selection bias. Last but not least, this study’s quantitative nature could not sufficiently explain the rationale of the relationships between the variables; thus, qualitative interviews are needed to better understand nurses’ perceptions of ethical sensitivity, hospital ethical climate, and how they influence the quality of care.