An important issue in the care of COVID-19 patients is the perception of medical service providers toward futile care of patients. The findings of this study showed the high level of nurses' futile care perception in COVID-19 patients, which can be attributed to the observation of futile agonies, the provision of overly aggressive treatments, and the significant costs associated with futile care in patients. Hajiloo et al. (2020) have reported an average level for the Iranian nurses' perception of futile care in COVID-19 patients(23). Also, Rostami et al. (2019) reported moderate levels of nurses' futile care perception(24), which disagrees with the result of our study. However, Studies carried out in the era before the COVID-19 pandemic reported high levels of nurses' futile care perception in line with the findings of our study(25–27). The difference in nurses' perception levels in different studies may result from the cultural differences of nurses, different sample sizes, futile care investigation in the era before or after the COVID-19 pandemic, the recovery rate of care-receiving patients, the use of different tools as a possible can also have an effect on the disagrees with the result of our study. Moreover, some experts explain futile care only based on patient survival, while others consider the quality of life in addition to patient survival; this difference in medical personnel's views can affect the results of futile care perception.
The relationship between demographic variables and nurses' futile care perception indicated significant relationships between the examined variables, except for gender and marital status variables. In line with the present results, Mohammadi et al. study (2014) presented evidence of a significant relationship between futile care and the variables of age and years of work experience (20). To justify the findings of the present study, it can be argued that the increase in work experience and age creates special psychophysical changes in people that make them more sensitive to futile care. On the other hand, teaching and higher scientific degrees help nurses to achieve a higher perception of aspects regarding the care of critically ill patients, especially futile care. For this reason, futile care perception was significantly higher in nurses holding a master's level of education.
According to findings, the nurses' resilience levels in ICUs was at a moderate level during the COVID-19 pandemic, which corresponds to Barkhordari et al. study (2020)(28), However, Ou X et al. (2021) reported a high level of nurses' resilience during the COVID-19 epidemic in China(29), which does not agree with the present study. Unlike the present results, Afshari (2021) and leng (2020) reported low resilience levels of nurses(3, 30). regional differences in the incidence of critical diseases lead to different work, psychological stresses and level Resilience faced by nurses. Therefore, the issue of resilience is an essential skill with a protective role that helps healthcare providers to effectively adapt to psychophysical injuries and work-related pressures.
In examining the relationship between demographic variables and resilience, a significant relationship was observed only in the gender variable as male nurses were more resilient than female ones. According to the study of Afshari et al. (2021), women showed significantly less resilience than men during the COVID-19 pandemic(3). In contrast to our findings, studies by Dai (2020) and Kakemam et al. (2019) indicated significant differences between resilience and work experience, age, and education, and the increase of the three factors individually led to an increase in the resilience level (31, 32). Using different questionnaires and considering the point that the concept of resilience is examined according to nurses' mental and behavioral variables, which are affected by individuals' knowledge and culture, can influence the findings of the obtained results.
The results revealed a moderate level of the turn over intention variable among nurses working in ICUs during the COVID-19 pandemic. futile care would affect professional caregivers so that early fatigue and burnout were among the cases experienced by nurses after working with futile care receivers, which could increase turnover intention in health workers. In line with the present study, Lotfi et al. claimed that the turnover intention at a moderate level in nurses working in the operating room wards during the COVID-19 pandemic(33). It can be argued that factors, such as the professional and organizational commitment level, the job satisfaction level, and profession-related stress can affect the job turnover rate. Varasteh et al. (2022) reported that nurses' sense of commitment and professional conscience were among the main reasons for staying in the nursing profession and even volunteering to work in COVID-19 wards and on the other hand, the fear of disease transmission to their families and the lack of protective equipment were inhibiting factors(34). Therefore, nursing managers should develop a better system to help increase nurses' job satisfaction and increase their professional commitment to stay in the nursing profession.
According to the findings turnover intention was not significantly correlated with all demographic variables. In line with these results, Graminejad et al. (2020) found no significant relationship between turnover intention and nurses' demographic variables(9). Inconsistent with our findings, Heo et al. (2021) in Korea showed that more female nurses were absent from work places than male ones. Differences in the culture and economy of two societies can also influence employees' turnover intention.
The findings of this study showed that nurses' futile care perception had an insignificant inverse relationship with resilience, and increasing nurses' futile care perception insignificantly reduced their resilience. Futile care of critically ill patients has negative consequences for patients and health workers. Nurses working in ICUs are at greater risk of job burnout and mental/emotional suffering due to their constant exposure to clinical situations where conflicts arise regarding treatment goals for critically ill patients(35). reduction of futile care perception can reduce job burnout and improve resilience.
The examination of futile care perception and turnover intention variables showed a significant association between these two variables, and an increase in nurses' futile care perception in COVID-19 patients elevated nurses' turnover intention. The results of koch study (2020) indicated that high quality of care and high job satisfaction were both important factors preventing turnover intention by nurses and young doctors(36). Schwarzkopf et al. (2017) state that futile care perception is related to job burnout and may increase turnover intention among ICU staff as a whole (37). Therefore, the aforementioned results are indirectly in agreement with those of our study. Accordingly, futile care should be directed toward useful and soothing care in patients to reduce the moral tension and turnover intention among medical staff.
Another finding of this study was the relationship between resilience and turnover intention variables, indicating a significant inverse association between the two variables. An increase in the nurses' resilience in ICUs during the COVID-19 pandemic reduced their turnover intention. In line with our findings, significant and inverse relationships between nurses' turnover intention and resilience were reported by Haji et al. (2021)(38). In contrast with our results, Graminejad (2020) studied the relationship between resilience and turnover intention in ICU nurses in Iran and found no significant relationship between their turnover intention and resilience(9). To explain the different results, it can be reasoned that nurses tend to stay in their profession despite their inner desire and the hard work due to socioeconomic conditions prevailing in different societies, which can affect the results of studies.
Labrague et al. (2021) pointed out the need for resilience and preventive measures to adequately support and protect nurses' mental and psychological health. These resilience measures produce a strong relationship with job satisfaction and reduce turnover intention for nurses(39). Implementation of teaching programs for resilience improvement is among the most important methods to increase people's resilience in critical situations. To prevent nurses' turnover intention in the difficult conditions of the COVID-19 pandemic, it is necessary to teach them and prepare the conditions to increase their resilience because resilient characteristics safeguards a person against crises such as COVID-19, which has caused high stress in all people.
Based on the findings of this study, nursing managers can adopt supportive strategies to reduce futile care levels and solve ICU nurses' problems, such as burnout and turnover intention. In iran, there are no guidelines that clarify the limits and instances of futile care. Therefore, it seems necessary to formulate guidelines for making decisions on futile care, particularly in cases such as care during the COVID-19 pandemic(37).
One of the strengths of this study is that this study was conducted for the first time in iran to investigate the relationship between these variables with the cooperation of ICUs nurses who care for patients with covid-19 in final stages of life admitted to ICU. On the other hand, according to the extensive review of the literature, the relationship between these three variables had not been done before the Covid-19 pandemic. this research was conducted only among nurses working in the ICUs of the COVID-19 teaching hospitals affiliated to Tabriz University of Medical Science, Iran and there are limitations in the generalization of the results to other nurses and hospitals.