Ethical challenges faced by nurses during the COVID-19 pandemic: a scoping review protocol : JBI Evidence Synthesis

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Ethical challenges faced by nurses during the COVID-19 pandemic: a scoping review protocol

Morley, Georgina1; Dierckx de Casterlé, Bernadette2; Kynoch, Kathryn3; Ramis, Mary-Anne3; Suhonen, Riitta4; Ventura, Carla5; Arries-Kleyenstuber, Ebin6

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JBI Evidence Synthesis 21(5):p 970-976, May 2023. | DOI: 10.11124/JBIES-22-00247
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On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic following the initial emergence of cases of pneumonia from Wuhan, China, in November 2019. For many health care professionals, and especially nurses who cared for patients 24/7 amid this crisis, the COVID-19 pandemic and its aftermath significantly affected their physical, emotional, and psychological health and well-being.1,2 This is evident from a large number of empirical studies published in the past 3 years on nurses’ experiences caring for patients during the COVID-19 pandemic across different countries,3–5 with nurses of various backgrounds and experience,6–8 and in different care settings.9–11 In addition to the psychosocial impact of the pandemic, there is growing evidence of the negative impact on nurses’ moral well-being, with links to moral distress, depression, and anxiety.12,13 Collectively, these studies point to multi-level and multi-dimensional concerns and challenges, ranging from negative experiences, such as physical and psychosocial burden of care, unmet needs, insufficient support, concerns about the workplace environment, and nurses struggling with and accepting uncertainty, to positive experiences, such as increased sense of teamwork and expressions of gratitude from patients and the public.14

More specifically, published studies have also emerged reporting on the challenges faced by nurses in fulfilling their ethical responsibilities of care during the COVID-19 pandemic. Peter et al.15 found that nurses struggled with nurse-patient/family tensions while trying to prevent COVID-19 infections and provide family-centered care, because of visitation restrictions. Silverman et al.16 conducted focus groups and interviews with nurses and reported that the heightened chaos, feelings of helplessness, and institutional changes contributed to moral distress and moral residue. An integrative review by Aydogdu17 synthesized 14 qualitative studies on ethical dilemmas experienced by nurses during the pandemic, and highlighted issues such as shortages of personal protective equipment, finite medical supplies, and overall uncertainty, often due to limited knowledge and skills to care for patients with COVID-19.17 However, the authors limited their search to “ethical dilemmas,” which occur when there are 2 or more competing and equally strong obligations that cannot both be met, which encompasses only one type of ethical challenge.18 Gebreheat and Teame19 expanded the definition of ethical challenges to “ethical issues, challenges and barriers,”(p.1030) but only 2 empirical studies were included at that time.19 A third integrative review by Firouzkouhi et al.20 reported on ethical challenges faced only by nurses working on inpatient wards during the COVID-19 pandemic. The integrative review included 12 papers from 4 databases, dated to 2020; however, most of the included publications were descriptive or discussion papers, letters to the editor, editorials, or perspective papers, rather than empirical research studies.

Additional primary studies have been published on this topic since 2020. For example, Thomas et al.21 reported on a survey of health care professionals in pediatric critical care and found that nurse respondents reported higher levels of moral distress than physicians, advanced practice providers, and respiratory therapists. This is despite 78.9% of the respondents describing feeling confident to address ethical challenges, even when under pressure. Each of these publications contributes to the available literature on an emerging topic.

The objective of this scoping review is to describe the existing empirical evidence on the scope and nature of the ethical challenges faced by nurses while caring for patients during the COVID-19 pandemic. The secondary objective is to identify strategies to address those challenges. Understanding the latter can facilitate the selection and implementation of preventive, supportive, and remedial strategies to proactively address and deal with ethical challenges in future pandemics. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted and no current or in-progress scoping reviews or systematic reviews on the topic were identified.

Review questions

  • What ethical challenges faced by nurses while caring for patients during the COVID-19 pandemic have been reported?
  • What are the contextual characteristics of the ethical challenges faced by nurses while caring for patients during the COVID-19 pandemic?
  • What are the reported strategies used by nurses to address ethical challenges?

Inclusion criteria


This review will consider studies that report on ethical challenges faced by nurses during the COVID-19 pandemic. For this review, a nurse will be defined according to 2 sub-categories identified by the International Council of Nurses, namely, an individual who is:

…prepared and authorized to (1) engage in the general scope of nursing practice, including the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages and in all health care and other community settings; and (2) participate fully as a member of the health care team.22(para 4)

Studies will be included regardless of the level of education or license/registration status for nursing staff.


The concept of interest for this review is ethical challenges that have been faced by nurses while caring for patients during the COVID-19 pandemic. For the purposes of this review, ethical challenges will be defined according to Schofield et al.23 as including ethical conflicts, ethical dilemmas, ethical issues, moral challenges, moral uncertainty, or difficult choices. Examples of ethical challenges that might occur in this review include challenges related to managing visitation restrictions,24 impact on patient safety and quality of care,25 and injustices between health care professionals’ roles and responsibilities.26


This review will consider published studies that report on nurses working within any clinical care setting, such as acute hospitals; nursing homes; residential aged care facilities; or specific units, such as intensive care, cancer care, or specific COVID-19 wards. For this review, we will also report on any contextual characteristics surrounding the ethical challenges. This may include, but not be limited to, environmental characteristics, staffing levels, or resource limitations.

Types of sources

This scoping review will consider quantitative, qualitative, and mixed methods study designs for inclusion. Systematic reviews, integrative reviews, and other forms of research syntheses will also be considered for inclusion. For this scoping review we are interested in empirical research on the topic; therefore, discussion papers, editorials, and opinion papers will be excluded.


The proposed review will be conducted in accordance with the JBI methodology for scoping reviews,27 and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).28

Search strategy

A 3-step search strategy will aim to locate both published and unpublished literature, with an initial limited search of PubMed and CINAHL (EBSCO) undertaken. This will be followed by an expanded search using all identified keywords and index terms used to describe the articles. Then a citation pearl-growing approach29 will be used for hand-searching the reference lists of articles selected for full-text review. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, will be used to develop a comprehensive search strategy for the other databases (see Appendix II). The search strategy, including all identified keywords and index terms, will be adapted for each included information source.

The databases to be searched will include PubMed, CINAHL (EBSCO), Ovid, PsycINFO (EBSCO), the Cochrane Library, and Scopus. Sources of unpublished studies and gray literature to be searched will include ProQuest Theses and Dissertations (Ovid) and the Canadian Agency for Drugs and Technologies in Health (CADTH), as well as Grey Matters. Articles published from November 2019 to the present will be included to align with the publication of literature specific to the COVID-19 pandemic. To minimize risk of language bias, language limitations will not be applied to the search; any studies that cannot be translated by the research team will be reported on in the final review.

Study selection

Following the search, all identified records will be collated and uploaded into EndNote v.X19 (Clarivate Analytics, PA, USA) and duplicates removed. Initial selections (approximately 25 studies) will be pilot tested by 2 reviewers to ensure congruence with inclusion criteria and to enable discussion and/or any modifications to definitions.30 Titles and abstracts will then be screened by 2 independent reviewers for assessment against the inclusion criteria for the review. Papers that are deemed potentially relevant will be retrieved in full and their citation details imported into a Microsoft Excel file (Redmond, Washington, USA). The full text of selected citations will be assessed in detail against the inclusion criteria by 2 independent reviewers. Reasons for exclusion of full-text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a PRISMA flow diagram.31

Data extraction

Papers will be divided between the authors and data will be extracted from papers included in the scoping review by 2 independent reviewers using a data extraction tool developed by the reviewers (Appendix II). The data extracted will include specific details about the research design, nurse participants, their practice context and setting, geographical location, and content relevant to the review questions. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data analysis and presentation

Data will be presented according to the concepts of interest. A narrative summary will be provided, with tables, figures, and graphs used to provide a visual display of the results in line with the objectives and questions of the scoping review. Images such as word clouds and infographics will also be considered for presenting results.

Author contributions

GM contributed to the project concept and coordination, manuscript development, and revisions. BDC, KK, MAR, RS, CV, EAK contributed to project concept, manuscript development, and revisions.

Appendix I: Search strategy


Search conducted: October 15, 2022

Search Query Records retrieved
#1 ((((Nurse*) OR (Nursing)) OR (nurses)) OR (Nurse [MeSH Major Topic])) OR (Nursing [MeSH Major Topic]) 1,006,883
#2 (((“ethic*“[All Fields] OR “ethics”[MeSH Terms] OR “ethics”[MeSH Subheading] OR “morals”[MeSH Terms] OR “moral*“[All Fields] OR (“ethic*“[Title/Abstract])) AND ((“dilemma”[Title/Abstract] OR “dilemmas”[Title/Abstract] OR “challenge*“[Title/Abstract] OR (“distress*“[Title/Abstract] OR “issue*“[Title/Abstract]))) ) OR (“ethical dilemma”[Title/Abstract])) OR (“ethical challenge*“[Title/Abstract]) 82,663
#3 ((((((Covid 19[MeSH Major Topic]) OR (covid-19)) OR (coronavirus)) OR (sars cov 2)) OR (sars cov 2[MeSH Major Topic])) OR (severe acute respiratory syndrome coronavirus 2)) OR (coronavirus[MeSH Major Topic]) 322,533
#4 #1 AND #2 AND #3 494
#5 Date filter: 01/11/2019–31/12/2022
Results 490

Appendix II: Draft data extraction instrument

Item Page number/comments
Year of publication
Type of paper
Research design
Country of origin
Participants (eg, nursing level, education level, licensed/registered nurse)
Context/setting of practice
Ethical challenges reported
Any other contextual factors surrounding reported issue
Strategy/strategies implemented


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COVID-19; ethics; moral distress; nurses; resilience

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