RESPONDER: A qualitative study of ethical issues faced by critical care nurses during the COVID-19 pandemic

To identify and understand ethical challenges arising during COVID-19 in intensive care and nurses' perceptions of how they made "good" decisions and provided "good" care when faced with ethical challenges and use of moral resilience.

Little is known about the ethical challenges that nurses faced during the COVID-19 pandemic and ways they responded.

Qualitative, descriptive free-text surveys and semi-structured interviews, underpinned by appreciative inquiry.

Nurses working in intensive care in one academic quaternary care centre and three community hospitals in Midwest United States were invited to participate. In total, 49 participants completed free-text surveys, and seven participants completed interviews. Data were analysed using content analysis.

Five themes captured ethical challenges: implementation of the visitation policy; patients dying alone; surrogate decision-making; diminished safety and quality of care; and imbalance and injustice between professionals. Four themes captured nurses' responses: personal strength and values, problem-solving, teamwork and peer support and resources.

Ethical challenges were not novel but were amplified due to repeated occurrence and duration. Some nurses' demonstrated capacities for moral resilience, but none described drawing on all four capacities.

Nurse managers would benefit from greater ethics training to support their nursing teams.