'Unable to dodge the bullet': a qualitative study of ethical dilemmas and moral distress of critical care nurses during the Covid-19 pandemic in a South African Province.

backgroundWorldwide, nurses have been at the frontline of the Covid-19 pandemic response and central to its effectiveness. They faced numerous ethical dilemmas which in turn resulted in considerable moral distress. However, there are knowledge gaps on the experiences of critical care nurses in South Africa during the pandemic.

aimExplore the experiences, specifically the ethical dilemmas and moral distress, of critical care nurses working in South African hospitals.

methodsGilligan's ethic of care theory informed this exploratory, qualitative descriptive study with nurses who had experience of taking care of individuals with Covid-19 and working in intensive (critical) care units in the Gauteng province of South Africa. We recruited eligible nurses through a combination of social media adverts, snowballing, and referral from professional associations or trade unions. Following voluntary informed consent, we conducted in-depth interviews with nurses using an interview guide that focused on personal and professional experiences during the pandemic, ethical dilemmas, relationships with other colleagues and/or management, and the availability of support systems. Data was analysed thematically.

resultsThe participants comprised 21 nurses, 16 females and 5 males with a mean age of 38 years. The majority were professional nurses (20/21 = 95%) and from the public health sector (17/21 = 81%). Nurses highlighted the tension between their deep caring for patients and the realities of taking care of patients during the Covid-19 pandemic that necessitated pragmatic compromises, such as doing the bare minimum. They expressed ambivalence about the Nursing Oath because they were acutely aware of the moral obligation to put the health of their patients as their first consideration, yet they faced the personal risk of infections and disease exposure. The uncertainty and fear of the pandemic, of infection, of the unknown, and of being in the frontline of health care provision resulted in considerable moral distress. Simultaneously, the perceived lack of appreciation for their work and for risking their lives as health care providers, and the resource constraints intersected with and exacerbated both ethical dilemmas and moral distress.

conclusionsThis study highlights the ethical dilemmas that nurses experienced during the pandemic, and their perceived moral distress. It contributes to the discourse on healthcare ethics, particularly in crisis situations, and highlights the need for robust support systems for nurses.