Original Manuscript

Nursing Ethics
2022, Vol. 29(1) 7 ­–18
Ethical dilemmas faced by frontline ª The Author(s) 2021
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support nurses fighting COVID-19 sagepub.com/journals-permissions

10.1177/09697330211015284
journals.sagepub.com/home/nej

Xinyi Liu , Yingying Xu, Yuanyuan Chen, Chen chen, Qiwei Wu

and Huiwen Xu and Pingting Zhu
Yangzhou University, China
Ericka Waidley
Linfield College, USA

Abstract
Background: In 2019, an outbreak of COVID-19 broke out in Hubei, China. Medical workers from all over
the country rushed to Hubei and participated in the treatment and care of COVID-19 patients. These
nurses, dedicated to their professional practice, volunteered to provide compassion and expert clinical care
during the pandemic. As with other acts of heroism, the ethical dilemmas associated with working on the
front line must be considered for future practice.
Purpose: To explore the ethical dilemmas of frontline nurses of Jiangsu Province in China during
deployment to Wuhan to fight the novel coronavirus pneumonia, and to provide a basis for developing
strategies to help nursing staff address personal and practice concerns in order to work more effectively
during this pandemic and other disasters in the future.
Research design and method: Using the phenomenological research method and the purpose sampling
method, semi-structured interviews were conducted with 10 nurses, post-deployment to Wuhan, who had
worked on the front line to fight the novel coronavirus.
Ethical considerations: The research proposal was approved by the Research Ethic Committee of
Yangzhou University, China.
Findings: From the analysis of the interviews of the 10 participants, three main themes were identified:
ethical dilemmas in clinical nursing, ethical dilemmas in interpersonal relationships, and ethical dilemmas in
nursing management.
Conclusion: During a quick response to public health emergencies, where nurses are deployed
immediately as a call to action, the issues surrounding ethical dilemmas from several perspectives must
be considered. This research suggests that a team approach to proactive planning and open communication
during the emergency is an efficient and productive strategy to improve the nurses’ experience and sense of
well-being.

Keywords
COVID-19, ethical dilemmas, frontline nurses, qualitative research, teamwork

Corresponding author: Pingting Zhu, School of Nursing, Yangzhou University, 136 Jiangyang Middle Road, Yangzhou 225009, China.
Email: ptzhu@yzu.edu.cn
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Introduction
The novel coronavirus pneumonia outbreak occurred in Wuhan, Hubei Province, China on the eve of New
Year’s Day in 2020. The number of patients diagnosed with the virus began to soar after the first case of the
new coronavirus pneumonia in Wuhan was detected. As with other countries, the impact of COVID-19 has
brought unprecedented challenges to China’s medical and health service system. Therefore, the National
Health Commission of the People’s Republic of China has increased the number of healthcare providers
from all over the country to support Wuhan. As an important part of medical and health services, nurses play
an important role on the care team. Similar to nurses in other countries1, nurses in China have an ethical
responsibility to protect and advocate for patients and to maintain their worth and dignity in all care settings.
However, during epidemic, the front-line nurses were confronted with several ethical dilemmas and con-
flicts. This study attempts to explore the ethical dilemmas of front-line nurses of Jiangsu Province in China
during deployment to Wuhan to fight the novel coronavirus pneumonia.

Background
The World Health Organization declared the COVID-19 pandemic as a public health event of interna-
tional concern2. The virus can cause severe acute lower respiratory syndrome with high infectivity, thus
causing it to spread quickly throughout several countries. COVID-19 continues to challenge the global
public health safety system and poses a serious threat to health and mortality. Compared with SARS in
2003, COVID-19 spreads faster, has a wider range of infection, and is more difficult to prevent, control
and treat.
In order to fight COVID-19, Wuhan local medical workers devoted themselves to the epidemic and took
steps to provide the resources needed to treat the influx of sick patients. Until the National Health Com-
mission of the People’s Republic of China deployed additional medical workers to support Wuhan (January
25,2020), the local workers had been working diligently for over 30 days. Due to the large number of acute
care hospitalized patients, in addition to the constant stream of COVID diagnosed patients, the providers
were under great work pressure. In addition, they were also facing the fear and risk of being infected. As
more patients were admitted they faced the shortage of personal protection equipment (PPE) and other
resources needed to take care of high acuity patients. As quickly as the patient infections surged, the
National Health Commission’s assistance to Wuhan was constantly focused on addressing the shortages,
both in staffing and equipment resources.
Since the outbreak of COVID-19, 42,000 medical staff from all over the country rushed to Wuhan to
support the care needs and work on the frontlines. However, when faced with the challenges of the
pandemic; such as unfamiliar working environments3, conflicts between shift workers4, rapid growth of
the number of infected and suspected cases5, extreme shortages of medical resources6, and difficulty in the
prevention and control of nosocomial infection, the front-line nurses were confronted with several ethical
dilemmas and conflicts7. Ethical dilemma refers to a situation when nurses are unable to solve the ethical
problems they are facing, which includes the difficulties encountered in interest balance, resource allocation
and interpersonal relationship8. Fundamentally, the cause of these dilemmas in nursing ethics is the gap
between existing nursing practice and the ideal nursing goal.
With the spread of novel coronavirus pneumonia worldwide, these issues of ethical dilemmas in nursing
practice, in the context of the pandemic, need to be addressed at all levels, including government, local,
facility and within the nursing profession. This study attempts to investigate these issues at the professional
level in order to better understand how to support nurses fighting the pandemic on the front lines and post-
deployment.
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Purpose
The purpose of the study was (1) to investigate nurses’ responses and reactions to quick deployment to fight
the COVID-19 epidemic with a focus on mental health and coping strategies, and to correlate responses with
ethical principles in nursing practice; (2) to provide relevant suggestions and references for strengthening
humanistic care and respecting professional values in nursing practice; and (3) to provide an empirical study
to improve the ethical decision-making ability of frontline nurses and the ability to deal with public health
emergencies.

Materials and methods

Study design
Using Colaizzi’s phenomenological method for qualitative research,9 this study details the ethical dilemmas
faced by nurses fighting COVID-19 in Jiangsu, China. Colaizzi’s phenomenological approach focuses on
the experiences and feelings of participants and finds common patterns in research objects rather than
personal characteristics. This scientific method can ensure the authenticity of the experience gathered by
participants in compliance with scientific standards.

Participants
The objective sampling method was adopted to interview 10 nurses who volunteered to be deployed to
Wuhan to work the front lines and care directly for the COVID-19 patients. Criteria for inclusion in this
study includes (1) volunteered to work under the pandemic conditions for at least 4 weeks, (2) provided
direct nursing care to victims of COVID-19, and (3) informed consent and voluntary participation to be
interviewed. The determination of sample size was based on participant availability and access post-
deployment and determination of consistent themes during data collection.

Data collection
Based on a literature review of topics consistent with the study purpose, the research team developed an
interview outline specific to conditions of the COVID-19 epidemic. The questions include the following:
(1) Please describe your experience of going to Wuhan for support. Did you encounter any difficulties and
why? (2) Did you have any internal conflicts and conflicts in the process of supporting work or providing
care for patients? If so, can you elaborate on this conflict? (3) Has the epidemic effected your professional
ethics? If so, what are the effects?
The researcher introduced the research objectives, methods, and contents to the research subjects prior to
the interview. The interviews were completed in a private environment and the data are protected for
confidentiality. After the interview, a repeated analysis was made of the data. If there were questions, the
interviewees were contacted to verify and ensure the credibility of the information. The research team
discussed the results together to prevent subjective bias.
The interview was conducted on the nurse’s rest day, and the one-on-one semi-structured in-depth
interview was conducted through the WeChat video, and was recorded. During the interview, the researcher
listened as much as possible, responded appropriately, and gave respect and understanding without inter-
rupting the nurse’s statement. The nurses’ expressions, tone, and body language were recorded, and each
interview lasted 60–90 min.
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Table 1. Characteristics of participants.

No. Gender Age, years Occupational title Work experience, years Marital status

A1 Female 23 Nurse practitioners 1.5 Single

A2 Female 32 Nurse-in-charge 11 Married
A3 Female 38 Associate chief nurse 15 Married
A4 Female 37 Associate chief nurse 13 Married
A5 Female 28 Nurse-in-charge 6 Married
A6 Female 45 Associate chief nurse 24 Married
A7 Male 25 Nurse practitioners 4 Single
A8 Female 30 Nurse-in-charge 8 Married
A9 Male 30 Nurse practitioners 7 Single
A10 Female 46 Associate chief nurse 26 Married

Data analysis
Within 24 h after the interview, the researcher transcribed the recording verbatim and documented the
emotional and facial changes of the interviewees. The process for analysis followed Colaizzi’s seven-step
analysis9: (1) Read the source carefully, (2) Extract phrases or sentences related to the research phenom-
enon, (3) Encode important statements that occur repeatedly, (4) Categorize the codes and integrate the
results, (5) Provide a detailed description of the research phenomenon, (6) Reduce the detailed description
to form the structural framework, and (7) Return the research object for verification. These steps were
adhered to in the process of data analysis of the 10 interview transcriptions.

Ethical consideration
This study has been ethically approved by Yangzhou University (YZUHL2020002). The purpose and
significance of the interview was explained to the nurse participant before the interview and oral informed
consent was confirmed. Anonymously, according to the interview order, the subjects were numbered with
English letter A (A1–A10), to ensure the confidentiality of participants’ information.

Results
A total of 10 (8 females and 2 males) nurses, with a working experience ranging between 1.5 and 26 years
(Table 1) were interviewed. Ethical dilemma, according to the experience reported by the participants
(frontline support nurses fighting COVID-19), was described through three main themes: ethical dilemmas
in clinical nursing, ethical dilemmas in interpersonal relationships, and ethical dilemmas in nursing
management.

Themes and sub-themes

According to McKenna,10 a foundation of nursing practice is the duty of care and an obligation to alleviate
suffering, restore health, and respect the rights and dignity of each patient (p. 1). This foundation of practice
is also embodied in the nurse practice acts in many countries and the professional nursing organizations’
ethics statements.2,11 As nurses continue to be recognized as leaders at the front lines of the pandemic, it is
important to continue to investigate the effects of the pandemic on nursing practice and personal well-being.
This study has identified some of the ethical dilemmas related to this concept.
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The three major themes identified in this study are ethical dilemmas in clinical nursing, ethical dilemmas
in interpersonal relationships, and ethical dilemmas in nursing management.

Ethical dilemmas in clinical nursing. The first theme cluster that was identified from the data analysis is “the
conflict between patient interests and nurses’ own safety.” The basic principle of nursing ethics is the
generalization of the universal law of the moral relationship.12 It reveals the ethical responsibility of nurses
and requires nurses must have the spirit of selflessness and the courage of conquering the disease when
faced with challenging situations. COVID-19 pneumonia is a newly emerging infectious disease, with high
susceptibility, and thus creates a new, and challenging, situation for nurses. During the process of these
treating patients, nurses face many problems such as high-intensity and difficulty of work and susceptibility
to infection. Some staff suffered pressure ulcers on their nose and face because of wearing masks and
goggles for extended periods of time. Several participants expressed an emotional concern for self-safety:

The first few days that I worked in the ward; I was really afraid of being infected because all of the treatments are
close operation. (A4)
When someone dies in the ward, the patient who sleeps in the next bed is so scared of what will happen to them,
but actually, we are also afraid. (A4)

In other comments, the conflict between protecting themselves and protecting the patients was revealed
and commitment to professional responsibility was evident:

We remind each other when we wear and took off the protecting clothing, every step must follow the restriction.
If I got infected, it would increase the burden of medical resources, and the most important is it might infect other
colleagues. (A6)
We have to make ourselves stronger before we comfort the patient. (A4)
Even (though) there are pressure ulcers and blisters on my face, I have to take protection properly and continue to
finish my job. It is my responsibility to hold my ground. (A3)

The second theme identified was “the conflict between the priority of patients’ life and the pursuits of
effective nursing care.” “Protect life, relieve pain, and recover health” is the professional purpose of
nurses.13 As professional nurses, all of the participants recognized their obligation of taking care of patients
and commitment to the ethical-moral aspect of nursing practice. Due to the infectious nature of the COVID-
19 virus, the use of full-body PPE, duplicate masking, and face shielding were required for often extensive
periods of time. This created new challenges in patient care delivery and self-preservation for the nurses on
the front line:

The first time when I step into the ward, I was wearing two masks, goggle and face shield. I was very stuffy and
couldn’t breathe so well. I was dizzy for the first half-hour even couldn’t do my job. (A1)
A few steps in such a thick protective suit: It’s easy to sweat and soused my body all over. Wearing gloves to
finish venipuncture is not easy, because when I prepare to find a blood vessel, my goggle was fogged up, . . . (A3)

Nurses on the front line continue to be challenged by the change in work environment that the extensive
PPE has mandated and struggle with the constant fatigue, health problems, and challenges in patient care
delivery that has become the “new normal.”
The third theme identified is “the conflict between patients’ personal freedom and compulsory iso-
lation.” Isolation is one of the effective ways to control the spread of infectious diseases and the COVID-19
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pneumonia is a severe infectious disease, which has strong pathogenicity and transmissibility. To advocate
for public interest, and prevent exposure to infection, most hospitals have had to restrict personal freedom of
patients, staff, and visitors. These restrictions have added to the stress of the work environment:

Patients and accompanist cannot walk around in the ward. (A1)

Any of them want to leave the ward to buy some articles of daily use, we will dissuade them and donate some of
our resources to them. And prepare some diapers for long-term bedridden patients. (A2)

The long-term effects of this social isolation, in hospitals and in the community, on healthcare providers,
individuals, and families will need to be a research topic for many years.
The fourth theme identified is “the conflict between high-tech application and improvement of patients’
mood.” The use of high-tech medical equipment was a valuable resource during the prevention and
treatment of COVID-19. However, it also exposed difficulties between nurses and patients. When using
monitoring equipment, movements are restricted which also reduces the comfort level for patients. The
equipment noises also can stimulate their senses and cause anxiety, which adds to the difficulties of
providing nursing care. Nurses not only have to know how to use high-tech medical equipment reasonably
and safely, but they also need to help the patients adapt to the high noise levels, over-stimulation in the care
environment, and restricted mobility.

I wasn’t an ICU nurse (before,) but now, I have to take care of some patients who are using a breathing machine,
which means I have to learn how to use the equipment. (A8)
We need to do some psychological counseling for the patient. Some of them are so scared, and even write a will,
at that moment, we have to accompany them. (A6)
I will do some psychological comfort to my patients to increase confidence by telling them some cases of
successful discharge. And for some critical patients, we do not have quite enough experiences, so some problems
require professional guidance form psychologists. (A7)

All of these themes indicate new challenges that these study participants, and all nurses, are faced with
when the work environment pivots rapidly and creates new concerns for personal safety, knowledge gaps
and lack of expertise, nurse–patient relationships, patient safety, and mental and emotional health for
patients and the nurses caring for them.

Ethical dilemmas in interpersonal relationships. The second category of themes, “ethical dilemmas in interper-
sonal relationships,” consisted of two clusters that deal with the ethical dilemmas of nurses’ relationships.
The first cluster identified was “doctor–nurse and nurse–nurse relationship—adaptation to unfamiliar
environments.” Building relationships between doctors and nurses based on cooperation and active listen-
ing can help improve teamwork and reduce the degree of nursing ethical dilemma. The nursing ethic stresses
the importance of supporting safeguard, acting responsibly, working together, and caring for each other.
After the outbreak, hospitals in Jiangsu province dispatched workers to form medical teams. These medical
providers from diverse hospitals are unfamiliar with each other and the new environment, and also vary in
terms of working habits and adaptability. In addition, when a person changes from a familiar and fixed
cultural environment to an unfamiliar one, there will often be a certain sense of crisis and strangeness due to
the difference in attitude and belief. Several study participants commented on this cultural shift:

I very much agree with the teams in batches 6 and 7 who came to Wuhan for support. They took over ICU as a
whole with smooth cooperation between doctors and nurses. A deeper and better understanding of each other can
enhance work efficiency. (A4)
Liu et al.
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The support nurse in the resident has a single room per person as accommodation. It was very lonely that the
nurses had to spend time alone when they came back from work. Communication with people is mainly through
the telephone and the Internet, which is a new relationship model and a test for our front-line nurses. (A7)
The resident organized study and discussion session every night to help the nurses alleviate pressure and solve
difficulties they faced with. (A10)

The second cluster identified was “nurse–patient relationship—cultural differences and communication
barriers.” After the outbreak of the epidemic, nurses from all over the country rushed into Wuhan to help
care for patients. As the patients came from a range of regions with different cultural backgrounds and
languages, there were unpredictable problems in communication between nurses and patients.

When I worked in the isolation ward, it was difficult for me to understand the accents of local people in Wuhan
and to communicate with them because I was wearing a mask. (A3)
Sometimes patients talk to us and we don’t understand, and the young patient next to us will explain it to us. (A8)

Although this can be a common challenge in countries with a diverse population of patients, the
challenges are exacerbated when there is an emergency and resources such as translators, bi-lingual written
information, and/or electronic assistance is not immediately available.

Ethical dilemma in nursing management. The third theme category was ethical dilemma in nursing manage-
ment. The first cluster identified was “the conflict between scarce supplies and equal distribution.” Several
of the nurses commented on this dilemma:

When we first arrived in Wuhan, too many hospitals were short of medical supplies. And some of them even
cannot last for a week, so we worried about it. (A2)
Many hospitals like Wuhan central hospital, Jinyintan hospital, and so on have been collecting medical supplies
such as N95 masks, goggles, protective suits through official Weibo. . . . We hope that the supplies can be
deployed as soon as possible . . . (A6)

These circumstances created a new need for policies and practices related to the optimal distribution of
resources:

There was only one ventilator in the ward. When the blood oxygen saturation of the patient drops and cannot be
relieved by back pat and sputum aspiration, we will borrow a ventilator form other ward or transfer to another
department or relieve the symptoms by using a high-flow oxygen therapy machine. (A2)
Some elder patients think they were too old and it’s not worthwhile to save them, we have to persuade them to
cooperate with treatment. (A7)

The frontline nurses felt responsible for the limited resources and had to be creative in developing new
interventions to provide comprehensive patient care.
The second cluster identified was “the conflict between insufficient human resources and flexible shift.”
There were many factors that effected short staffing and allocation of human resources during the first
weeks and months of the pandemic. One nurse commented on the need for diligent patient observation:

She was trying to get out of the ward for 9 times, we have to lock up the door and paramedics took turns to watch
her 24 hours and make sure she wouldn’t run again. (A8)
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Other participants noticed the lack of adequate staff to care for the high acuity of patients:

Scheduling is still difficult. The main reason is we lack human resources. (A3)
If some nurses got a fever or have some mental issues, they have been placed on temporary rest so that they will
not be put at high risks which from the front-line. (A10)
Our team leader is really good. Because even under such a situation which we lack human resources, he can
help us to learn some professional knowledge and handle all kinds of interpersonal relationships in a coordi-
nated way. (A6)

The issues of staffing and allocation of human resources in an emergency will continue to be an issue due to
the nature of any disaster. However, nurse managers and administrators must continue to learn from these
experiences and prepare policies and procedures to guide the medical provider teams in the future as needed.
The third cluster identified was “the conflict between professional obligations and family roles.” Since
the outbreak of the epidemic, the medical professions in many countries, including those in China, have
volunteered their time and expertise to care for those in need. The loyalty and responsibility of nurses,
whether they stayed at home to help or volunteered to be deployed, have demonstrated their noble profes-
sion. However, many nurses not only have professional responsibilities, but they also play an important role
in the family. This personal–professional conflict was expressed by several participants:

Our country is in trouble, due to the responsibility and the sense of mission, I have to be a warrior, a front-line
staff. After discussing with my family, I decided to postpone the wedding date. Sacrificing individual interests for
public benefits. (A1)
My very young child did not want me to come to Wuhan. He couldn’t understand my duties and responsibility.
He was worried about my safety and cried for a while. (A6)
Thanks to my government, for helping my family settle down, so that we can focus on the campaign and devote
ourselves to work. (A1)

This sense of dedication and commitment to help people in need is a universal theme of the nursing
profession and one embodied by nurses throughout history.
The fourth cluster identified was “the conflict between ethical principles and ethical decision-making.”
The foundations of nursing practice provide the guiding principle of ethical decision-making for nurses.
These ethical principles have different scopes of adjustment in differing situations. In an epidemic situation,
internal conflicts and ethical problems may mean that nurses, and administrators, have to re-examine the
normal or expected standard of care and be creative in adapting to the varying degrees of need from patients,
families, and staff.

When I first came to the ward, I was worried that my protection was not good enough and I didn’t dare get too close
to the patient. But, when I saw the patient was in pain, I want to help him or her from the bottom of my heart. (A1)
We won’t let the patient, themselves, see the indicators of oxygen saturation on the monitor because it will bring
extra huge mental stress. (A7)
The patient was so young, and his desire to live was so strong. We already know we couldn’t save his life, but we
try to because we knew there were his wife and child waiting for him. (A10)

Situations like these put the nurse in a difficult position and often as the primary communicator within
the team and with families. This adds additional stress to individual nurses and reinforces the concept that a
nurse’s duty to care for patients is not absolute.
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Discussion
Since the outbreak of the new coronavirus in Wuhan, the Chinese government has attached great importance
to it and made timely prevention and control arrangements.
Current source data in China have presented the proportion of infected medical staff at 3.8%, mainly due
to early contact with infected patients without any protection.4,14,15 Covid-19 is such a new virus that we do
not know enough about its pathophysiology, transmission patterns, susceptibility, infectivity, and failures in
the supply chain of PPE.16 Based on early research findings,17,18 healthcare workers were faced with many
unknowns including a fear of being infected and possibly death. However, they see their role as a “life
saver” and know that the role of a medical professional cannot be replaced by others which makes it
impossible to abandon any patients.19 Based on the uniqueness of the medical industry and the goal to
maintain national life and physical health, the state (China) requires healthcare workers to respond to
national polices and support national decision-making in this situation, and to put the life safety and
physical health of the people first. Every nurse is expected to fulfill social responsibilities and obligations
and cannot refuse to perform duties because of the danger.20
However, one aspect of the code of ethics for nursing is self-care. American nurse association codes of
ethics also stipulate that nurses have a duty to promote their own health and safety.2,11 In times of a
pandemic, and in alignment with the need for additional resources, nurses are pulled between providing
care to others and protecting themselves and their families.
This creates a balancing act between patients’ interest and self-interest? Even when using comprehensive
and necessary precautions, healthcare workers were exposed daily to a high-risk environment. In some
scenarios, the basic physiological needs of nurses as human beings, such as drinking water, eating, going to
the toilet and taking a break to recover, could not be met. These challenges are not acceptable on a long-term
basis and must be addressed in order to protect our healthcare workforce.21,22 The themes found in this study
reinforce the need for better planning; shared problem solving; creative changes in nursing practice; a focus
on individual well-being and safety; and the development of policies, procedures, and guidelines to improve
the work environment of the future.

Recommendations
This study investigated the feelings and attitudes of 10 nurses who were deployed to the frontline caregiving
team in Wuhan, China, in the early stages of the COVID-19 pandemic. Although a small sample size, the
nurse participants included men and women, diversity in age, and a wide range of experience and roles. The
quotes from the interviews are heartfelt and indicate a passion for helping others, even when fear and
anxiety are present. The recommendations from the analysis of the data includes the following:
1. The nursing profession, in collaboration with hospital administrators, need to develop policies,
procedures, and guidelines that focus on supporting nurse (and other providers) safety specifically
in disasters and public health emergencies. These policies can include short, and efficient, onboard-
ing programs for deployed staff, guidelines that provide triaging protocols for staff and equipment,
guides describing chain of command for decision-making, and policies for minimum expectations to
maintain physical health and emotional well-being.
2. Senior team members must be expected to maintain open lines of communication and establish a
community of caring that benefits both patients and staff. Faced with a new work environment
including unfamiliar colleagues, it is necessary to establish a cooperative relationship quickly,
which is conducive to more efficient teamwork. The premise of cooperation is mutual understand-
ing.23 And the team leader/manager must determine ways to increase this interprofessional
teamwork.
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3. Professional nurses must be allowed, and encouraged, to function at their full scope of practice.
Nurses are adept at developing a comprehensive plan of care for patients, and these plans must be
respected and followed by all providers in order to provide the most efficient and quality of care
possible. The treatment plan for patients under special circumstances needs to be implemented
jointly after full communication and consensus between doctors and nurses.16 In the epidemic
situation, nurses and doctors are a close and unified cooperative community,24 and must establish
effective peer support, pay attention to the physical and mental health of the team, and work together
to overcome difficulties.25
4. Security measures must be maintained, and possibly increased due to the high stress levels of
everyone involved with the pandemic. Although violence has occurred during the pandemic, it is
also during this time that the relationship between doctors and nurses and patients has reached
unprecedented solidarity. Guidelines need to be developed that reinforce that any interference with
medical order and workplace violence should be seriously dealt with and condemned by the media in
accordance with the law.
5. Protocols for ethical decision-making are needed so the stress of these decisions is not always on the
nurse or other providers. Although the need for human survival is higher than individual rights, the
balance between individual rights and social public health needs cannot be ignored. It is generally
believed that saving the lives of all people takes priority over personal desires.16 During the COVID-
19 pandemic, in order to protect more people, family members of the patients are not allowed to
visit, even at the end of life. The challenge for nurses and other healthcare workers is how to use
imaginative solutions to alleviate these potentially dehumanizing situations without sacrificing
compassion and equal respect for safety and efficiency.26 Nurses must identify ethical issues and
to seek sources of ethical support.27 In China, there is a need for clinical ethics counseling services,
trained ethicists, and other resources that can support the providers and families during high-stress
occurrences.
This study and experiences during the pandemic have helped us learn that healthcare systems are often
overwhelmed in terms of decision-making, resource allocation, and patient priorities when confronted
with public health emergencies.28 For example, there was neither enough PPE nor enough beds or
respirators for those patients who needed them.5 As a result, many frontline medical workers suffer
infection or even lost their lives.29 Developing protocols and procedures with a goal of Zero Infections
of healthcare workers is a start.
Nursing managers should pay attention to the health and physical and mental needs of nurses, reasonably
arrange human resources and working hours, investigate the scheduling needs, and make flexible schedul-
ing. In addition to patients, nurses should be given humanistic care. Humanistic care is an endorsement of
humanity and human values. Humanistic care gives nurses spiritual support and becomes an effective way
for managers and nurses to cope and get along with each other. During the special period of the epidemic,
managers should provide the frontline nurses with optimized working procedures and adequate and safe
protective materials, in order to reduce the stress levels of nurses and reduce the risk of occupational
exposure. Psychological counseling and logistic support can be provided to nurses to optimize the working
environment under the unusual scenario of a pandemic.

Conclusion
In each country, health workers face professional and personal challenges that require rapid clinical
decisions and action in the event of a disaster or public health emergency. The COVID-19 epidemic in
2019–2020 has created new requirements and challenges that effect the professional ethics of nursing staff.
Liu et al.
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As the pandemic evolves, we need to focus on how to effectively and creatively provide patient care, ensure
the safety of nursing, and remove the ethical dilemmas in nursing practice. In the face of occupational risks
concerning public health, nurses must firmly establish the concept of selfless dedication, have the courage
to take professional responsibility, challenge themselves, and use professional skills and professionalism to
fight against diseases and safeguard people’s health and social stability. But they can’t do this alone. The
responsibility to improve health, and respond effectively and safely to public health emergencies, is a role
for us all.

Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This work was supported by Postgraduate Research & Practice Innovation
Program of Jiangsu Province(No.KYCX20_3006) and Training Program of Innovation and Entrepreneur-
ship for Undergraduates of Jiangsu Province (No.201911117085Y)

ORCID iD
Xinyi Liu https://orcid.org/0000-0003-2990-1905
Pingting Zhu https://orcid.org/0000-0002-1826-2725

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