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

Objective: 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.

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

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

Results: 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.

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