The model of solving ethical challenges with nursing based on faith in God: a new model for nurses to care during epidemics

Abstract

Background

The existence of various ethical challenges, the inability to resolve ethical conflicts, and, as a result, the low quality of care and the occurrence of dissatisfaction in patients and nurses have been discussed for years. By creating new ethical challenges, the Covid-19pandemic has played an important role in making the process of care for these patients more difficult and complicated. This study was conducted with the aim of designing a prescriptive model to help provide ethical-care and resolve ethical conflicts during the Covid-19pandemic.

Methods

In this two-stage qualitative study, a grounded theory research method was used in the first stage, and data were collected through semi-structured interviews. Sampling started purposefully and continued theoretically. In the second step, the appropriate model was designed using the three-step method proposed by Walker and Avant.

Results

The core concept was “behavior based on faith in God”, based on which the grounded theory of “faithful nursing” and then “model of solving ethical challenges with nursing based on faith in God” were presented. The strategies of the model in three parts are strengthening the beliefs of nurse, strengthening environmental facilitators to help nurse, and strengthening situational analysis in duty diagnosis in nurse were presented.

Conclusions

According to this model, nurses’ beliefs play a key role, and the strengthening of environmental factors play a secondary role in ethical-care.

Background

The existence of various ethical challenges, on the one hand, and the inability to solve them, on the other hand, and, as a result, the low quality of care and the dissatisfaction of patients and nurses have been discussed for years [1,2,3,4]. Providing ethical-care is a serious challenge not only in Iran but also in other countries. Among these, one of the conditions that complicates the provision of ethical-care is the care of patients during epidemics such as Covid-19 [5]. Covid-19has become a great ethical challenge because it affects various aspects of human health and the appearance of many ethical challenges that did not exist until now [5,6,7]. Challenges such as decision-making by treatment staff instead of patients, a lack of accurate information about treatment and care methods [8,9,10], the occurrence of remorse due to the uncertainty of treatment choices and the compulsion to perform actions that are in contrast with personal ethical values have created complexity in the provision of ethical-care [9,10,11].

In this regard, the results of Morley’s study (2020) revealed the ineffectiveness of the four principles of biomedical ethics, namely, usefulness, justice, autonomy, and non-harm in the care of people with Covid-19 [12]. Therefore, different studies have proposed a look beyond the four principles of biomedical ethics or the need to change their content [5, 11, 13]. Additionally, other studies that have reported the unpredictability of death in patients with Covid-19have pointed to the lack of effectiveness of triage principles in overcoming ethical challenges [5, 12, 13]. One way to resolve ethical conflicts is to use models [14, 15]. By creating a better and more complete attitude toward phenomena, models provide solutions that can be used to find answers to many questions [15].

However, despite such ethical challenges, there is no organized model to support nurses in resolving ethical conflicts while caring for patients with Covid-19. In this regard, in a study conducted by Karimi (2020), nurses wanted to design guidelines related not only to the realities and ethical complexities of Covid-19but also to help resolve ethical contradictions while caring for these patients [4]. Although there are currently different decision-making models for ethical challenges, for several reasons, it is not possible to localize the existing ethical models and use them in the current situation.

The first reason is that in formulating models, it is very important to identify the experiences of nurses in the field under investigation, and providing a model based on experiences is very helpful [16]. This is despite the fact that none of the models are based on the experiences of nurses in the field of Covid-19. The next reason is that the results of various studies indicate the existence of serious flaws in ethical theories and models. For example, in Hajaty-Shoraky’s study (2013), it is stated that obedience to rationality is the only reason for doing one’s duty in the theory of deontology, whereas a person performs an action as a duty that he considers perfect for himself. Of course, different goals may be chosen as perfection for each person [17]. Additionally, the results of numerous studies show that in the theory of virtue-ethics, the main virtues are secular, and the meaning of virtues is sometimes contradictory in different societies [18,19,20,21,22]. Another reason is that because people’s behavior is regulated on the basis of the philosophical conditions governing society, to improve the quality of local models, it is necessary to pay attention to the conformity of ethical models with the values ​​and norms of society [23,24,25,26].

Considering the emergence of new ethical challenges caused by the Covid-19disease and its negative consequences, nurses need to use a model to help provide ethical-care and resolve ethical conflicts during care. In view of the researcher’s search in various databases, which indicates the lack of a model to support nurses in making decisions in ethical conflicts during the care of patients with Covid-19, the researcher decided to design a prescriptive model in this field. Since the most appropriate model is the model based on the social context using grounded theory, this study aims to provide a supportive model based on the grounded theory of faithful nursing that describes the process of ethical-care based on faith in God [27] to improve the quality of care and satisfaction and resolve ethical conflicts during the care of patients with Covid-19.

Methods

Study design

The objective of this study was to provide a support model for nurses to promote the ethical-care of patients with Covid-19. This study was conducted in two stages from2021-2024. In the first stage, grounded theory was adopted to fully examine the ethical-care process of patients with Covid-19. In the second stage, the findings were employed through Walker and Avant’s method (2019) for theory construction [28]. Therefore, a supportive model was designed for nursing support to promote the ethical-care of patients with Covid-19. The study was carried out at hospitals affiliated with the University of Medical Sciences in Tehran and Qazvin, Iran.

Participants and procedure

The sampling was initially purposeful and then theoretically based on emerging concepts and continued until data saturation. The data were collected through semi‑structured interviews, field notes, and unstructured observations. The interviews were conducted face-to-face and web-based. A total of21interviews were administered with19participants. Each interview was recorded by a digital device and then typed on the same day. The first author has access to information to identify participants during or after data collection. The data were analyzed through the Corbin and Strauss (2008) method, which involves the analysis of the concepts, context, process and, finally, the integration of categories to build a theoretical framework [29]. Techniques such as continuous comparison, theoretical comparison, and the flip‒flop were used to improve the theoretical sensitivity.

This article is a product of the results of a grounded theory study called “faithful nursing” theory, which describes the ethical-care process of Iranian nurses for patients with Covid-19based on their faith in God [27]. This study adopted an independent research method (published work), resulting in an independent prescriptive model/theory. The model suggested in this article is a model with a practice‑theory approach. Since conceptualization is derived from practice on the basis of experiences in clinical settings and this process begins with a question rooted in clinical situations [30], the prescriptive model suggested in this article started its course through initiation in the actual arena of nurses’ clinical practice.

To introduce the prescriptive model, the synthesis approach of Walker and Avant (2019) has been adopted. With this aim, Walker and Avant proposed that the theory synthesis strategy is more applicable than the theory derivation strategy. They stated that when a theorist has initial concepts for theory development, it is better to begin theory development from a theory synthesis approach rather than concept synthesis [28]. They suggested three stages in the synthesis of a theory:

• 1. Specifying focal concept(s) to serve as anchors for the synthesized theory:

The focal concept of this theory was chosen based on the main findings of the grounded theory study [27]. Grounded theory study led to the emergence of a theory, “faithful nursing.” The findings of the grounded theory revealed that “the challenge of doing the right thing as an inner commitment” was the main concern of nurses while caring for patients with Covid-19. The deep analysis of the data revealed that, based on the level of the nurses’ faith in God, a sense of inner commitment or duty is formed in doing what is correct and necessary for the patient so that they can finally achieve God’s satisfaction while satisfying the patient and their conscience. Therefore, the nurses tried to fulfill their duties voluntarily and without any external requirements by performing various methods. In this process, the level of existential faith in God is considered the main context, and environmental conditions are considered the secondary context. Achieving God’s satisfaction while satisfying the patient’s and the nurse’s conscience is also considered an outcome [27]. Therefore, the focal concept of the support model for solving ethical challenges during the care of patients with Covid-19 is “care based on faith in God”. Since the ethics of nursing are mixed with human, society and health, and considering that the four meta-paradigmatic concepts of nursing, human, health and environment are the essence of nursing theories, the concepts of “human”, “nursing”, “health” and “environment” in addition to the focal concept constitute the conceptual framework of the present prescription model.

• 2. The published studies are reviewed to identify the factors related to focal concepts and specify the nature of the relationships:

Before reviewing these studies, it is necessary to focus on the research question. The research question in brief was “how do nurses provide ethical-care for patients with Covid-19?”In addition, according to the explicit opinion of Walker and Avant, texts that are valid from the point of view of the research team should be selected [28], so the following four items were considered the criteria for the inclusion of studies. A) There must be a match between the worldview of the studies and the researcher [31, 32]. B) The selected studies must accept that ethic propositions refer to reality and that reality exists independently of the order and will of a group of people [33]. C) It should be ensured that the studies are in accordance with reality [34]. D) Selected studies should be appropriate for culture and religion because they are very effective in making the model more applicable [25, 26, 29, 35,36,37].

According to the focal concept “care base on faith in God” and four criteria, as well as due to the religious context of Iran and the fact that more than95%of Iranian people are Muslims, the review of studies was considered only in Islamic texts. Therefore, the available Islamic books and articles published in Persian and Arabic without time limits using the combined keywords “ethical care”, “moral care”, “faith in behavior”, “faith-based care”, “ethics-based behavior”, and “ethics-based care” were reviewed. Related books and articles were searched in available search engines and e‑Journals containing Noormagz, Magiran, the Faqahat school library, the Imamat and Velayat specialized library, and the SID and Quran interpretation software. The sources were carefully studied from 1 December 2023 to 29 December 2023. The primary screening of the titles and the secondary screening of the texts of the studies were performed on the basis of the research question and the focal concept.

An in-depth review of various studies revealed that the theories related to the definitions of faith and methods of ethical refinement are in line with the objectives of the present research. Finally, the researchers identified seven theories from seven Islamic philosophers (Allameh Tabatabai, Mullah Sadra, Ibn Sina, Imam Khomeini, Ayatollah Mesbah-Yazdi, Ayatollah Javadi-Amoli, and Ayatollah Motahhari). All seven theories were reviewed, related statements were recorded, and concepts were extracted by the first researcher. Additionally, predicting or leading factors and variables of the focal concept and their relationships were also identified. After each concept is determined, similar concepts are categorized and named in a more comprehensive and concise form since Walker and Avant proposed that interpreting data in theory synthesis into logical statements is helpful.

• 3. Organizing concepts and statements into an integrated and efficient representation of the phenomena of interest:

The concepts and statements were organized into a unified whole. In the results section, an organized supportive model with its structural components, including assumptions, concepts, objectives, and strategies, is described in detail.

Data reliability

The quality of the first stage of the current study was assessed on the basis of the criteria of Corbin and Strauss. (Table 1)

Table 1 Data reliability

Results

Among the participants, 15were women and four were men. Other demographic characteristics of the participants are presented in Table 2.

Table 2 The characteristics of the participants and the interviews

Data analysis led to the extraction of1549primary codes, 10subcategories and four main categories. The main categories included “movement on a turbulent path”, “honest care”, “selfless care”, and “compassionate care”. “The challenge of doing the right thing as an inner commitment” was the main issue of the participants, whereas “behavior based on faith in God” was the core concept extracted from the data. Hence, the grounded theory of “faithful nursing” was developed (Table 3).

Table 3 The main categories and subcategories derived from the data

The ultimate objective of the study was achieved through analyzing the first‑stage findings via Walker and Avant’s method. Since the core concept and grounded theory in the first stage involved “behavior based on faith in God” and “faithful nursing”, the focal concept in the second stage was “care based on faith in God”.

The results were presented on the basis of the reviewed studies relevant to the conceptual framework and their organization in the context of an overall integrated caring model/theory. Overall, in the “Solving ethical challenges with nursing based on faith in God” model, the following theories were used, and related statements and concepts were extracted:

There are seven theories resulting from the comprehensive search:

• 1. Allameh Tabatabai’s theory: Faith is the knowledge of the phenomena and then the acknowledgment of the heart that causes action on the knowledge. In addition to the internal characteristics of people, the environment affects moral behavior. Reason and conscience, along with religion, can also help people determine what should and should not be done. Ethical education involves defining goals, recognizing ethics virtues and vices, using love, and compiling educational content that is based on the true happiness of humans [38,39,40,41].

• 2. Mullah Sadra’s theory: The basic principle in faith is the certainty and proof of knowledge. As much as the knowledge is correct, the actions will also be correct, so the level of faith will be higher. The criterion of correctness and value of behavior is the degree of being close to the true happiness of a human, that is, closeness to God. The ultimate limit of faith is love for the absolute perfect lover. While paying attention to true happiness, we should pay attention to the happiness of the body as a prelude to true happiness [42,43,44,45,46].

• 3. Ibn Sina’s theory: The appearance of faith depends on the proof of God’s existence. To prove God, in addition to human reason, superhuman reason is needed, so religion is necessary for believing in God. Getting close to God is true happiness. In addition to the inherent value and desirability of true happiness, what leads a person to true happiness is also of the highest value, so paying attention to ethical education is important [47,48,49].

• 4. Imam Khomeini’s theory: Faith is intellectual understanding and evidence, followed by submission of the heart and the fulfilling its requirements. The focus of human tendencies and behavior is the quality of a person’s faith in absolute perfection. The value criterion of behavior is an absolute criterion because it is related to human nature. Different upbringings of humans cause errors in determining the example of absolute perfection. Cultivating the body, imagination, and intellect and using divine assignments, indoctrination, and repetition can be effective in moral education [50,51,52,53].

• 5. Ayatollah Mesbah-Yazdi’s theory: The condition of faith is knowledge, which can be obtained in three natural, intellectual and intuitive ways. Along with knowledge and belief, the duties derived from faith must be done voluntarily and willingly by the believer. Insight and tendency factors affect human will and, consequently, the occurrence of behavior. Moreover, if there are any obstacles, they should be removed. It is possible to correct external and internal obstacles with moral education [33, 54,55,56].

• 6. Ayatollah Javadi-Amoli’s theory: Faith is a belief of the heart that is also manifested in language and behavior. In the case of a lack of access to divine knowledge, two divine proofs, i.e., Intellect’s and nature’s sound can determine divine duties for humans. It is necessary to polish nature with behavior and refine the soul and morals. After self-refinement is achieved, it is necessary to take care it, as well as calculate and evaluate itself [57,58,59,60,61,62].

• 7. Ayatollah Motahhari’s theory: Faith and science are the dividing lines between humans and animals. Faith inspires, directs, strengthens, secures and comforts and determines duty. The voice of conscience is also the reflection of God’s voice, so the reflected duties of conscience are divine duties. Behavior based on religious faith, while being holy, brings satisfaction to the conscience and, finally, God’s satisfaction [63].

Before dealing with the final model, in accordance with the principles of every theory development, the dimensions and structural components of the model are initially explained in the following order: the assumptions, concepts, goals and strategies are defined.

Structural components of solving ethical challenges with nursing based on faith in God model

• 1. Assumptions.

  • If a person finds himself in a situation where he faces problems in the way of taking care of himself, it is the duty of another person called the nurse to help him.

  • The nurse’s ethical-care is bordered, on the one hand, by her belief and, on the other hand, by her actions because belief, which is faith, creates her own special ethics, that is, unique behaviors.

  • With a combination of kindness and compassion, and on the other hand, knowledge, experience and skill, the nurse helps the needy person pass through the difficult path of the disease.

  • The nurse should note that the physical and mental symptoms of the patient are related to the world inside the patient, the world inside the nurse, the environment of the patient and the nurse, or a combination of the mentioned cases.

• 2. Concepts.

  Paradigmatic concept.

  • Care based on faith in God: It is a form of care in which the behavioral dos and don’ts of nurses toward the patient are regulated based on faith in God. The starting point of setting the dos and don’ts is the feeling of inner commitment or duty that is formed after the nurse meets the patient. The level of nurses’ sense of inner commitment is related to the degree of faith and intensity of love for God, which makes them walk on the turbulent path full of obstacles to save the patient’s life, despite the difficulties of the path.

  Meta‑paradigmatic concepts.

  • Human: Human refer to nurse and patient (patient’s companions). The behavioral system or human ethics is the result of self-awareness of an individual’s insights, tendencies and abilities. By properly guiding a human’s insight, tendency and ability, ethical behavior can be created and strengthened.

  • Health: Health is a road that must be traveled by the person himself. A person has the duty and ability to use his powers wisely to achieve the best benefit and soul health. In addition to the patient, the nurse and the patient’s companions are also included in the human circle; thus, not only the health of the patient but also the health of the nurse and companions are important.

  • Environment: Environment is everything that is outside of a person, including family, nurse, patient, society, nature, etc. The confrontation or interaction of environmental factors with the set of human existential dimensions causes them to have a limiting or facilitating effect on the behavior that is expressed.

  • Nursing: Nurses feel the inner commitment and duty to help patients because of a set of unique characteristics. The sense of duty can be strong or weak depending on the type of individual characteristics. In fact, nursing is an active and not a passive task whose mission is to help the patient.

• 3. Objectives.

  • Ultimate objective: Promotion of ethical patient care.

  • Specific objectives: Correcting the improper insight and attitudes of the nurse; improving the proper insight and attitudes of the nurse; correcting the non-supportive environment for the nurse; improving the supportive environment for the nurse; reducing or removing the ethical conflicts of the nurse; and increasing the satisfaction of the nurse and the patient.

• 4. Strategies for overcoming ethical challenges with nursing based on faith in God model: In the present suggested model, practical strategies were extracted and drawn up according to the findings and faithful nursing theory of the study conducted by Azimi et al. [27], and theories related to the definitions of faith and methods of ethical refinement mentioned at the beginning of this section.

  • A) Strengthening the beliefs and knowledge of nurse: the following three steps should be considered:

    • 1. Promotion of knowledge: The sources of knowledge, i.e., intellect and nature, must be cleaned of impurities. For this reason, it is necessary to hold workshops and creative courses of ethical refinement as well as continuous training courses from preliminary to advance to express the characteristics of human and the universe, the purpose of creation and the duties of human. In addition, the educational content provided must be accurate and comprehensive. To compile the appropriate educational content, owing to the divine and solidity of Islamic philosophy and the deep connection between the Islamic religion and the culture of the Iranian people, the general educational content should be compiled by Islamic scholars and then professionalized by nursing scholars. The training of nursing students should also be based on the educational content developed so that nurses can progress over time. On the other hand, peer group discussion and guidance, provided that it is done in the right way, can be an effective solution for improving knowledge.

    • 2. Strengthening motivation: With methods such as determining rewards, injecting hope in reaching the goal, taking advantage of human spiritual experiences and presenting an objective model, it is possible to play a role in creating love and motivation.

    • 3. Consolidation: Methods such as indoctrination, repetition and evaluation can be effective in consolidating what has been gained.

• B) Strengthening environmental facilitators to help nurse: the following three steps should be considered:

  • 1. Attention to human factors: The nurse shortage can be addressed by providing financial and spiritual rewards to more committed and diligent nurses, reducing the workload by canceling tasks that are not part of the nursing philosophy, giving importance to the nurse’s morale and emphasizing its improvement, providing appropriate comfort facilities, requesting staff from other departments and hospitals, closing unnecessary hospital departments and merging departments, not accepting non-chronic patients in some hospitals, saving time by monthly control of drugs instead of weekly and using jihadist and volunteer groups. Managers, by having respectful behavior with nurses, setting ethical indicators in the selection of nurses for recruitment, fair management in the division of duties, listening to nurses’ objections and problems, creating a mechanism for the confidential reporting of immorality and objections, and creating a legal evaluation system to encourage good behavior and punishment of bad behavior, can create an atmosphere of support and security in wards and prevent dissatisfaction.

  • 2. Attention to structural factors: The shortage of equipment can be compensated to a large extent by attracting donors, short-time hospitalization of patients to keep beds empty, use of the capacity of clinics to admit patients and fair distribution of funds.

  • 3. Attention to legal factors: by holding consensus meetings with managers, policy makers, nurses and physicians of different levels, the conflict between laws and guidelines and moral values ​​should be corrected. A reward or punishment system should be set based on moral values ​​and not just legal values. Additionally, the path of blindly following the orders of the World Health Organization, such as testing different drugs that sometimes have serious side effects or performing unnecessary care, such as various tests, should be corrected and followed based on definitive knowledge. If there is no definite information, a briefing session for nurses and physicians should be held regarding the necessity of implementing these orders.

• C) Strengthening situational analysis in duty diagnosis in nurse: the following six steps should be considered:

  • 1. Knowledge of the hereditary and educational characteristics of the patient: Hereditary and educational characteristics such as history of underlying and congenital diseases; culture and customs; literacy level; religious prejudices; sleep and nutritional patterns; attitudes toward life; and temperamental characteristics such as nervousness, stress, and anxiety can be obtained by referring to the patient’s medical record and interviewing the patient and his companion.

  • 2. Knowledge of environmental conditions: Relying on nurses’ own experiences and consulting with experienced people can be a guide in this field.

  • 3. Knowledge of the existing and potential obstacles on the road to health: In the field of insight, unknowns or incorrect knowledge, in the field of tendencies, lack tendencies or incorrect tendencies, and finally, in the field of abilities, individual disabilities or the creation of obstacles by environmental factors (including two categories: (1) internal characteristics of the nurse, (2) everything that is related to the environment such as doctor, companion, equipment, rules, etc.), are expressed as obstacles. The nurse can become aware of the presence of obstacles by observing and understanding the objective effects of the behavior of the patient and others as well as the rules and conditions of the organization. Then, the nurse can identify the problem area (insight, tendencies or ability) by communicating with the patient, observing and listening to his speech and asking probing questions.

  • 4. Knowledge to act honestly: In addition to identifying the obstacles on the road to health, it is also important to know how to remove these obstacles. Honestly performing tasks is the first duty of the nurse in removing obstacles. There are different ways to implement honesty in speech and behavior, including stating the truth clearly, telling the truth while joking, distracting the patient to avoid telling the truth, double-talking, adding words such as God willing and accurate performance of tasks, and even performing actions beyond the mentioned tasks.

  • 5. Knowledge of compassionate behavior: The characteristics of some obstacles are such that they can be resolved with compassion. It is possible to carry out tasks with compassion through healing grief with empathy and gentleness while interacting with the patient, alleviating grief by providing comfort to the patient and his companions, encouraging the patient to continue living by injecting hope and energy and seeking help from spirituality or creating peace of mind by gaining trust and modulating stress and financial concerns and valuing the patient’s opinions.

  • 6. Knowledge of selfless behavior: Removing other obstacles requires the selfless action of the nurse, which is bitter and difficult in nature. The self-sacrifice of a nurse can be accomplished through guiding patients through raising awareness and removing the patient’s wrong insights and tendencies and then accompanying them, as well as struggling with their own and others’ desires and comforts.

The organization of operational strategies and steps in an interconnected whole is shown in a schematic model of solving ethical challenges with nursing based on faith in God in Fig. 1. This prescriptive model is in the shape of a dome. The design of the dome in architecture is introduced as a geometric shape that rotates around the vertical axis. In the present study, all the steps and strategies are based on the upward axis of faith and love in God, and for this reason, the dome design has been used to show the prescriptive model.

Fig. 1

The model of solving ethical challenges with nursing based on faith in God

Discussion

On the basis of the analysis of the obtained results, strengthening nurses’ beliefs is suggested as a strategy in the model. Strengthening the nurse’s beliefs includes promoting correct knowledge and motivations and then stabilizing them. The results of various studies confirm the influence of nurses’ beliefs on their ethical behavior. In this regard, Gassas (2023) reported that the beliefs, personalities, and educational characteristics of nurses affect their degree of adherence to their personal and professional values [64]. Jasmi’s (2020) results indicated that the degree of compliance with ethical values among different personality types of nursing students is different [65]. According to the results of these studies, understanding the significant relationship between the professional behavior of nurses and efficient and ineffective personality traits is possible. In this way, nurses who were optimistic and experienced, as well as extroverted and conscientious, were more diligent in observing professional values, and nurses who were neurotic and irritable showed less ethical behavior [66,67,68].

Another strategy that was recommended to promote ethical-care is strengthening environmental facilitators to help nurse behave ethically more easily. The human environment, which includes humans, organizations and nature, can affect a person by transmitting verbal or nonverbal messages [69]. In this regard, Ebrahimi (2015) reported that the ethical behavior of nurses is related to their environmental conditions in addition to their internal characteristics. Therefore, it is important to pay attention to both internal and external conditions when exploring the cause of the ethical behavior of nurses [70]. In the present study, environmental facilitators and challenges can be classified into three categories: human factors, structural factors, and legal factors. In this regard, the results of Haahr’s (2020) study indicated that nurses’ performance is challenged by organizational policies and structures and prevents nurses from making professional decisions so that they are forced to ignore their professional values [71]. In Butts’s (2019) and Rathert’s (2016) studies, in some cases, nurses consider doing something right, but due to the existence of organizational conditions and restrictions such as insufficient support for nursing management, imbalance of power between physicians and nurses, organizational policies or legal or structural restrictions, they cannot act [72, 73]. Despite these challenges, there are other components in the environment that have facilitators. In the present study, the interaction of the treatment staff with each other and the management support of the nurses increased the occurrence of ethical behavior among the nurses. In line with these results, Caro-Alonso(2023)reported that the cooperation of colleagues can reduce ethical tensions during the Covid-19pandemic [74]. Additionally, the results of various studies show that good communication between the members of the treatment team and the managers and the nurses can improve the intimacy of the work environment and reduce the dissatisfaction among the nurses, which in turn improves the quality of care services and the satisfaction of the patients [75,76,77].

On the other hand, the existence of Jihadi thinking in solving the shortage of equipment and nurses in the present study caused major obstacles to the disappearance of ethical behavior. Jihadi thinking is a kind of creative thinking that people based on their faith in God, can discover innovative and new ways to solve problems. In line with the results of the present study, in Jalali-Farahahni’s (2020) and Aliahmadi-Jeshfaghani’s (2020) studies, the results indicated that during the Covid-19 pandemic, Jihadi and volunteer groups in Iran went to the aid of nurses and patients [78, 79]. Paying attention to capacities such as renewing nurses’ contracts, using the capacity of clinics to admit patients, closing unnecessary hospital departments, attracting donors, controlling medications monthly instead of weekly, and preventing nurses from leaving their jobs by providing support to compensate for the lack of human resources and equipment are manifestations of Jihadi thinking in nurses. In line with these results, various solutions have been mentioned in various studies, such as giving a call to retired nurses, preventing nurses from leaving their workplace by providing a place to take care of their children, and removing license restrictions for nurses who do not have an RN license [80,81,82]. Short-time admitting patients to keep the beds empty was another example of jihadist thinking that was done to compensate for the lack of equipment. This performance, which is rare and perhaps unique worldwide, caused patients who were admitted to the hospital only to receive medicine without the need to receive any other services. This leaves more beds free for patients who need more care.

Another recommended strategy in promoting ethical-care is to strengthen situational analysis in duty diagnosis. As mentioned, the main duty of nurses is to remove the obstacles on the road to the patient’s health. If the previous two strategies are carried out correctly and accurately, nurses in this strategy can easily reach a correct diagnosis about their task in any situation by performing step-by-step actions; otherwise, the duty diagnosis will not be performed correctly, or it is achieved with difficulty. Since the origin of human behavior is his awareness, a person who does not have the ability to remove obstacles has become polluted in his insight, tendency or ability [83]. Therefore, one of the important components in the correct identification of the situation is to understand the hereditary and educational characteristics of the patients and the environmental conditions that have positive or negative effects on their insight, tendency, and, ultimately, ability. At this time, nurses can know their duty in terms of the type of intervention to remove obstacles. In fact, they should know their duty in choosing compassionate behavior or selfless behavior and act honestly according to their duty.

Among the obstacles that can be removed by the compassionate behavior of the nurse, we can mention the presence of sadness, lack of motivation, or anxiety in patients. In this regard, various studies have considered the presence of environmental conditions such as quarantine and the prohibition of meetings during the Covid-19 pandemic to be effective in promoting feelings of loneliness and sadness [84, 85]. A study conducted by Tabassum (2021) indicated that having interactions with patient during the Covid-19pandemic has been considered effective in improving patient’s vitality [86]. A study by Asadi (2023) revealed that solving patients’ worries, talking about things that interest them, and greetings from nurses to them can be helpful in promoting the motivation and energy to continue fighting the disease [87]. On the other hand, the unknown nature of Covid-19and the general fear induced by the media caused anxiety in some patients. In this regard, in a study conducted by Gad (2023), approximately90%of patients with Covid-19experienced stress and anxiety, which in some patients caused mental illnesses and prolonged recovery time [88]. Stress and anxiety not only reduce the ability to deal with the disease by weakening the body’s immune system but also help anxious patients take a lesser role in self-care and have less compliance with treatment orders [89, 90].

In addition to the obstacles that require the compassionate behavior of nurses, some obstacles can be solved only by the sacrifice of nurses. The root of some obstacles is related to the patient himself, in such a way that there is no correct thinking or insight in the patient, which causes the occurrence of behavior contrary to health in the patient. In this situation, nurses considered themselves committed to making scientific sacrifices, despite the hardships and the possibility of contracting the disease. The scientific sacrifice of the nurses was through the use of their science to correct the incorrect thinking and attitudes of the patients. In this regard, in a study conducted by Russ (2020), the use of methods of satisfaction, such as receiving help from the patient’s family, recommending all the treatment staff to the patient at different times and consulting with a psychiatrist to discover the reason for refusal, was found to be effective in changing the attitudes of patients [91]. Additionally, in Swindell’s study, patients were satisfied with methods such as showing live and real examples of the consequences of the patient’s decision, reminding patients of the feeling of regret that they would suffer later, and the benefits of performing the procedure were suggested [92].

On the other hand, the root of some other obstacles is related to some egoistic tendencies of the nurse, such as seeking comfort, avoiding hardship, and loving life. In fact, these tendencies hinder the implementation of the nurse’s duty in fighting against environmental obstacles. In this regard, in a study conducted by Pazokian (2021) revealed that nurses endured hardships related to a lack of equipment, irregular management, high workload, and concerns about disease transmission during the Covid-19pandemic [93]. In Rad’s (2023) study, nurses still cared for patients with Covid-19despite difficulties such as overcrowding in the ward, changing patterns, the complexity of patient care, and feeling tired [94]. The high point of overcoming the ego of the nurses was to sacrifice their lives to save the lives of the patients. In line with these results, in a study conducted by Khanjarian(2021),nurses with a sense of becoming superhuman saw themselves as soldiers in the war who were committed to making sacrifices to save the lives of patients even if they were martyred on this path [84]. Momeni(2023)reported tolerating changing and chaotic conditions, accepting social isolation and prioritizing the savings of patients’ lives, including the sacrifices of nurses caring for patients with Covid-19 [95]. Despite the abovementioned studies in the field of self-sacrifice, the nurses involved in the study of Ciezar-Andersen(2021)reported that self-sacrifice in the nursing profession is the result of the prevailing stereotype of the “ideal nurse”, which leads to job dissatisfaction and job burnout in nurses, and sacrifice has been described as a type of irrationality [96]. Conflicting studies in this field support the claim that the degree of faith is related to the intensity of the sense of commitment of nurses; thus, sacrifice in some nurses is an ethical action and duty, whereas in other, it is a stereotyped image leading to job burnout.

By reviewing various databases, no study was found that led to the design of a prescriptive model of ethical-care for patients with Covid-19. Only two studies of the virtue ethics model by Nikkhah (2015) and the ethical performance model of nurses by Abbaszadeh( 2003) were found [97, 98], which, although not related to Covid-19,were conducted with the aim of designing a model of ethical-care, so they provide a valuable framework for comparing the results. Although in Nikkhah’s(2003)and Abbaszadeh’s(2015)models of ethical-care, ethical concepts are mentioned at different levels of care, in none of them are the ultimate goal and educational content mentioned, and the modification of environmental conditions is more important than the modification of people’s personality traits in creating ethical behavior. This is while in the present model, while the ultimate goal and the dos and don’ts of achieving this goal are specified, the characteristics of the appropriate educational content are expressed, and the strengthening of nurse’s beliefs is considered more important than the strengthening of environmental conditions.

Limitations

One of the limitations of the present study was the lack of free time among nurses and the fatigue of nurses due to the increase in workload during the Covid-19pandemic, which limited access to participants. To address this limitation, a web-based interview in addition to face-to-face interviews was used. Another limitation was a lack of access to nurses at managerial levels, such as supervisors. After long-term follow-up, three people were interviewed. The last limitation was the presence of the first researcher in the hospital to observe the care, which was associated with difficulty in coordination, and this limitation was finally resolved with the help and guidance of the supervisor.

Conclusions

A descriptive theory based on data with the title “Faithful Nursing” was designed at the end of the first stage. This theory provides an outline of the process that nurses go through after encountering a patient with Covid-19. In the model designed in the second stage of the study, which was based on the concept of “care based on faith in God”, which is based on the findings of grounded theory and uses a broad and integrated review of available Islamic texts, three main strategies to improve the resolution of ethical challenges were obtained. The first strategy is to strengthen the nurse’s beliefs, which includes improving knowledge, strengthening motivation and stabilizing. The second strategy is to strengthen the environmental facilitators to help nurses, which includes components of attention to human, structural and legal factors. Finally, the third strategy is to strengthen situational analysis in duty diagnosis in nurse, which has the components of identifying the patient’s hereditary and educational characteristics, environmental conditions, obstacles, act honestly, compassionate behavior, and selfless behavior. The prescriptive model of “solving ethical challenges with nursing based on faith in God” can be used as a guide to describe and expand the role of nurses in providing ethical-care, developing clinical guidelines, and planning educational programs for nursing students and nursing staff.