Ethical challenges of social work in Spain during COVID-19

This article presents the main ethical challenges faced by social work professionals in Spain during the "first wave" of COVID-19 in 2020. The pandemic had a serious impact not only on the health sector, but also in the field of social work. During this time, social workers had to address serious ethical questions regarding issues such as confidentiality breaches, how to fairly distribute available resources, the lack of personal contact and emotional connection with the service users, the difficulties of working in isolation and online, doubts about the reliability of the information they were handling and the difficulty of making proper diagnoses. An international research group led by Dr. Sara Banks conducted a broader research project in collaboration with the International Federation of Social Workers, which collected information through an online questionnaire aimed at social workers from various countries. In this article we analyse the results related to the main ethical challenges faced by social workers in Spain. The research group identified two types of ethical challenges that they have separated into two sections: the first section is related to direct intervention with users, which includes topics such as the lack of emotional support, reliability, use of technology, the appropriate care, compliance with the highest professional standards, confidentiality, vulnerability, and the fair distribution of resources. The other section is related to the ethical challenges around the daily work within social entities, which involved dealing with issues such as the e-social work and coordination difficulties, the management of pressure in social bodies and changes in the intervention methodology.


Introduction
The rapid spread of COVID-19 around the world has impacted people from all nations and socio-economic groups, but it has particularly affected the most vulnerable social classes (Farkas & Romaniuk 2020). The severity of the pandemic This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
has not only been significant in terms of the number of deaths and people affected, but has also had an elevated and unequal economic and social impact, affecting the most disadvantaged groups in society more severely. The speed and severity of the pandemic's impact on health and social care forced the authorities to take urgent and immediate action.
Besides the health professionals, social workers also had to respond quickly to the new needs and challenges created by the pandemic. Situated at the forefront of the fight against the social impact of the pandemic, social workers have had to adapt to a whole series of changes to be able to help and protect marginalized groups that were deemed even more vulnerable in this exceptional situation.
An international research group led by Dr. Sarah Banks in collaboration with the International Federation of Social Workers (IFSW) was formed in May 2020, with the objective of studying the major ethical challenges facing social work professionals worldwide (Dawson et al., 2020). The group consisted of researchers from various countries who designed an online questionnaire that asked social work professionals what they thought were the main ethical challenges faced during the first wave of the pandemic. In addition to English, the questionnaire was translated into several languages (French, Slovenian, German, Chinese and Spanish). In total, 505 responses were received from 54 countries, which were analysed and disseminated by the research group as well as by the IFSW itself (Banks et al., 2020a(Banks et al., , 2020b(Banks et al., , 2020c. Of the total number of responses, 58 came from Spain and are the ones we have used to develop this analysis of the ethical challenges faced in social work in Spain during the pandemic.
Responding to the social effects of the pandemic was incredibly demanding for social work professionals as their workload increased significantly. Concurrently, they had to adapt to constant changes in legislation, in existing measures, resources and supports, new protocols and more. The combination of an increased workload, scarce resources and a sense of urgency to act immediately put considerable strain on their professional lives. Furthermore, all of this took place in a virtual context, since the relationships with and between people -the main instruments of assessment, intervention and evaluation of social work -had been suspended or shifted to the use of new communication channels.
These experiences generated tensions, consequences and ethical challenges that we need to explore and analyse in order to learn from them and be better prepared for potentially similar situations in the future. It is precisely with this objective in mind that we have carried out this research, to highlight the level of care provided by social workers in Spain during the first wave of COVID-19, as well as the effect of the pandemic on the ethical and motivational aspects of social care. We will present these ethical challenges in two groups, explaining on one hand the difficulties encountered concerning direct intervention with service users and, on the other hand, the obstacles related to management and relationships with entities.

Methodology
Our aim was not to quantify the incidence of different types of ethical challenges, but to obtain a qualitative view of the challenges related to ethics in practice (Miller & Lee 2020). We therefore set out to understand and identify the specific ethical challenges that have emerged from the circumstances of COVID-19: how social workers have responded, the moral impact of the pandemic on their professional practice, and what further guidance could be given to support ethical decisionmaking in similar crisis situations (Kramer, Brown & Kopar 2020;Santillán-García & Ferrer-Arnedo 2020).
An online survey form (qualitative questionnaire) was used to ask two main questions (for details see Banks et al., 2020a): 1) Briefly describe some of the ethical challenges you face or have faced during the COVID-19 outbreak; 2) Provide more details on a particular situation that you found ethically challenging. Ethical challenges were described as "situations that give you cause for professional concern or when it is difficult to decide on the right action to take". Invitations to participate were distributed electronically by the IFSW, as well as by members of the international research team, across national and provincial associations and other professional and academic networks. Responses were received from 505 social workers from 58 countries, 58 of them from Spain. Some of these responses were based on telephone interviews or video calls, using the survey questions.
Almost 80 per cent identified themselves as women and more than half had over 11 years of experience in social work, across various fields of social intervention, such as social services, NGOs, social workers in hospitals and primary care centres, or social workers in residential care homes. The respondents are not a representative sample as this was not the aim of the research. Furthermore, it should be noted that the respondents needed to be individuals with knowledge of the study, access to the internet, familiarity with the language in the survey and for whom the idea of "ethical challenges" resonated. Members of the research team shared the task of conducting preliminary analyses of the questionnaire responses, and those in languages other than English were read and translated by native speakers. Questions about meaning and translation were checked within the international group.
Qualitative analysis was used to study the results obtained in Spain. This analytical method is defined as a framework of empirical approximation and as a method of controlled analysis of the communication process between the text and the context. Establishing a set of rules separates the results step by step from certain quantifying trends and can emerge in part from the same (Bardin 2002, Cáceres 2003, Krippendorf 2002. For Arbeláez and Onrubia (2014:19), the objective of qualitative content analysis is "to verify the presence of themes, words or concepts in a content and their meaning within a text in a context". These same authors consider qualitative content analysis an investigative technique for drawing inferences by systematically and objectively identifying certain specific characteristics within a text. The idea is to develop the interpretative perspective of the texts, going beyond the manifest content, to consider the context and latent content expressed within the message. From the perspective of inductive qualitative content analysis, there is a core focus on developing categories as close as possible to the material being interpreted.
The proposal that is made is based on consideration of the qualitative material obtained, aimed at establishing the categories that emerge from its various segments. The fundamental idea of the process has been to formulate definition criteria, ultimately derived from the substance of the research through the textual material analysed. According to this criterion, the material has been worked on continuously until completion, and the codes and categories have been tentatively induced step by step. In a feedback stage, these categories were continuously reviewed and refined to finally obtain the main categories. In the data reduction stage, the general trend was to condense all units, categories and subcategories of analysis. The data was then placed into the main categories, which were more conceptual, and finally the topics were extracted. Research triangulation was also used to ensure the reliability of the coding and results throughout the study.

Results
We have classified the results of the research into two large sections: one referred to the ethical challenges that arise in direct intervention with users, and the other centred on the ethical challenges faced by social workers in relation to the entities in which they carry out their professional work.

Ethical challenges in direct intervention with users Lack of emotional support
One of the most complex situations faced by social workers during COVID-19 has been the impossibility of accompanying and providing emotional support to service users or to relatives of patients suspected of having COVID-19 in cases of hospitalisation or death. The exceptional situation experienced during COVID-19 meant that many people died alone, without the comfort provided by the company of family members or loved ones. Furthermore, the relatives were not able to receive direct emotional support from professionals either. They expressed the helplessness they felt at the time with questions such as: "How do you tell someone on the phone that their family member has died?" As we know, personal contact and emotional support are deeply instrumental in the field of social work, but "how can we give emotional support in this type of situation without putting ourselves at risk?" (Silva & Smith 2020). At times like these, social workers experienced all kinds of emotions, sometimes contradictory, including fear, guilt, anger, sadness and anxiety. As one professional who participated in projects aimed at older people related, "I think that humane treatment and maintaining relationships with the sick should have been an essential activity. They should have let us do our work by providing us with the necessary means...." (Professional 1) However, this was practically impossible, as the scarce protective equipment and COVID tests available at the time were prioritized for health personnel, but not for social services personnel (Muñoz-Moreno et al., 2020).

Reliability
Reliability has proved to be yet another ethical hurdle within social intervention. The lack of direct sources of information about the people involved and the inability to compare their data (for example, in the Social Services Users' Information System) often caused complications -from corroborating their identity to checking the reliability of what they were being told, as well as deciding which resource was the most viable.
A number of community social workers reported that all they had to work with was the information that users gave over the phone. Social workers were thus very hesitant to apply for family allowances, emergency allowances or food allowances as they did not have the required documentation and sometimes found it impossible to coordinate with other services (for example, to ascertain whether or not users were already receiving allowances from other services). Working in these circumstances sparked feelings of anger, helplessness, anxiety, despair and even moral distress (a feeling that arises when you do not do what you feel you should do): Personally, on numerous occasions I have decided to administer the aid. On other occasions I asked for documentation, and even then I had doubts when it came to processing it. My feelings are obviously very negative, because I don't know if I'm providing help for a person who doesn't need it or perhaps doesn't need it urgently and so others are being left out who really need it. (Professional 8)

Use of technology
The technological tools that were necessary during the pandemic (mainly the telephone) have not always proved adequate to correctly assess the situations in which users found themselves: "How do we access the most vulnerable people through electronic means when they themselves do not have access to it?" (Professional 7. Social worker in dependency assessment). Some people did not have a mobile phone or electronic tools. The "digital divide" is evident when talking about people who, due to their precarious living conditions, do not have access to technological tools.
Social interventions conducted over the phone in such challenging and painful circumstances is proving to be difficult to digest at times. The coordination between professionals and information provided in writing or by telephone is causing me to have doubts and question myself. (Professional 11) In addition, as one grassroots social worker points out, "digital illiteracy" (Professional 22) is still quite common so more training is required to work with telematic media. In this complex context, it was very difficult both to gather the necessary information and to conduct interviews under adequate conditions.

Appropriate care
In Spain, nursing homes were one of the places most affected by the pandemic. Because of this, one of the great challenges that professionals have had to face has been managing the confinement of the elderly in residential centres (Coronado-Vázquez et al., 2020). The emergence of positive cases of COVID-19 forced many people into isolation in their rooms to minimize the risk of contagion. The shared areas were also divided into different spaces (red, yellow) according to the risk detected.
The residential centres needed many more staff members due to the necessary precautionary measures that had to be taken, but at that time it was impossible to recruit more staff. A social worker at such a residential centre reported: We were then faced with the dilemma of prioritising the welfare of some users over others. Because the staff dedicated to these people also had to isolate, in this case nursing assistants and, in certain exceptional circumstances, medical staff, they are the only people the residents have been able to interact with during the time of confinement. (Professional 53) In general, people in isolation received more attention and care, which in turn reduced the level of care given to other groups (who were also isolated from contact with their families and therefore also in a vulnerable situation). Individual health protection teams arrived late and polymerase chain reaction (PCR) testing was not possible at the time, so access to rooms had to be restricted, resulting in a deterioration of the care provided to users (Csoba & Diebel 2020;Flaatten et al., 2020).

Guarantee of the highest professional standards
Another great ethical challenge in social interventions was to find the required time to guarantee the highest professional standards. The many situations of extreme need that arose meant that decisions had to be made urgently, often in isolation and without supervision. This is how one social worker expresses it, referring to a case in which a woman was being abused in a flat and had to be extracted quickly: "In that moment my main ethical dilemma in the intervention is that I have to decide between the speed of the response and waiting for the administrative procedure…. We are totally tied up in a cumbersome procedure" (Professional 13, Women's Institute). However, the urgency of decision making can also reduce the quality of interventions. This was reflected by a social worker who was involved in direct care and also in management: "We are not spending the time that would normally be required for the evaluation of social demands, and this can lead to social injustice" (Professional 23).

Confidentiality
Another big problem during the pandemic was related to protecting confidential information. Social workers had to discuss private information about users over the phone, but how can you carry out assessments with minors or victims of sexual abuse under these conditions? How do you carry out a correct expert assessment without social proximity? Furthermore, in numerous cases, social workers had to use their personal telephone to carry out their work and, in emergency situations, they used data without the explicit written consent of the users (Ausín & Andreu 2020;Turnham et al., 2020). As one social worker pointed out when referring to dependency assessments: "We used what was available to us even though we know we are skipping the data protection protocol" (Professional 7. Social worker in assessment of situations of dependency). This is what some professionals described as "professional reinvention without guarantees" (Professional 16. Social worker on the Violence against Women Court team). In short, social workers have had to "reinvent themselves" to find solutions, but without any assurances that they are doing their job correctly.

Vulnerability
The pandemic caused even more damage to the most vulnerable groups, such as victims of gender-based violence, children at risk, the elderly, illegal immigrants, drug addicts, and people with mental health problems (Cheung & Ip 2020;Yue et al., 2020), which has led to ethical dilemmas: With drug addicts, the ethical dilemma faced is considerable due to the characteristics of the cases in question, and because it is true that at this time it is very difficult to work through the whole process because of what it involves in terms of individual, group and family intervention... Here the dilemma is great. (Professional 2) Another particularly vulnerable group consisted of elderly people who were living alone, without any support, displaying symptoms of COVID-19. This was also the case for illegal immigrants who were not able to access existing resources (Farrell et al., 2020). In many cases they could not speak Spanish and therefore could not even communicate their needs. The necessity of people having to stay at home so much has led to an increase in domestic abuse, gender-based violence and family violence cases.
Another group that has particularly suffered from the consequences of the pandemic are people with some form of mental illness. In many cases, these people were even more frightened and unstable, so they demanded more attention (as one social worker reported, they even demanded "excessive care"). The occupational therapy professionals who normally teach their patients had to do so by phone and to follow up as adequately as is possible under the circumstances (Ross et al., 2020).
Finally, several hospital social workers reported situations where destitute people were being discharged from hospital very quickly, resulting in vulnerable people (those suffering from dementia, "Diogenes syndrome" or abuse) having to return to complex situations of social exclusion.

The fair distribution of resources
Another major ethical challenge that social workers have had to face is the fair distribution of scarce resources. The following is a quote from a local council social worker who manages financial aid: "It is very difficult for me to decide who to give aid to and how much.... Furthermore, the aid given requires a follow-up and interviews -in other words, more time, which is precisely what we do not have now" (Professional 12).
The lack of adequate resources caused professionals to feel helpless: "I am facing so many demands and I would love to be able to resolve them and help, but there are not enough resources for that. It creates a feeling of helplessness for me" (Professional 48. Social worker in a health centre).
The question of how to manage resources fairly was also problematic in the case of primary health care resources. The social worker at a primary health care centre said, "There is an equity problem arising from the accessibility of resources in a confined situation. Care assumes a barrier, as we serve those who have a better capacity to use digital media or support networks" (Professional 46).
During the pandemic, providing for health centres was prioritised over residential centres for the elderly and people with disabilities. As expressed by a social worker, who works on the organization and development of health and social-health projects: The system allowed residences to be left out in some way or other from the welfare system aimed at the entire population.... In addition, once these people were admitted to the residential centre, we lost contact and couldn't follow-up.... 'Case solved'. As if having basic needs covered was the only thing people needed.... (Professional 49) Ethical challenges in the organization of work within social entities The second section of results is structured around the impact on social entities organization. We divide the section into three main topics: e-social work and coordination difficulties, management of social bodies and changes in the intervention methodology.

E-social work and coordination difficulties
Just like all of the other businesses and services in the country, the social bodies also suffered an initial phase of total closure, effectively ceasing the face-to-face care they had been providing. This emergency situation forced many services and entities to attempt to adapt rapidly and abruptly to a "virtual" format of action, for which they were not prepared, as professional intervention from social services typically involves in-person care. This traditional way of working was quickly replaced in many areas of the social work field by a model of e-social work (digital social work), still in its inception for most social entities in our country. "The first challenge was to see how we dealt with this remote modality, with the uncertainty of being unbiased when it came to the intervention of health social work" (Professional 56).
The implementation of teleworking generated more than a few problems for social entities, which had to reorganise their professional teams, processes and ways of working, often improvising solutions from scratch. Social workers noted in their accounts that this situation impacted three fundamental aspects of the daily modus operandi: working alone, internal team coordination and inter-institutional coordination. They had to make decisions urgently and quickly, often without clear directives or important and authoritative documentation: "They are barely giving us indications of how to manage the issues raised above, having to act under pressure, with urgency and at your own discretion" (Professional 8). The new situation also caused a big impact on internal coordination (teams) within the entities themselves, because they had to redistribute functions, tasks and obligations. In the new health crisis situation "we have rarely been able to work as a team, along with our own fears of death and contagion, without the possibility of asking questions..." (Professional 25). Workers also point out the lack of interinstitutional coordination and communication: Greater communication and inter-institutional coordination are needed. Organisation of inter-administrative communication channels, new telephone lines, electronic mail, and any useful tool that speeds up communication between entities to assess situations that require immediate responses. (Professional 5)

Management of social bodies
In addition to organisational stress, the pandemic also subjected institutions to stress testing on various aspects of resource management. Furthermore, the closure of economic activity has led to an exponential increase in the demands on social services for financial support, information and guidance, including from social groups and profiles that had not been seen previously in social services: Main problems encountered: those who don't use social services, temporarily unemployed workers (ERTE), or possible dismissal, key services sector, those with dependent children, many single parent families. Now with no or insufficient income. Older people, retired people, dependents, without a family support network, some with human losses due to COVID. Each case is a desperate call for help, they need to know that they are not simply a number, that we are there, that we are doing our best.... (Professional 28) This increased volume of demands, arising from the augmented social vulnerability of the population as a whole, has had a direct impact on the management of social bodies: I am a social worker in a town hall. We are manning the phones and almost constantly we need to access platforms that compare data and manage financial aid. We can manage up to 300 euros per family, considering that these are not unlimited funds and that it is public money. It is becoming very complicated for me to decide who receives it and how much, (Professional 12) The situation was so extreme that it caused regulatory and legislative changes (such as new protocols and new emergency aid) to be made and, on the other hand, increased working hours for professionals. Social workers had to carry out their work under the pressure of constant updates, and this caused doubt about implementing processes: More than concern, misunderstanding about the measures taken. For example, in the social emergency channel established in Andalusia for dependency cases, there were cases that were not included in that channel, whereas we deemed that they should have been. I believe that there is a conflict between the professional and the institutional response. (Professional 52) The management of new resources, together with the management of the wellestablished and traditional demands on social services, generates a complex situation: When the time comes to make it operational, conflicts begin. Not among the network of social intervention professionals, but with all the "administrative apparatus" that my work involves. There has been no way to make the "legaladministrative" part coincide with the need to change our usual ways of proceeding. (Professional 13) In that situation, professionals must work overtime. The virtual context in which they work means that professional hours extend far beyond the established working day and, in many cases, there was no limit or differentiation between the personal and professional spheres.

Methodology of intervention
The extreme conditions experienced during COVID-19 also led to changes in the methodology of the interventions. The need to act quickly and efficiently often led to the elimination of certain control and verification processes. Sometimes the documentation could not be verified or followed up on due to the urgency. In addition, the possible duplication of applications was not controlled: It is difficult to determine the viability of a family resource without the use of collateral information sources that provide us with information on the community context, the person's development within the community and other indicators of risk for that family." (Professional 51) Social workers responded to emergencies, but it was not possible to provide any response other than that assistance. Urgent aid (such as access to the "Food Bank", aid for the payment of rent, transport, supplies, aid for the purchase of food and basic necessities, family economic aid, integration aid) were processed, but social action and intervention were further bureaucratized: One of the aspects that I have been reflecting on these days is the welfareoriented part of the social work that is taking place these days: food distribution, management of guaranteed income benefits, emergency aid.... How can we continue to carry out our work without it being merely welfare-oriented? I understand that basic needs have to be covered for those who do not have them covered, but "there is no time" to do other types of work. Due to this lack of time, it is impossible to continue to cover all of these requirements when there is a social and personal background that is being greatly affected. Who is covering this part? (Professional 40) The resultant situation (pressure, urgency, lack of direct contact with people) implied that some of the differentiating elements of professional intervention in social work were overlooked, such as the reflective diagnostic assessment, which is the result of interaction, observation and active listening: The emergency leads to unforeseen situations, indicating the need to be flexible in intervention but also in the application of certain aid. This unforeseen emergency situation leads to doubts and insecurities. (Professional 27).

Conclusion
The first wave of the pandemic caused an unprecedented situation in the Spanish health and social care systems. Neither system was prepared for such a situation, so both were completely overwhelmed. The lack of resources led to extreme circumstances, such as having to decide which people would or would not be admitted to the ICU or who should receive a benefit. It could be said that the pandemic has provoked global re-examination, from the design of the socio-health space to the system of coordination between entities. Furthermore, as is often the case in extreme situations, the coronavirus hit the most vulnerable groups even more severely, including the elderly in residential homes, people affected by unemployment or extreme poverty, abused women and minors. In these exceptional circumstances, the ethical challenges faced by the social workers encompassed all kinds: lack of physical contact (Novoa & Pirela 2020) with the service users and the impossibility of making assessments based on direct evidence, having to work in isolation and without guidance, lack of time to make vital decisions, doubts about how to establish priorities to fairly distribute the available resources, questioning their way of working within the entities and the methodology of intervention they could use, and breaking confidentiality due to the urgency of the demands.
We have tried to explain these ethical challenges, with the aim of highlighting the necessary work carried out by social work professionals. Many of these ethical challenges clashed with the very essence of social work, so professionals had to seek imaginative and creative solutions to adapt to new contexts and to endeavour to respond as fairly as possible to user demands.
Without this "re-invention" of their own professional essence, the situation faced by the country's most disadvantaged groups would have been even worse. Therefore, it is necessary to validate the field of social work as a profession that, far beyond bureaucratisation and welfarism, has an essential role to play within our society. The pandemic has brought to light the strengths (but also the weaknesses) of the service system, so it is important to reflect on the situations experienced in the hopes of improving the ethical quality of the service that social work provides to its users.