Morality is an inseparable part of human life, which explains the right from the wrong or the good from some bad behaviors (1). Ethics is necessary in occupations in addition to the personal life, which is even more necessary in the nursing profession due to the spiritual behaviors associated with nurses' responsibility in saving patients' lives (2). The importance of doing moral work becomes even more since nurses work in a system, which is constantly changing and evolving. Further, the society demands the high quality services of nurses based on the existing conditions (3).
Moral behavior is an important feature of nurses, which has a significant effect on the treatment process (4). Caring the patients in various physical, mental, psychological, and spiritual aspects is always associated with the moral considerations. Nursing is inherently considered as the moral profession since it emphasizes the care of others (5). Nowadays, paying attention to legal and ethical issues in nursing is more important due to the advancement of technology, medical and pharmaceutical equipment (6). Nurses are forced to face different aspects of ethics since they usually present at the patients' beds and communicate closely with them causing the moral decisions and comments (7). Therefore, they face an unpleasant experience called moral distress (MD) (8).
Initially described by Andrew Jameton in 1984, MD is defined as knowing what to do in an ethical situation, but not being allowed to do it. He reported that the moral distress causes the anger, frustration, anxiety, headache, sadness, grief, depression, as well as conflict between doing the right thing and organizational rules (9). Corley considered the moral distress as a major problem in nursing (10). Moral distress is an emotional and mental disorder in which a person commits a mistake while being aware of the right decision and having the necessary ability to judge and make decisions due to real and organizational moral limitations (11, 12). Nurses are exposed to moral distress due to the factors such as shortage of time and lack of specific organizational rules, which disrupts their decision-making process and psychological balance (13). Various studies referred to the level of moral distress in nurses. Abbaszadeh et al. indicated the moderate moral distress of the nurses in different wards (14). However, Altaker et al. demonstrated that the high levels of the moral distress were observed among the nurses working in the intensive care units (15). Moreover, Jalali et al. reported the high moral distress of the nurses in emergency department (16).
Based on the studies, the type of the environment of the work is effective in the occurrence of nurses' moral distress (17). The emergency department due to the direct contact with the patients and staff, high workload, and lack of the necessary facilities (18, 13), and the intensive care unit for high exposure of the nurses to the patient mortality are considered as the stressful situations (19). During Coronavirus Disease (COVID-19) Pandemic, problems such as the increased stress, faster care, use of personal protective equipment, not allowing patients' families to visit due to their risk of infection, and many other factors make the situation more critical in addition to previous stressors (20). Moreover, working in unfamiliar environments, participating in unknown processes, workforce shortages, existing more the patients in need of the urgent care at the same time, fear of infection, new waves of the disease, deadly nature, and disease disability are challenged the nurses' decision-making between doing what is morally right and doing what is cost-effective (20, 21).
The occurrence of moral distress is predictable in nurses following the spread of the disease, which causes the placement of nurses at the forefront of the struggle and endangering their lives (22, 23). The serious moral and emotional stress is caused due to the unprecedented experience of covid-19 disease, which is a new global pandemic (24), as well as the ongoing and difficult work of nurses during epidemics (25) and the respect for the patient's rights referring to the effort to balance all conditions (26). Moreover, nurses caring for the patients with covid-19 disease faced the problems such as unknown work environment, exposure to the disease, lack of experience in seeking new diseases, as well as more public and media attention, which could expose the nurses to the moral challenges (27), affect adversely the quality of care, and interfere with the patient treatment. Therefore, it seems necessary to be aware of the level of moral distress in nurses in these wards. In this regard, this study aims to determine the level of moral distress and its related factors in the nurses working in covid-19 wards of Ardabil city.