This qualitative study identified factors that cause moral distress among Iranian psychiatric nurses during the COVID-19 pandemic.
In the category of emotional responses, psychiatric nurses repeatedly expressed that they felt serious concern about being exposed to the virus while providing care, that they had doubts about leaving the nursing profession and that they worked in unsafe conditions, or that they continued to breastfeed where their lives were in danger. Thus, they could not fulfill their moral and professional obligations in the COVID-19 pandemic and felt that they had no power to change the situation. Nurses’ commitment to care and the right and responsibility to protect themselves and their families created a conflict between the psychiatric nurse’s professional duties and personal obligations.
Hossein and Klati explored nurses’ self-care strategies in 2020 during the COVID-19 pandemic and noted this conflict among nurses. They stated that nurses, like other people, have families and loved ones in their lives. They find themselves competing with commitments to work, family and loved ones, and conflicting between professional obligations and responsibility to their families .
Zhang et al.  in China showed a contradiction between the fear of contracting COVID-19 () and their professional commitment in nursing. The sense of helplessness or inability to perform moral action perceived by nurses has been identified as one of the leading causes of moral distress. This is usually due to nurses’ personal feelings, such as doubt and fear .
Also, observing doctors’ fear of contracting the COVID disease and psychiatrists’ avoidance of patients cause moral stress to psychiatric nurses. In this regard, Abdelghani et al.  reported a strong association between fears and greater burnout symptoms and poor quality of life among physicians.
Empowering nurses to deal with their doubts and fears can reduce moral distress, and ethics training that emphasizes moral debriefing and decision-making is also recommended.
In relational factors, psychiatric nurses described the changes during the pandemic in the relationships between them and their colleagues, doctors and patients. Working with nurses who are negligent in providing patient care due to fear of exposure to the virus has caused them moral distress. Silverman also pointed out that nurses who did not provide adequate care to patients caused them moral distress . It is recommended to empower nurses to reduce their negligence in performing their duties, especially in critical situations. This can prevent nurses from feeling self-blame, powerlessness and moral distress.
Nurses spoke about the challenges they face, especially doctors, when dealing with patients with suspected or developing COVID-19 disease. Keeping a distance from psychiatric patients and visiting them with high restrictions by doctors due to their fear of Corona disease is an example of failure to fulfill the professional and moral duties of doctors, which is considered unethical by nurses. On the other hand, given that nurses do not have the ability and power to challenge doctors, they are not allowed to participate in the therapeutic decisions made by doctors.
Providing an environment in which the nurse can participate in clinical decisions and solve ethical problems and express their views without fear of organizational and professional problems is very effective in reducing the moral stress that is needed in this regard. Managers must provide the necessary support to nurses.
In a study conducted by Silverman et al.  regarding working in COVID-19 wards, one of the causes of moral distress for nurses is the observation of patients suffering due to the misconduct of doctors in the management of their treatment. This result is consistent with the results of our study.
Lack of proper communication between nurses and their patients due to fear of the disease COVID-19 was also reported in this study. Other studies conducted among nurses in the setting of COVID-19 also show that nurses and patients should maintain a certain distance when communicating to reduce the spread of infection. This leads to a feeling of insecurity in patients and nurses, so that they feel unable to support their patients [25,26,27]. Because the ethical climate of any organization has a significant effect on the level of moral distress [28, 29]creating a favorable climate with an emphasis on strengthening nurses’ communication skills, moreover, physicians can be effective in enforcing an ethical climate and reducing moral distress among nurses.
In the category of institutional factors, the problem that is specific to psychiatric hospitals and their patients, which has caused moral distress to nurses, is the non-compliance with patient protection guidelines. Nurses working in non-psychiatric hospitals care for patients who have sufficient insight into their illness and adhere to protective guidelines. But psychiatric nurses care for patients who not only care about their condition, but also do not adhere to safety guidelines, such as wearing masks and maintaining social distance. They are also clueless and oblivious to nursing education. So, this problem has made them worry more about Corona disease than other nurses.
All these circumstances cause nurses to avoid patients and experience moral distress by avoiding their patients. This problem, along with the lack of facilities and limited access to personal protective equipment in psychiatric hospitals, also increased the moral distress of psychiatric nurses. Inequity and discrimination reported in patient triage studies and allocation of critical beds and ventilators during pandemics [26, 30]. A survey conducted by Kalate Sadati among 24 Iranian nurses in 2020 explored their experiences during the COVID-19 outbreak; they found that Iranian nurses were also in critical condition at the time of the attack. Lack of personal protective equipment, uncertainty about the treatment given to their patients and the need for psychosocial support are widespread among all nurses . However, this discrimination mentioned by psychiatric nurses is unique to psychiatric hospitals.
Like other nurses in this pandemic, psychiatric nurses have been affected by the critical situation. However, the impacts of this crisis on this group of nurses have unfortunately been overlooked due to managers’ focus on central hospitals for COVID-19 ; These managers and politicians should pay more attention to the needs of mental hospitals by allocating sufficient and appropriate budget and facilities.
The implementation of some institutional policies, such as limiting visits to psychiatric patients by their families, was a cause of moral distress. The critical role of the family in the treatment of psychiatric patients is obvious, so one of the additional treatments for these patients, along with medication, is family therapy. Additionally, studies show an increased risk of loneliness, confusion and delirium due to lack of family visits during the COVID-19 outbreak [25, 26]. Psychiatric nurses’ observation of patients’ suffering and distress caused moral distress.
It seems necessary for managers to promote these policies in order to improve the quality of care, increase patient satisfaction, reduce nurses’ moral distress, and make it possible for patients to visit their families in safe conditions based on instructions for health protection.
Another institutional policy relevant to psychiatric nurses is mandatory overtime and early return from sick leave. In the critical situation, along with the shortage of nursing staff in the Iranian health system, some managers were forced to make difficult decisions to compensate for the lack of manpower. The study by Navab et al.  investigated patient care during the COVID-19 pandemic, pointing to the lack of human passion in critical situations, which reduced the quality of care and nurses’ unsatisfied sense of support and prevented them from assuming nursing duties.
As a major strength of this study, we conducted one of the qualitative studies that investigated situations and factors that caused moral distress based on the experiences of psychiatric nurses caring for psychiatric patients with COVID-19. Limitations of this study include the fact that this study was conducted during the COVID-19 pandemic and nurses were under high work pressure, it was challenging to coordinate interview sessions with them and face-to-face interviews due to the need to comply with social distancing and health guidelines. Furthermore, another limitation is the small sample size and convenience sampling due to this situation, therefore the participants may not be representative of a general population of Iranian psychiatric nurses. Although most conditions in hospitals during this crisis were much the same as in other hospitals, the results of this study cannot be generalized to other hospitals that experienced different degrees of anxiety from COVID-19.