Abstract
Background: The coronavirus pandemic led to significant moral distress among nurses, diminishing care quality and increasing their intention to leave the profession. Since the intention to leave the profession can predict future career abandonment, this study was conducted in 2022 to investigate the relationship between the intention to leave the profession and the moral distress of novice nurses working in the COVID-19 wards.
Methods: In this descriptive correlational study, 181 novice nurses working in the COVID-19 wards were recruited using the census method. Data were collected using Corley’s moral distress and intention to leave the profession questionnaires and analyzed using SPSS26.
Results: The results of the data analysis showed that the mean score of novice nurses’ intention to leave the profession was 40.70±8.02 and at a moderate level, and their mean moral distress was 71.03±35.60 and at a low level. Moreover, the results indicated a positive and significant relationship between the intention to leave the profession and moral distress (p<0.001, r=0.61). No significant relationship was observed between these nurses’ demographic variables, their intention to leave the profession, and moral distress (p>0.05).
Conclusion: This level of intention to leave the profession, the moral distress experienced by novice nurses working in the COVID-19 wards, and the positive and significant relationship between them is a warning for health policymakers. Therefore, holding training courses to manage moral distress in the workplace can be considered a solution.
Keywords: Censuses, COVID-19, Intention, Morals, Pandemics, Quality of health care, Workplace

Introduction
Nurses frequently encounter complex decisions and ethical dilemmas in their profession. It is primarily because they spend most of their time at the bedside and engage closely with patients’ different experiences (1). As the COVID-19 pandemic emerged, nurses worldwide experienced various challenges, such as increased patient volume and disease burden and the protocols of COVID-19 (2). Therefore, these conditions placed nurses, as the backbone of the health system, at the forefront of developing and implementing patient care standards (3). Hence, not only did they experience long working hours, fatigue, fear of infection, and concerns about family and physical complications in that condition, but they also faced abundant moral distress (4,5). On the other hand, organizational factors, including the specialization of the nursing profession, lack of resources and equipment, technological advancement, insufficient organizational support, and budget constraints, took a toll. Besides, intergroup relations, including unfair distribution of power among colleagues, lack of professional independence, patient-related factors, and treatment processes, including invasive treatments, terminally ill patients, unnecessary tests, and inadequate treatments, aggravated moral distress (6). In addition, frontline nurses often witnessed the suffering and death of patients, which also affected their emotional health and resulted in their double fatigue (7). Furthermore, unmanaged anxiety and fear related to COVID-19 potentially affected nurses’ performance and job satisfaction and led to their frequent absences (8). Sadness, shame, deprivation and loss, stress, burnout, job dissatisfaction, and leaving the profession were among the negative consequences of these conditions (9). 
In Patricia Benner’s theory of nursing, there are five stages of clinical competence: novice, advanced beginner, competent, proficient, and expert. A novice nurse is someone who is just beginning to learn the rules and basic skills necessary to perform their nursing duties effectively (10). Hence, novice nurses experienced a period of stress and anxiety, role adjustment, and more shock at the beginning of their actual work. The reality of independent nursing practice extends far beyond the training programs at nursing colleges and the care provided in clinical settings. However, some nursing managers and doctors expect them to quickly master psychomotor skills and critical thinking and act as competent nurses (11). In Patricia Benner’s nursing theory, there are five stages of clinical competence: novice, advanced beginner, competent, proficient, and expert. A novice nurse is someone who is just starting to learn the essential rules and basic skills needed to perform nursing duties effectively. The novice or beginner has no experience in the situations in which they are expected to perform.
Before the COVID-19 pandemic, studies had already reported that 15 to 44% of nurses globally intended to leave the profession (12). It makes the treatment environment unsafe for patients because it can lead to disengagement or even neglect of care duties, even when nurses are aware of those needs. In more severe cases, they avoid approaching patients and providing care, which can ultimately result in indifference or their leaving the profession, all of which decrease the quality of care provided (13). As a result, poor quality of care can lead to more extended hospital stays and increased patient complaints and dissatisfaction. It, in turn, raises the likelihood that nurses will leave the profession. Therefore, because nursing education is expensive, if a nurse leaves this profession, healthcare organizations will face inevitable economic consequences. Given the high cost of nursing education, the departure of nurses from the field can have significant economic consequences for healthcare organizations. It’s also essential to recognize that novice nurses are the future of the profession, and their ongoing professional development depends on their active and meaningful engagement in clinical settings (14). Consequently, if organizations can identify the reasons and influential factors behind employees’ intention to leave the profession, they will be able to apply effective policies and methods to preserve and maintain (15). Regarding prevention as an effective method, figuring out the cause of the intention to leave the profession can help eliminate the underlying factors since it can predict employees’ future abonnement (16).
Global trends indicate that the COVID-19 pandemic has heightened efforts to recruit nurses from low- and middle-income countries. Influencing factors include low salaries, limited local job prospects, youth, and proficiency in foreign languages have been among the factors affecting professional abandonment in these countries (17). Studies in Iran report a similar pattern. These indicate an increase in the nurses’ tendency to migrate, which is a warning for the Iranian health system This study is important because understanding the factors influencing novice nurses’ intention to leave and their moral distress can help healthcare managers and policymakers design targeted interventions. These interventions aim to improve nurse retention, enhance job satisfaction, and ultimately improve the quality of patient care. Therefore, considering the importance of the impact of nurses’ intention to leave the profession and their moral distress on the quality of care provided to patients, this study was conducted in the hospitals of Iran in 2022 to investigate the relationship between novice nurses’ intention to leave the profession and their moral distress during COVID-19 outbreak.

Materials and Methods
Study design and setting
This descriptive-correlational study was conducted to investigate the relationship between the intention to leave the profession and the moral distress of novice nurses working in the COVID-19 wards of the University of Medical Sciences hospitals from September 20 to the end of December 2022.

Participants and procedure
The list of novice nurses directly involved in caring for patients hospitalized in the COVID-19 wards of these three hospitals (n=210) was obtained from nursing managers. Sampling was performed through the census method. The inclusion criteria included the willingness to participate in the study, at least one year of work experience in the COVID-19 ward, and at least a bachelor’s degree in nursing. Exclusion criteria included incomplete questionnaires. Given that novice nurses are those with less than three years of work experience (18), nurses with more than three years of work experience were also excluded from the study, and a total of 181 novice nurses participated. After obtaining permission and a letter of introduction from the ethics committee, permission to participate in the study setting was obtained. Afterward, if the nurses were willing to participate in the study, they completed the questionnaires after introducing themselves, receiving an explanation about the purpose of the study, and providing written informed consent. Also, nurses were instructed to study and complete the questionnaires during their free time to avoid interfering with work hours.

Data collection tools and variable measurement
A 3-part questionnaire was used to collect data. The first part of the nurses’ demographic information included age, sex, marital status, education, years and type of employment, work hours per week, and the ward. The second part of the questionnaire included Kim et al’s intention to leave the profession questionnaire, whose reliability was reported as 0.86 (19). This questionnaire consists of 15 questions scored on a five-point Likert scale (1=strongly disagree to 5=strongly agree), and the total scores range from 15 to 75, with higher scores indicating higher intention for abandonment. The Persian version of this questionnaire has been validated in Iran, and its Cronbach’s alpha is 0.82 (20). In the present study, Cronbach’s alpha value of this questionnaire was 0.78. The cut-off point was considered low=15-34, medium= 35-54, and high= 55-75.
The third part was Corley’s Moral Distress Questionnaire (21). This questionnaire has been psychometrically evaluated to reflect the cultural and social background and service delivery conditions in Iranian hospitals, and its internal correlation has been reported with Cronbach’s alpha of 0.86 (22). In the present study, its Cronbach’s alpha value was 0.84. The mentioned questionnaire contains 36 options scored on a 7-point Likert scale (0=none to 6=severe). Therefore, the highest and the lowest scores are 216 and 0, respectively, and a score of 0-72 is considered a low, 73-144 a moderate, and 145-216 a high level of moral distress. 

Statistics and data analysis 
The normal distribution of the study variables was evaluated based on skewness and elongation indices. The results showed that the absolute values ​​of skewness and elongation for all variables were between ±3 and ±10, respectively. Therefore, according to Klein, the data distribution was normal (23). Thus, in the descriptive statistics section, the frequency, percentage, mean, and standard deviation were used, and in the inferential statistics section, after checking the normality of the distribution of moral distress scores and participants’ tendency to leave the profession, independent t-test, analysis of variance, and Pearson’s correlation coefficient were used. To analyze the data, SPSS 26 was used at a significance level of 0.05.

Ethical approval
Ethical considerations in this study were observed based on the human subject protection codes in medical research. The subject and method of the study were approved by the ethics committee with the code IR.IAU.KERMAN.REC.1401.043. Written informed consent was completed, and the participants were assured of voluntary participation in the study, withdrawal from the study at any time, the anonymity of the questionnaire, and confidentiality of information. They were also assured that their information would be treated anonymously and confidentially for research purposes only.

Results
A total of 181 novice nurses working in the COVID-19 wards participated in the present study. The findings showed that participants’ mean age was 27.72±2.93 years, and the age range was 25-40. The results of the data analysis indicated that the majority of the participants were married female training nurses with a bachelor’s degree. Other demographic information is presented in table 1.
The results of the data analysis showed that the mean score of nurses’ intention to leave the profession was 40.70 (8.02) at the moderate level, and their moral distress score was 71.03 (35.60) at the low level. Moreover, the Pearson correlation coefficient test results showed a positive and significant relationship between participants’ intention to leave the profession and their moral distress (p<0.001, r=0.616). Other information is provided in table 2. 
Furthermore, the results of nurses’ intention to leave the profession by options indicated that 53.1% of the nurses chose the option “If another job is going to be offered to me tomorrow, I will seriously think about it.” The option “I am sure I will stay here for a short time” had the lowest response rate (19.9 %). Moreover, the results of the data analysis in the moral distress section by options showed that 37% of the nurses selected the option “treatment and care of the patient under ventilator without hope of survival” as the most significant cause of moral distress and 68% chose “terminating treatment and care of the patient who is unable to pay the expenses according to the regulations” as the factor causing the lowest level of moral distress.
The results of the Univariate covariance test showed that, although the intention to leave the profession was higher among male, single nurses with a bachelor’s degree and contractual and registered employment status, no significant relationship was observed between these variables and the intention to leave the profession (p>0.05).  In the moral distress section, the Univariate covariance test results indicated that demographic variables’ effect on the participants’ moral distress was not significant. However, the mean moral distress was higher in male, single nurses with a bachelor’s degree and contractual status (Table 3). 

Table 1. Participants’ demographic characteristics and background information (n=181)

 *  Standard deviation

Table 2. The mean score of participants’ intention to leave the profession and their moral distress, and the correlation between them

 * Standard deviation.

Table 3. The relationship between the mean score of participants’ intention to leave the profession and their moral distress with their demographic characteristics

 MD: Mean difference, ES: Effect Size.

Discussion
The present study was conducted to investigate the relationship between the intention to leave the profession and the moral distress of novice nurses working in the COVID-19 wards University of Medical Sciences. The results of the data analysis showed that nurses’ mean intention to leave the profession was at a moderate level. Moreover, the option “If another job is going to be offered to me tomorrow, I will seriously think about it” obtained the highest level of intention to leave the profession, and the option “I am sure I will stay here for a short time” was identified as the lowest level of intention to leave the profession. Consistent with these findings, Ariapooran et al reported a 56.41% intention to leave among nurses in public hospitals during the COVID-19 pandemic, emphasizing the need to improve work-life quality components to reduce turnover (24). Similarly, a study from South Korea found that nurses in COVID-19 wards exhibited higher turnover intention compared to those in general wards, with frontline nurses being more likely to consider leaving the profession (25). 
Regarding moral distress, the present study found the overall level of moral distress among nurses was low. The item “treatment and care of patients on ventilators with no hope of survival” caused the highest moral distress for 37% of participants It aligns with previous research reporting low moral distress levels among Iranian nurses caring for COVID-19 patients. Also, further research is recommended to identify the broader dimensions of moral distress  (26). Laurs et al’s study reported that of 612 Lithuanian nurses, 32.3% experienced a low level of moral distress (mean 1.09), 33.9% experienced a moderate level (mean 2.53), and 33.8% experienced a high level (mean 3.0). The findings of this study provided evidence about the relationship between moral distress and the intention to leave the profession. Moreover, it showed that the situations that may put health professionals in a moral dilemma were mainly related to the unethical work environment (27). The cultural differences in societies and nationalities, the type of work environment, and individual characteristics can be mentioned as the reasons for the inconsistency between the results of the mentioned studies and the present study. Consequently, distress occurs intensely and frequently in those who are emotionally sensitive and affected by the patient’s conditions (26). Overall, according to the level of moral distress in nurses and the prevention of its possible consequences, strategies, and solutions should be considered to familiarize nurses with moral distress and its underlying factors so that they can act more effectively and reduce this moral phenomenon as much as possible.
Another study result was a positive, significant relationship between the intention to leave the profession and moral distress in novice nurses working in the COVID-19 wards. Consistent results were observed in Naboureh A  et al’s study in cardiac intensive care and the intensive care unit nurses (28). Moreover, in another study, nurses with a high level of moral distress were three times more likely to leave their position than those with moderate or low levels of moral distress. Therefore, identifying the reasons for leaving the profession and analyzing whether the data is correlated with the data of countries where nursing has a much longer history is of utmost importance. That is because by identifying underlying reasons, interventions can be designed to minimize moral distress with the ultimate goal of increasing patient care and employee satisfaction (27). Although, in some studies, no significant relationship was observed between moral distress and nurses leaving the profession (29), it seems that programs aiming at reducing moral distress and the intention to leave should be developed, and studies aiming at identifying variables affecting moral distress and leaving the profession should be conducted. Meanwhile, in some studies, no relationship was observed between nurses’ intention to leave the profession and their moral distress. In addition, it has been stated in those studies that nurses are sometimes forced to remain in the profession due to inadequate employment and challenging economic conditions. Moreover, the specific organizational conditions do not allow the personnel to leave the profession quickly, and they are not able to immediately implement their intention to leave the profession (30).
In the present study, no significant relationship was observed between demographic variables, the intention to leave the profession, and the moral distress of novice nurses working in the COVID-19 wards. These results are consistent with the results of some studies. Therefore, these researchers believe that educational programs to reduce moral distress can be provided for all medical personnel providing care regardless of their demographic characteristics (26,30). However, in some other studies, statistically significant differences were observed between the intention to leave the profession and age and nursing experience and between moral distress and age, education level, nursing experience, and working ward (31). A study reported a positive and significant relationship between age, nursing experience, and experience in the intensive care unit and the intention to leave the profession (29). The review of the results emphasizes the complex relationship between moral distress and nurses’ intentions to leave the profession during the COVID-19 crisis. As a result, healthcare organizations may face challenges in developing targeted strategies to reduce moral distress. Addressing these challenges is crucial for improving nurse retention and enhancing the quality of patient care. Therefore, further research is recommended to explore specific dimensions of moral distress and its impact on workforce sustainability in various healthcare settings.

Conclusion
This study was conducted to investigate the relationship between the intention to leave the profession and the moral distress of novice nurses working in the COVID-19 wards of University of Medical Sciences in 2022. The results showed that the mean intention to leave the profession in novice nurses working in the COVID-19 wards was moderate, threatening the current conditions of Iranian hospitals. Although the mean moral distress of these nurses was at a low level, the presence of a positive and significant relationship between moral distress and the intention to leave the profession and the effect it might have on their productivity and quality of work requires health policymakers’ closer to identify the factors that aggravate moral distress and formulate supportive and educational solutions for better management of moral distress by these nurses. Therefore, it seems necessary to explore strategies that can strengthen the professional identity of novice nurses and commit them staying in clinical settings.

Study limitations
Given that this study was conducted cross-sectionally during the COVID-19 pandemic and involved a relatively small sample size, this may limit the generalizability of the results. Therefore, it is recommended that future studies use larger sample sizes and explore different contexts through longitudinal or multi-center approaches to validate the findings and examine changes over time.

Acknowledgement
This article is the result of the MSc thesis by the first author (ZRM). The authors would like to appreciate the Vice-Chancellor for Research of the Islamic Azad University of Kerman brunch and nurses who sincerely cooperated in this study. 

Conflict of Interest
There was no conflict of interest in this manuscript.