Table 3.

Description of moral distress during the COVID-19 pandemic (free-text response)

Category	Subcategory	Quotes
1. Unusual treatment and care
	1) Limitation on medical treatment and care and deterioration in quality caused by prioritizing infection control	• Infection control based on hospital policy was prioritized over the rights of patients and medical providers • Deep sedation and muscle relaxation, which is not normally necessary, was used to prevent infection by health care providers • Because of concerns about the risk of infection to medical providers, contact with patients was restricted, and the usual treatment could not be performed
	2) Problems of medical treatment and care other than infection control	• There were situations where we had to give up, even when we would not normally give up • Support nurses from general wards who had little experience in caring for critically ill patients also provided care to these patients, resulting in differences in the quality of nursing • When there were too many patients, it was necessary to triage patients to get them admitted to the ICU • Insufficient medical resources
2. Restricted visits
	1) Patient and family could not meet	• Patients who were encouraged by family visits could not see them due to visiting restrictions • No one was allowed to visit the patients before or after the patient died • There were restrictions on visits to patients who do not have COVID-19
	2) Difficulty in dealing with visitation restrictions	• It was difficult to establish a visitation system with infection control measures, both financially and in terms of information management; hence, restrictions on family visitations were not easily resolved • We wanted patients and families to meet online or exchange photos but could not because the hospital did not give approval
3. Challenging situations for health care providers
	1) Conflict and prejudice	• There was conflict and a feeling of unfairness between staff who were involved in COVID-19 practice and those who were not • Low awareness of infection prevention among physicians and staff who were not involved in COVID-19 practice • The physician did not enter the room of the COVID-19 patient and gave instructions from outside the patient’s room. The nurses were doing most of the work in the room
	2) System of hospitals for COVID-19	• Opinions from people on the frontline were not communicated to hospital administrators • There was no physician to take leadership
	3) Support system for health care providers	• Harmful effects due to workload, fatigue of healthcare providers • Conflict between ensuring staff safety and accepting COVID-19
4. Psychological burden
	1) Fear of infection	• I could not work because I was worried about my family • If I had an asymptomatic infection, I might infect my family or others. I was afraid that information about infected people would be reported and that the infection would spread
	2) Conflict in medical treatment and care	• It was hard for many staff members to maintain a sense of normality • I was not in a psychological state where I could make normal judgments. At the same time, I was working with a feeling of fatigue
5. Others
		• Overall social activities were restricted to prevent infection in the elderly • Differences in perceptions between the public and health care providers lead to excessive fear and discriminatory behavior