1. Introduction
ue to direct contact with patients, nurses have an important role in preventing the spread of COVID-19 [7]. Hence, nurses are highly exposed to stress induced by COVID-19 [8, 9, 10]. In studies conducted outside Iran, the prevalence of psychological problems (depression and anxiety) in nurses during the COVID-19 pandemic has been reported between 10.7 to 42.8% [31, 32, 33, 34, 35]. In Iran, depression and anxiety during the pandemic have been studied in nurses [36, 37, 38, 39], but their suicidal ideation has not been studied. Before the outbreak of COVID-19, it was shown that nurses in ICU, CCU and emergency departments have more occupational stress [41, 42], and their psychological disorders have been reported more compared to nurses in other wards [43, 44]. Therefore, the main purpose of this study was to investigate the prevalence of depression, anxiety and suicidal ideation in nurses during the COVID-19 outbreak, and evaluate the role of gender, educational level, marital status and department.
2. Materials and Methods
This is a descriptive-survey study. The study population consists of all nurses in Malayer, Iran in 2020 with a total number of 525 (205 in Shahid Gharazi Hospital, 200 in Imam Hossein Hospital and 120 in Mehr Hospital). Samples were selected using census method. After distributing questionnaires among nurses, 312 were returned completed and their data were used in the analysis. Questionnaires were the short form of Beck Depression Inventory (BDI) with 13 items [45] and acceptable psychometric properties [45, 46, 47], Beck Anxiety Inventory (BAI) with 21 items [48] and acceptable psychometric properties [48, 49, 50], and Scale for Suicidal Ideation (SSI) with 19 items and acceptable psychometric properties [51, 52, 53]. Prevalence of psychological problems was described by using frequency and percentage. To compare the variables based on demographic factors, multivariate Analysis of Covariance (MANCOVA) was used by controling the effects of age and work experience.
3. Results
According to the results, 15.38% of nurses had moderate to severe depression; 46.47% had moderate to severe anxiety, 27.56% had plans for suicide, and 9.94% had active suicidal desire (Tables 1 and 2). 




The results of MANCOVA showed that the mean of depression and anxiety of female nurses were higher than those of male nurses, and there was no significant
difference in suicidal between male and female nurses, although they were higher in females. Depression and suicidal ideation were higher in nurses with a bachelor’s degree than in nurses with a master’s degree or higher, but there was no significant difference in anxiety between the two education groups. Anxiety and suicidal ideation of single nurses were higher than that of married nurses, and no significant difference was observed in depression between single and married nurses. Only anxiety in nurses differed based on their department. According to the results of LSD post hoc test, the mean anxiety of nurses in the emergency department and ICU/CCU were higher than in the pre-hospital emergency department, but there was no significant difference in depression and suicidal ideation between nurses based on department.
4. Discussion and Conclusion
The results of this study related to the prevalence of psychological problems were against the findings of studies conducted before the COVID-19 outbreak [31, 32], but consistent with the findings of studies conducted during the COVID-19 outbreak [32, 33, 34]. The high prevalence of psychological problems is probably due to the stress caused by the coronavirus. Nurses in the COVID-19 outbreak are more likely to experience deaths of patients and even hospital staff, which can increase their rates of depression, anxiety, and suicidal ideation. Female nurses were more anxious and depressed than men and suicidal ideation was not significantly different between them. This is against the findings of a previous study [28] and consistent with the findings of some previous studies [29, 35, 55]. Women’s vulnerability to stress compared to men [56] can play a role in this difference. Nurses with a bachelor’s degree had more depression and suicidal ideation, which is consistent with the findings of a previous study [28]. The higher incomes of nurses with a master’s degree may play a role in this outcome. The difference in anxiety and suicidal ideation and the lack of difference in depression based on marital status in our study are against the findings of a previous study [28] and consistent with the findings of other study [57]. Married nurses join their families after work and are supported by their spouse and even children; contact with the family makes them less likely to experience anxiety and suicidal thoughts. The nurses of the emergency department and the ICU/CCU were more anxious than the pre-hospital emergency nurses, which is consistent with the findings of some previous studies [43, 44]. The high level of stress induced by COVID-19 in nurses working in ICU/CCU and emergency department can cause nurses to experience anxiety symptoms. One of the limitations of this study was the use of self-report scales. The use of qualitative methods and interviews in future studies is recommended. Psychologists, counselors, and psychiatrists working in hospitals are highly recommended to pay attention to the symptoms of depression, anxiety, and suicidal ideation in nurses.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Malayer University (Code: IR.MALAYERU.REC.1399.002). All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization: Saeed Ariapooran; Research, editing and finalizatio: Both authors.

Conflicts of interest
The authors declare no conflict of interest.


References

1. Gorbalenya AE, Baker SC, Baric RS, de Groot RJ, Drosten C, Gulyaeva AA, et al. Severe acute respiratory syndrome-related coronavirus: The species and its viruses-a statement of the Coronavirus Study Group. bioRxiv 2020. [DOI:10.1101/2020.02.07.937862]
2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel Coronavirus pneumonia in Wuhan, China:A descriptive study. Lancet. 2020; 395(10223):507-13. [DOI:10.1016/S0140-6736(20)30211-7]
3. Zandifar A, Badrfam R. Iranian mental health during the COVID-19 epidemic. Asian J Psychiatr. 2020; 51:101990. [DOI:10.1016/j.ajp.2020.101990] [PMID] [PMCID]
4. Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic:Address mental health care to empower society. Lancet. 2020; 395(10224):e37-8. [DOI:10.1016/S0140-6736(20)30309-3]
5. Smith GD, Ng F, Li WH. COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity. J Clin Nurs. 2020; 29(9-10):1425-8 [DOI:10.1111/jocn.15231] [PMID] [PMCID]
6. Dar KA, Iqbal N, Mushtaq A. Intolerance of uncertainty, depression, and anxiety: Examining the indirect and moderating effects of worry. Asian J Psychiatr. 2017; 29:129-33. [DOI:10.1016/j.ajp.2017.04.017] [PMID]
7. Nemati M, Ebrahimi B, Nemati F. Assessment of Iranian nurses’ knowledge and anxiety toward COVID-19 during the current outbreak in Iran. Arch Clin Infect Dis. 2020; 15:e102848. [DOI:10.5812/archcid.102848]
8. Mo Y, Deng L, Zhang L, Lang Q, Liao C, Wang N, et al. Work stress among Chinese nurses to support Wuhan in fighting against COVID-19 epidemic. J Nurs Mana. 2020; 28(5):1001-9. [DOI:10.1111/jonm.13014] [PMID] [PMCID]
9. Shen X, Zou X, Zhong X, Yan J, Li L. Psychological stress of ICU nurses in the time of COVID-19. Crit Care. 2020; 24(1):200 [DOI:10.1186/s13054-020-02926-2] [PMID] [PMCID]
10. Sodeify R, Habibpour Z. [Determining nurses understanding of psychological factors at workplace:A qualitative study (Persian)]. Sci J Nurs Midwif Paramed. 2020; 5(4):49-61. http://sjnmp.muk.ac.ir/article-1-277-en.html
11. Sharifah Zainiyah SY, Afiq IM, Chow CY, Siti Sara D. Stress and its associated factors amongst ward nurses in a public hospital Kuala Lumpur. Malaysia J Pub Health Med. 2011; 11(1):78-85. https://www.mjphm.org.my/mjphm/index.php?option=com_content&view=article&id=488:stress-and-its-associated-factors-amongst-ward-nurses-in-a-public-hospital-kuala-lumpur&catid=79:volume-11-1&Itemid=97
12. McGibbon E, Peter E, Gallop R. An institutional ethnography of nurses’ stress. Qual Health Res. 2010; 20(10):1353-78. [DOI:10.1177/1049732310375435] [PMID]
13. Lim J, Bogossian F, Ahern K. Stress and coping in Australian nurses:A systematic review. Intl Nurs Rev. 2010; 57(1):22-31. [DOI:10.1111/j.1466-7657.2009.00765.x] [PMID]
14. Moustaka E, Constantinidis TC. Sources and effects of work-related stress in nursing. Health Sci J. 2010; 4(4):210-6. https://www.hsj.gr/medicine/sources-and-effects-of-workrelated-stress-in-nursing.php?aid=3575
15. Wu H, Chi TS, Chen LI, Wang L, Jin YP. Occupational stress among hospital nurses: Cross-sectional survey. J Adv Nurs. 2010; 66(3):627-34. [DOI:10.1111/j.1365-2648.2009.05203.x] [PMID]
16. Murgia C, Sansoni J. [Stress and nursing:Study to evaluation the level of satisfaction in nurses (Italian)]. Prof Inferm. 2011; 64(1):33-44. [PMID]
17. Chou LP, Li CY, Hu SC. Job stress and burnout in hospital employees:Comparisons of different medical professions in a regional hospital in Taiwan. BMJ Open. 2014; 4(2):e004185. [DOI:10.1136/bmjopen-2013-004185] [PMID] [PMCID]
18. Khamisa N, Oldenburg B, Peltzer K, Ilic D. Work related stress, burnout, job satisfaction and general health of nurses. Int J Environ Res Public Health. 2015; 12(1):652-66. [DOI:10.3390/ijerph120100652] [PMID] [PMCID]
19. Lin SH, Liao WC, Chen MY, Fan JY. The impact of shift work on nurses’ job stress, sleep quality and self-perceived health status. J Nurs Manag. 2014; 22(5):604-12. [DOI:10.1111/jonm.12020] [PMID]
20. Malinauskiene V, Leisyte P, Romualdas M, Kirtiklyte K. Associations between self-rated health and psychosocial conditions, lifestyle factors and health resources among hospital nurses in Lithuania. J Adv Nurs. 2011; 67(11):2383-93. [DOI:10.1111/j.1365-2648.2011.05685.x] [PMID]
21. Kuhn CM, Flanagan EM. Self-care as a professional imperative:Physician burnout, depression, and suicide. Can J Anaesth. 2017; 64(2):158-68. [DOI:10.1007/s12630-016-0781-0] [PMID]
22. Maharaj S, Lees T, Lal S. Prevalence and risk factors of depression, anxiety, and stress in a cohort of Australian nurses. Int J Environ Res Public Health. 2018; 16(1):61. [DOI:10.3390/ijerph16010061] [PMID] [PMCID]
23. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of depression and depressive symptoms among resident physicians:A systematic review and meta-analysis. JAMA. 2015; 314(22):2373-83. [DOI:10.1001/jama.2015.15845] [PMID] [PMCID]
24. Melnyk BM, Orsolini L, Tan A, Arslanian-Engoren C, Melkus GD, Dunbar-Jacob J, et al. A national study links nurses’ physical and mental health to medical errors and perceived worksite wellness. J Occup Environ Med. 2018; 60(2):126-31. [DOI:10.1097/JOM.0000000000001198] [PMID]
25. Davidson JE, Proudfoot J, Lee K, Terterian G, Zisook S. A longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action. Worldviews Evid Based Nurs. 2020; 17(1):6-15. [DOI:10.1111/wvn.12419] [PMID]
26. Fink-Miller EL, Nestler LM. Suicide in physicians and veterinarians:Risk factors and theories. Curr Opin Psychol. 2018; 22:23-6. [DOI:10.1016/j.copsyc.2017.07.019] [PMID]
27. Wang R, Zhang D, Wang S, Zhao T, Zang Y, Su Y. Limitation on activities of daily living, depressive symptoms and suicidal ideation among nursing home residents:The moderating role of resilience. Geriatr Nurs. 2020; 41(5):622-8. [DOI:10.1016/j.gerinurse.2020.03.018] [PMID]
28. Ariapooran S. Sleep problems and depression in Iranian nurses:The predictive role of workaholism. Iranian J Nursing Midwifery Res. 2019; 24(1):30-7. [DOI:10.4103/ijnmr.IJNMR_188_17] [PMID] [PMCID]
29. Azad Zandi M, Sayari R, Ebadi A, Sanainasab H. Frequency of depression, anxiety and stress in military nurses. J Mil Med. 2011; 13(2):103-8. http://militarymedj.ir/article-1-774-en.html
30. Sánchez Núñez RA, Ramírez C, Gómez Meza MV. Smoking, depression, and suicide risk in the nursing staff of a Third-Level Hospital. Medicina Universitaria. 2014; 16(63):60-5. https://www.elsevier.es/en-revista-medicina-universitaria-304-articulo-smoking-depression-suicide-risk-in-X1665579614365251
31. Hu D, Kong Y, Li W, Han Q, Zhang X, Zhu LX, et al. Frontline nurses’ burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A big-scale cross-sectional study. 2020. [DOI:10.2139/ssrn.3566144]
32. Sun N, Wei L, Shi S, Jiao D, Song R, Ma L, et al. A qualitative study on the psychological experience of caregivers of COVID-19 patients. Am J Infect Control. 2020; 48(6):592-8. [DOI:10.1016/j.ajic.2020.03.018] [PMID] [PMCID]
33. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic:A systematic review and meta-analysis. Brain Behav Immun. 2020; 88:901-7. [DOI:10.1016/j.bbi.2020.05.026] [PMID] [PMCID]
34. Savitsky B, Findling Y, Ereli A, Hendel T. Anxiety and coping strategies among nursing students during the covid-19 pandemic. Nurse Educ Pract. 2020; 46:102809. [DOI:10.1016/j.nepr.2020.102809] [PMID] [PMCID]
35. Pouralizadeh M, Bostani Z, Maroufizadeh S, Ghanbari A, Khoshbakht M, Alavi SA, et al. Anxiety and depression and the related factors in nurses of Guilan University of Medical Sciences Hospitals during COVID-19: A web-based cross-sectional study. Int J Afr Nurs Sci. 2020; 13:100233. [DOI:10.1016/j.ijans.2020.100233] [PMID] [PMCID]
36. Sepahvand R, Momeni Mofrad M, Taghipour S. [Identifying and prioritizing the psychological consequences of the Covid 19 virus in nurses (Persian)]. J Hosp. 2020; 19(2):25-32. http://jhosp.tums.ac.ir/article-1-6277-en.html
37. Sarboozi Hosein Abadi T, Askari M, Miri K, Namazi Nia M. [Depression, stress and anxiety of nurses in COVID-19 pandemic in Nohe-Dey Hospital in Torbat-e-Heydariyeh city, Iran (Persian)]. J Mil Med. 2020; 22(6):526-33.http://militarymedj.ir/article-1-2543-en.html
38. Shahed Hagh Ghadam H, Fathi Ashtiani A, Rahnejat A M, Ahmadi Tahour Soltani M, Taghva A, Ebrahimi MR, et al. [Psychological consequences and interventions during the COVID-19 pandemic: Narrative review (Persian)]. J Mar Med. 2020; 2(1):1-11. http://jmarmed.ir/article-1-74-en.html
39. Ashikur R, Virginia P. COVID-19 related suicide among hospital nurses:Case study evidence from worldwide media reports. Psychiatry Res. 2020; 291:113272. [DOI:10.1016/j.psychres.2020.113272] [PMID] [PMCID]
40. Gabilondo A, Alonso J, Pinto-Meza A, Vilagut G, Fernández A, Serrano-Blanco A, et al. Prevalence and risk factors for suicide ideation, plans and attempts in the Spanish general population. Results from the ESEMeD study. Med Clin. 2007; 129(13):494-500. [DOI:10.1157/13111370] [PMID]
41. Preto, VA, Pedrão, LJ. Stress among nurses who work at the intensive care unit. Rev Esc Enferm USP. 2009; 43(4):838-45. [DOI:10.1590/S0080-62342009000400015] [PMID]
42. Latifzadeh S, Zarea, K. Occupational stress and its related factors in nurses working in intensive care units of educational hospitals in Ahwaz, Iran. J Nov Appl Sci. 2015; 4(4):483-7. http://jnasci.org/wp-content/uploads/2015/05/JNASCI-2015-483-487.pdf
43. Adriaenssens J, De Gucht V, Maes S. Causes and consequences of occupational stress in emergency nurses, a longitudinal study. J Nurs Manag. 2015; 23(3):346-58. [DOI:10.1111/jonm.12138] [PMID]
44. Tajvar A, Nasl Saraji G, Amin Ghanbarnejad A, Omidi L, Seyed Hosseini SS, Salehi Sahl Abadi A. Occupational stress and mental health among nurses in a medical intensive care unit of a general hospital in Bandar Abbas in 2013. Electron Physician. 2015; 7(3):1108-13. [DOI:10.1155/2016/8196463] [PMID] [PMCID]
45. Dadfar M, Kalibatseva Z. Psychometric properties of the Persian version of the short Beck Depression Inventory with Iranian psychiatric outpatients. Scientifica (Cairo). 2016; 2016:8196463. [DOI:10.1155/2016/8196463] [PMID] [PMCID]
46. Nouri A, Mohammadi Y. [An action guide to research humanities (Persian)]. Tehran: Viraiesh; 2016. http://opac.nlai.ir/opac-prod/bibliographic/4410529
47. Ebrahimi A, Barekatin M, Bornamanesh A, Nasiri H. [Psychometric characteristics of Persian form of BDRS among patients and normal people (Persian)]. Iran J Psychiatry Clin Psychol. 2015; 21(1):60-8. http://ijpcp.iums.ac.ir/article-1-2355-en.html
48. Hossein Kaviani H , Mousavi AS. [Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI) (Persian)]. Tehran Univ Med J. 2008; 66(2):136-40. https://tumj.tums.ac.ir/article-1-641-en.html
49. Rafiei M, Seifi A. [An investigation into the reliability and validity of beck anxiety inventory among the university students (Persian)]. J Thought Behav Clin Psychol. 2013; 7(27):37-46. https://jtbcp.riau.ac.ir/article_13_en.html
50. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention:The scale for suicide ideation. J Consult Clin Psychol. 1979; 47(2):343-52. [DOI:10.1037/0022-006X.47.2.343] [PMID]
51. Hakim Shooshtari MH, Malakouti SK, Panaghi L, Mohseni S, Mansouri N, Movaghar AR. Factors associated with suicidal attempts in Iran:a systematic review. Iran J Psychiatry Behav Sci. 2016; 10(1):e948. [DOI:10.17795/ijpbs-948] [PMID] [PMCID]
52. Anisi J, Majdian M, Mirzamani SM. The factors associated with suicide ideation in Iranian soldiers. Iran J Psychiat. 2010; 5(3):97-101. https://ijps.tums.ac.ir/index.php/ijps/article/view/365
53. Polanco-Roman L, Gomez J, Miranda R, Jeglic E. Stress-related symptoms and suicidal ideation:The roles of rumination and depressive symptoms vary by gender. Cognit Ther Res. 2016; 40(5):606-16. [DOI:10.1007/s10608-016-9782-0] [PMID] [PMCID]
54. Javidi Zaher S, Vafaei M, Ebrahimi Abianeh E. Comparing depression, anxiety and stress among the Nurses in the critical care and internal surgical units at the selected hospitals of the Social Security Organization of Tehran in 2016. Int J Med Res Health Sci. 2016; 5(S5):254-61. https://www.ijmrhs.com/abstract/comparing-depression-anxiety-and-stress-among-thenurses-in-the-critical-care-and-internal-surgical-units-at-the-selected-6645.html
55. Verma R, Balhara YP, Gupta CS. Gender differences in stress response:Role of developmental and biological determinants. Ind Psychiatry J. 2011; 20(1):4-10. [DOI:10.4103/0972-6748.98407] [PMID] [PMCID]
56. Khamseh F, Roohi H, Ebaady A, Hajiamini Z, Salimi H, Radfar S. [Survey Relationship between demographic factors and stress, anxiety and depression in nurses working in selected hospitals in Tehran city (Persian)]. J Holist Nurs Midwifery. 2011; 21(1):13-21. http://hnmj.gums.ac.ir/article-1-189-en.html
57. Ledema R, Ball C, Daly B, Young J, Green T, Middleton PM, et al. Design and trial of a new ambulance-to-emergency department handover protocol:‘IMIST-AMBO’. BMJ Qual Saf. 2012; 21(8):627-33. [DOI:10.1136/bmjqs-2011-000766] [PMID]