Psychological impacts of the COVID-19 pandemic on nurses and coping strategies: a systematic review

Introduction

Background

Coronavirus disease 2019 (COVID-19) where the first case was found in Wuhan, Hubei Province, China in 2019 became a world crisis problem because it spread very quickly. In March 2020, COVID-19 spread around the world so quickly that the World Health Organization (WHO) officially declared it a world pandemic (1). Until June 2023, it was approximately 767,750,853 confirmed cases, a total of 6,941,095 deaths have been reported almost worldwide (2). Even though large-scale social restrictions have been carried out and the implementation of strict health protocols, the rate of spread of the COVID-19 virus has not been significantly reduced (3). Until June 2023, it was reported that 2,087 health care workers (HCWs) in Indonesia died from COVID-19, of which there were 670 nurses (4).

Rationale and knowledge gap

The rapid spread, high infection rates and even death have an impact on the psychology of nurses as the frontline such as experiencing anxiety, stress and depression (5). Data shows that during the COVID-19 pandemic the number of nurses who experienced acute stress was 64%, depression was 53% and anxiety was 40% (6). In addition, nurses also experience fear and even desire to leave their jobs (7). Nurses sometimes choose to hide the fact that they work in a COVID-19 isolation ward (8). Nurses in Indonesia also experience psychological impacts during the pandemic as happened at the West Sumatera Pulmonary Hospital, namely stress, severe anxiety, to depression (9). Other symptoms that are often experienced by nurses are anxiety, excessive worry, fear of infection, difficulty concentrating, disappointment and doubt that result in psychological stress (10). If this is not managed properly, it is feared that they will experience acute stress disorder which puts them at risk for post-traumatic stress disorder or post-traumatic stress disorder (PTSD), decreased immunity and decreased work productivity (11).

The COVID-19 pandemic situation requires nurses’ psychological adaptations that depend on their assessment of the situation and behavior, whether to continue to face reality or avoid this outbreak. Responding to this situation, each individual is different in responding to it (12). Coping strategies will affect a person’s emotions or thoughts in order to produce a good quality of life and produce a positive action, but if the use of coping strategies is not appropriate, it can produce severe psychological stress (13). Nurses have their own coping strategies in dealing with pandemic situations such as in New York, 80% of nurses use coping strategies to manage stress by choosing physical activities/exercises (59%) and implementing virtual group spiritual practices (16%) (6). Thus, someone who uses coping strategies will experience lower stress (14). There are similar studies that have been carried out, but healthcare workers fighting against COVID-19 with study limitations in the western region do not focus on nurses in the wider world region (15). This study also expands the database and data period used by previous similar studies (16).

Objective

Based on this background, the researchers were interested in being to explore and describe the psychological impact that occurs on nurses and the types of coping strategies used by nurses in dealing with the COVID-19 pandemic reported in the literature. We present this article in accordance with the PRISMA reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-22-57/rc) (17).

Methods

The type of research used is a systematic review through searching for articles in four databases, namely Scopus, PubMed, ScienceDirect and SAGE, the literature review focuses on the psychological impact of the COVID-19 pandemic on nurses and coping strategies. Literature review involves finding, reading, understanding and forming conclusions about the published research and theory and presenting it in an organized manner (18).

Eligibility criteria

The search used four databases from Scopus, PubMed, ScienceDirect and SAGE. The search is limited, namely from January 2020 to December 2022. Search literature using keywords that are adjusted to the Medical Subject Heading (MeSH) namely ((psychological) OR (mental AND health) OR (psychological AND stress) AND (impact) OR (effect) OR (disturbance) AND (COVID-19) OR (coronavirus AND disease 2019) OR (sars AND cov-2) OR (novel AND coronavirus AND disease) AND (nurse) OR (nurses) AND (coping AND strategies) OR (emotional AND adjustment) OR (coping AND behavior) OR (coping AND adaptation)). We included articles that were: (I) published in English, (II) published in a peer-reviewed journal, and (III) published in an original article form. We excluded studies that were not related to coping strategies and emotional states of nurses during the COVID-19 pandemic.

Study selection

Based on the results of a literature search on four databases using keywords that have been adapted to MeSH, the researchers identified 400 journals. Then three reviewers (Nihayati HE, Pratiwi IN and Santus R) independently screened all identified articles based on the January 2020 to December 2022 limit and using English the results are 1,478 articles, including Scopus (n=162), ScienceDirect (n=374), PubMed (n=697) and SAGE (n=245). The next step is to select the duplication of the four databases (n=423). The next stage is eligibility by excluding titles and abstracts whose research subjects are non-nurse participation (n=480), does not explain coping (n=300), not related to the psychological impact of COVID-19 nurses and coping strategies (n=60) so that 215 article titles and relevant abstracts were obtained. The next stage is to search for the availability of full text articles and exclude full text articles that do not discuss the psychological impact of COVID-19 nurses and coping strategies (n=78) so that articles that are included full text can be analyzed (n=23) (Figure 1) (19). Any disagreement between the two reviewers during the screening process was discussed until a consensus was reached.

Figure 1 Flow chart of the literature search and screening process. COVID-19, coronavirus disease 2019.

Quality assessment

Articles that met the inclusion criteria were independently assessed by three reviewers (Nihayati HE, Pratiwi IN and Santus R) for methodological validity prior to inclusion in the review using The Joanna Briggs Institute’s (JBI) Critical Assessment Checklist for several types of correlational (20) and qualitative studies (21). The JBI-based checklist lists several questions to assess the quality of the study. The assessment criteria are given a score of “yes”, “no”, “unclear” or “not applicable”, and each “yes” score is assigned one point and the other scores are zero. Each score is then calculated and summed. If the research score is at least 50% it meets the critical appraisal at the cut-off point. The risk of bias in this literature review uses an assessment of the research methods of each study, namely in the aspects of theory, design, samples, variables, instruments and data analysis used.

Results

Assessment criteria study results

Table 1 shows the results of a literature review search that obtained 23 articles that passed the screening according to the criteria that have been determined based on JBI Critical Appraisal Tools (41).

The results of critical appraisal in Table 1 use The JBI Critical Appraisal Tools, where 17 articles use the JBI critical appraisal checklist for analytical cross-sectional studies with a total score of 8 and 6 articles use the JBI critical appraisal checklist for qualitative studies with a total score of 10 points. The value of criteria 1 to 10 is the number of critical appraisal questions in The JBI Critical Appraisal Tools according to the research design of each article. The symbol “yes” (√) is eligible and the symbol “no” (×) is not eligible. Nine articles with the checklist for analytical cross-sectional studies received a “yes” rating of 8 out of a total score of 8 or 100% (8/8) with good quality and seven articles that received an answer/rating of “no” were all on the first question 7/8 (88%) good quality. There are six qualitative studies with a total criteria of questions 1–10, where only 1 article received two “no” ratings with a score of 8/10 (80%) but still categorized as good quality. The results of the study review of the 23 articles achieved a higher score of more than 50% so that it met the critical appraisal which will then be analyzed for data.

Characteristics of the selected studies

Table 2 shows the results obtained by 23 articles with 2020–2022 limitations and using English which consists of 17 articles with cross-sectional studies and 6 articles with qualitative studies. Six articles are from China including Wuhan, where COVID-19 started, two articles are from Italy, USA, Spain and Iran. The rest are spread by one article each from Turkey, Romania, Croatia, Jordan, Brazil, Saudi Arabia, France, Poland, Belarus, and Brunei Darussalam.

The psychological impact during the COVID-19 pandemic

From a total of 23 articles obtained, all agreed that frontline nurses dealing with COVID-19 pose a threat to mental health (Table 3). The psychological impacts experienced by nurses during the COVID-19 pandemic were 16 studies reporting stress (6,7,12,22,24,27,29-37,39) both emergency stress (35) to acute stress disorder (39) which are at risk of predisposing to PTSD (26), then 9 studies reported experiencing anxiety (22,23,25,26,28,30,31,34,38), six studies reported feeling fear (7,26,28,31,34,37), five studies reported depression (6,25,26,31,38), three studies reported sadness (28,30,31), two studies reported anger (28,31) and two studies reported burnout (26,34).

The risk factors for the emergence of psychological problems experienced by nurses during the COVID-19 pandemic include the majority of which can be associated with the demographic conditions of nurses, namely the young age of nurses (22,25,39) and female gender (12,25,35). Then other causes of psychological problems that are felt are only in the early weeks of carrying out duties in the COVID-19 nation (24,28,36), direct contact with COVID-19 patients (25,35), low social support (12), lack of personal protective equipment (PPE) (35), low work experience (37), unmarried status, workload and shift arrangements and physical fatigue (25).

The types of coping strategies

In overcoming the psychological problems experienced by nurses during the COVID-19 pandemic, nurses used coping strategies (Table 3). The majority of studies reported that nurses used positive attitudes towards stressful situations (7,8,12,28,29,32,33,36,38,40) and psychological counseling (6,24,25,28,30,31,39) as coping strategies for psychological problems experienced. In addition, other coping strategies used by nurses are strengthening social support (24,28,31,38), complying with protocols, using PPE and taking precautions to prevent transmission, avoiding public transportation and crowded spaces (22,23,26,28), participating in training (28,37), exercising (6,30,34), watching television, cooking, painting, listening to music (30), always keep abreast of the latest knowledge about COVID-19 (23), reading books on mental health (31) and positive religious behavior (27,34). Resilience and coping strategies play a protective role (35,40) and require safeguarding and provision of personal security measures (25,26).

Discussion

Key findings

During the early COVID-19 outbreak, nurses had various negative emotional experiences. The psychological impact experienced by nurses during the COVID-19 pandemic were varied, but can increase the risk of PTSD. This review also identified, resilience and coping strategies originating from internal and external sources play a protective role and require safeguards and the provision of personal security measures.

Strengths and limitations

In general, the information obtained from the findings of this study can help nurses to effectively cope with the mental challenges caused by the COVID-19 pandemic through adequate coping strategies. The high number of negative psychological problems that occur in nurses during a pandemic, increases the risk of mental illness in nurses. It is important to provide psychological support through mental health screening and psychological condition counseling to deal with pandemic outbreaks in the future.

This review has included mostly cross-sectional studies (17 studies included), which may not establish a causal relationship between psychological problems and coping strategies used. More longitudinal studies are needed to show a significant relationship between psychological conditions and coping strategies that can be used. Another problem is that young female nurses are represented in most of the studies. Due to selection bias and overrepresentation of certain groups, most studies may not be representative of the original population. Importantly, studies on inclusion have only been conducted in a few countries. As a result, generalizations regarding mental health in the global nursing population cannot be made.

Apart from that, an article search for this review was also carried out mainly from the four medical databases Scopus, ScienceDirect, PubMed and SAGE. This database was chosen because it tends to be free in access and has flexibility. Relevant articles obtained from this search are not exhaustive, and searches on other databases may be performed in the future to gather more evidence on the subject.

Comparison with similar researches

During the COVID-19 pandemic, the nurse’s job situation became unusual where the demands of the job were high, with great responsibility and a strong commitment to work, so that it had an impact on psychological problems that affect mental health. This study aims to explore and describe the psychological impact that occurs on nurses and the types of coping strategies used by nurses in dealing with the COVID-19 pandemic through a literature review. There are similar studies that have been carried out, but healthcare workers fighting against COVID-19 with study limitations in the western region do not focus on nurses in the wider world region (15). This study focuses on nurses, in accordance with previous research that nurses play an important role in the health system which is 60% of the total health workforce and their contribution is very beneficial to public health (31). In dealing with the COVID-19 pandemic situation, in several studies relevant to this study where the symptoms that are often experienced by nurses are anxiety, excessive worry, fear of infection, difficulty concentrating, disappointment and doubt that results in psychological stress (10,16).

In this study focusing on the COVID-19 pandemic situation requires nurses’ psychological adaptations that depend on their assessment of the situation and behavior, whether to continue to face reality or avoid this outbreak. Responding to this situation, each individual is different in responding to it, which is relevant to several other studies (12,42,43). The results of this study are in line with other research that coping strategies will affect a person’s emotions or thoughts in order to produce a good quality of life and produce a positive action, but if the use of coping strategies is not appropriate, it can produce severe psychological stress (13).

Explanations of findings

All of the articles reviewed agree that nurses on the front lines dealing with COVID-19 pose a threat to mental health, nurses experience stress (6,7,12,22,24,27,29-37,39) both emergency stress (35) to acute stress disorder (39) which are at risk of predisposing to PTSD. The prevalence of among health workers dealing with disasters, including nurses, ranged from 14.6% (44). Nurses caring for COVID-19 patients have an increased risk of experiencing secondary trauma symptoms (10,45). Follow-up of in nurses and preventing it from developing into PTSD requires referral to appropriate psychological services (39). It is necessary to implement urgent interventions aimed at increasing the activation of protective factors that can reduce and prevent the development of serious psychological consequences (35,42).

Other psychological impacts experienced by nurses who handle COVID-19 in the articles reviewed are feeling anxiety (22,23,25,26,28,30,31,34,38), fear (7,26,28,31,34,37), depression (6,25,26,31,38), sadness (28,30,31) and anger (28,31). In the early stages, negative emotions dominate then positive emotions appear gradually (7,8,40). Several studies have shown that individuals experience four stages of mental development when responding to stress, namely shock, followed by defense, resolution, and growth (40). Thirty-six-point-nine percent of nurses experienced mental health disorders below the threshold immediately after the COVID-19 epidemic occurred, which were divided into three categories, namely experiencing mild mental health disorders (34.4%), moderate (22.4%) and experiencing severe disorders (6.2%) (31).

Based on the results of the literature review, the risk factors for the emergence of psychological problems experienced by nurses during the COVID-19 pandemic can be mostly associated with the demographic conditions of nurses, namely the young age of nurses (22,25,39) and female gender (12,25,35). Young people are more likely to use ineffective coping strategies during an outbreak (46). One possibility is that brain aging affects emotional responses. Older adults were found to be less likely to exhibit negative emotional experiences (39). Many articles related to trauma due to psychological stress show that women have higher psychological distress than men (13,47). In addition, a greater number of women are represented in the nursing profession (48-50).

Then other causes of psychological problems that are felt are only in the early weeks of carrying out duties in the COVID-19 nation (24,28,36), direct contact with COVID-19 patients (25,35), low social support (12), lack of PPE (35), low work experience (37), unmarried status, workload and shift arrangements and physical fatigue (25). Mental health problems that arise in nurses who work in the covid isolation ward are stress (26.09%) which appears on the 7–10 days after they work in the room. Then the number of nurses experiencing stress decreased (9.30%) in the COVID-19 isolation ward after 60 days (24). The lack of PPE and the uncertainty experienced in the early phase produced a predictive effect in terms of increasing stress levels (35,43,51). Years of nursing experience are protective against stress from situations of overwork, inadequate preparation, and fear of infection (37).

In overcoming the psychological problems experienced by nurses during the COVID-19 pandemic, nurses use coping strategies. The majority of studies reported that nurses used positive attitudes towards stressful situations (7,8,12,28,29,32,33,36,38,40) and psychological counseling (6,24,25,28,30,31,39) as coping strategies for psychological problems experienced. Always be positive at work as a strategy with a great impact in reducing stress (12,52). Functional coping strategies allow individuals to reinterpret negative situations in a positive way, which is closely related to self-efficacy, greater psychological well-being, and better quality of life (12). Frontline nurses dealing with COVID-19 require special attention, so hospitals should offer timely counselling, identifying high-risk individuals with common screening tools (24,53,54).

Implications and actions needed

Coping strategies based on the literature obtained reveal that nurses make efforts to strengthen social support (24,28,31,38), washing hands, wearing face masks, avoiding public transportation and crowded spaces (22,28), participating in training (28,37), exercising (6,30,34), watching television, cooking, painting, listening to music (30) and reading books on mental health (31). Resilience and coping strategies play a protective role (35) and require safeguarding and provision of personal security measures (25). In addition, the existence of family support becomes an important part of the social support system and can effectively reduce negative emotions and encourage positive responses (55,56).

Regarding the mental problems experienced by nurses during the COVID-19 pandemic, there is a need for social and organizational support for adaptation to the situation that occurs. Previous experience with pandemics and similar training is suggested as a useful coping strategy for health workers during a pandemic, in addition to provision of PPE, testing kits, orientation of worker training, work shift arrangements, provision of online counseling, provision of food and accommodation and prompt payment of benefits by management health services to nurses, provision of rooms for online consultation with psychologists/psychiatrists and easy access to social facilities and religious activities are important protective measures.

Managers in health care organizations need to recognize that primary prevention is the key to the success of any intervention to contain and control any epidemic. Thus, regular training with such objectives needs to be planned, oriented and ongoing based on proven infection control measures. These measures need to be supported by the timely provision of protective equipment, medicines, testing facilities, vaccines, isolation facilities, clinical and mental health support, and the welfare of health workers.

Conclusions

The COVID-19 pandemic which quickly spreads and infects humans can cause a heavy psychological impact on nurses. This review can inform current and future research priorities in the psychological impact of nurses in dealing with the COVID-19 pandemic. The COVID-19 pandemic situation has had a negative psychological impact on nurses. Nurses experience mental conditions ranging from stress, feeling fear, depression, sadness and anger. Appropriate and effective positive coping strategies can maintain the mental health and quality of life of nurses. More and more extensive studies are still needed to understand the coping strategies that nurses can use for the level of mental health problems experienced during the COVID-19 pandemic. Nurses in clinical settings need to be given the role and reinforcement regarding effective coping strategies to deal with stress and burnout conditions during the COVID-19 pandemic.

Acknowledgments

The authors would like to acknowledge the authors of sources used in this study.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Li Ping Wong) for the series “Psychological and Physical Impacts of COVID-19 Pandemic” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-22-57/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-22-57/coif). The series “Psychological and Physical Impacts of COVID-19 Pandemic” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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