Impact of COVID-19 in nursing professionals: systematic review and meta-analysis

Impacto da Covid-19 em profissionais de enfermagem: revisão sistemática e meta-análise

Impacto del Covid-19 en los profesionales de enfermería: revisión sistemática y metanálisis

Tamires Patrícia Souza tamirespatriciasouza@gmail.com

Universidade Metodista de Piracicaba, Brazil

Maíra Rossetto mairarossetto@gmail.com

Universidade Federal da Fronteira Sul, Brazil

Carlos Podalirio Borges de Almeida carlos.almeida@unifesspa.edu.br

Universidade Federal do Sul e Sudeste do Pará, Brasil

Nurses and midwives constitute approximately 50% of the health workforce, which represents 20.7 million people worldwide (World Health Organization - WHO, 2021). These professionals work in various sectors, be they public, private, philanthropic, or educational institutions. Although it is a traditional profession, with significant influence in science and health care work, nursing professionals often face heavy challenges in their daily work such as low prestige, poor public perception, low financial recognition, work overload, stressful working conditions, and the lack of professional gratification. In addition to the shortage of nursing staff and the poor quality of training and education (Mishra, 2015).

This situation became even more evident during the coronavirus pandemic. Nursing professionals stood out by acting on the front line of patient care, which exposes them to extremely stressful situations (Lam et al., 2020). The outbreak of cases with the consequent collapse of the health services overwhelms all health care workers, especially the nursing team (Lam et al., 2020). The impact on workload has led to longer hours and nurses being more tired from work (Cotrin et al., 2020; Irshad et al., 2020; Labrague and Los Santos, 2020a). In Brazil, there are currently about 583,682 nurses, and more than 1,379,000 nursing technicians, assistants, and attendants (Solidarity Research Network, 2021). In the context of the pandemic, a total of 49,86 reported cases of COVID-19 were observed among nursing professionals. The lethality rate was 2.31%, which corresponds to one third of COVID-19 deaths worldwide (Conselho Federal de Enfermagem - COFEN, 2021; Sant’ana, 2020).

For these reasons, nursing work has been extremely demanding, with a significant increase in the magnitude and intensity of it, requiring healthcare workers to learn and adapt new health protocols, and constant changes in disease management (Lam et al., 2020). This source of insecurity and anxiety is exacerbated as more healthcare workers are affected by the disease, requiring them to be in quarantine (Gómez-Durán, Martin-Fumadó and Forero, 2020).

Recognizing this atmosphere can create significant stress and can affect health and well-being, this systematic review and meta-analysis aimed to assess the health impacts of the COVID-19 pandemic on nursing professionals.

We included studies that evaluated the health impacts of the COVID-19 pandemic on nursing professionals.

Eligible study designs were randomized clinical trials, cohort and/or case-control, and cross-sectional. Studies that did not fulfill inclusion criteria, such as qualitative studies, articles only related to methodological research, and those that did not involve human beings were not included.

Studies were identified by searching the databases Web of Science, PubMed, and SciELO. Papers published in English, Portuguese, Spanish, and French were included. The publication period was the year 2020, and the search was performed between December 2020 and January 2021.

Following search terms were used: (“COVID-19” OR “coronavirus” OR “sars-cov-2”) AND (“nurse” OR “nurs*”) AND (“health impacts” OR “health outcomes” OR “outcomes”), using the Boolean operators according to the databases used.

In the first phase, a data search was performed by the author TPS using the selected databases and keywords. In the second phase, the authors CPBA and MR analyzed the title, abstracts, and objectives of the studies, selecting those that fit the inclusion criteria. In concluding this phase, the authors met to compare their findings, and discussed the disagreement with the author TPS to help the final decision. The degree of agreement between the authors for the selection of the studies was >0.80, which indicates an almost perfect agreement (Landis and Koch, 1977).

In the third phase, all the authors read independently the studies in full and, subsequently, they met again to compare their findings. The degree of agreement between the authors for the third phase was >0.61, which indicates substantial agreement (Landis and Koch, 1977). And, finally, in the fourth phase, CPBA and MR extracted the data into a data set. Duplicate articles were excluded, and the disagreements were discussed to reach a consensus. The study selection process is illustrated in Supplementary I.

The authors extracted the following data from the selected studies: Authors; Year; Country; Title; Objective; Study design; Participants; Sample size; Results; How was the risk reported (OR/RR/HR); Journal and Impact Factor (Table 1 and Table 2). The process of study selection was performed by using the methods according to the PRISMA guidelines, presented in the flow diagram (Figure 1).

Figure 1
Flow diagram of study selection corpus.
Source: Prepared by the authors.

We executed a meta-analysis for all variables that were reported by more than one study. The BioEstat software was used to perform the analysis, and the association of binary variables and psychological distress was assessed by odds ratios (ORs) and 95% Confidence Interval (CI). We used fixed-effects models (Mantel-Haenszel and odds ratio) for all meta-analyses. We used data from the most fully adjusted model when the study presented more than 1 regression model. The heterogeneity for all pooled estimates was performed through visual inspection of forest plots because statistical tests of heterogeneity can be delusive when sample sizes are large and CIs are therefore squeezed (Rucker et al., 2008).

For meta-analyses with at least 10 studies, we assessed publication bias by visual assessment of asymmetry of the funnel plot and performed the Begg rank correlation test (Begg and Mazumdar, 1994). The risk of bias and quality of the evidence in included studies was assessed by The Newcastle-Ottawa scale, modified for cross-sectional design (Supplementary II) (Wells et al., 2000).

We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to summarize the quality of evidence for all meta-analyses (Atkins et al., 2004). We categorized the confidence in estimates (quality of evidence) as high, moderate, low, or very low, based on the risk of bias (Guyatt et al., 2011a), imprecision (Guyatt et al., 2011b), indirectness, inconsistency (Guyatt et al., 2011c) and publication bias (Guyatt et al., 2011d). We used GRADE evidence profiles to provide a succinct, easily digestible presentation of the quality of evidence and magnitude of associations (Atkins et al., 2004).

This study is based on published data, and therefore ethical approval was not a requirement. This systematic review and meta-analysis are expected to serve as a basis for evidence to improve health quality between nursing professionals, and as a guide for future research based on identified knowledge gaps. It is anticipated that findings from this review will be useful for informing policy, practice, and research priorities, improving the management of nursing professionals’ health. We also plan to update the review in the future to monitor changes and guide health services and policy solutions.

In this study, we assessed the impact of the COVID-19 pandemic on the nursing professionals’ health. The initial search identified 2,212 possible articles which were transferred to Mendeley®. We excluded four duplicates and at the screening stage, 2,175 articles were removed considering the inclusion criteria. At the eligibility evaluation phase, out of the remaining 33 studies, eight articles were removed after the examination of their full text, by considering the inclusion and exclusion criteria. A PRISMA diagram detailing the study retrieval process is shown in Figure 1. We considered for meta-analysis the results of 2 articles (Figure 2).

Figure 2
Association between frontline workers and psychological distress among nursing professionals.
Source: Prepared by the authors.

All studies included were published in 2020 and have a cross-sectional design. Twenty studies, which correspond to 80% of publications were from Asia, being 13 from China, two from the Philippines, and one publication from each of the following countries: Korea, Nepal, Turkey, Israel, and Pakistan. Studies from Europe represent 12% of our analyses, being one from Germany and Malaysia, one from Croatia, and one from Spain. In Latin America, Brazil had two publications, corresponding to 8% of the total.

Regarding study participants, 68% were nurses or nursing teams, and 32% were other health professionals attending COVID-19 patients. In the sample size of each study, 52% were composed of up to 500 participants, 20% were composed of 500 to 1,000 participants, and 28% were composed of over 1,000 participants, thus totaling 36,665 participants included in the review. A summary of the characteristics of the studies is presented in Table 1.

Table 1
Publication profile according to authors, local of study, year of publication, study design, participants, sample size, journal, and impact factor.

Source: Prepared by the authors.

According to the scope of the journal chosen for the author of each study, 56% were in the nursing field, 32% in the medical field, and 12% in the public health field. The impact factor of the journals ranged from 0.20 to 45.0, with a median of 2.10.

The studies presented approximately 73% of non-risk bias. The Newcastle-Ottawa results are shown in Supplementary II. The meta-analysis of psychological distress variables is shown in Figure 2.

Problems related to the mental health of nursing workers

Mental health disorders were estimated in 15 studies (Aksoya and Koçak, 2020; An et al., 2020; Cai et al., 2020; Chen et al., 2020; Cotrin et al., 2020; Dal’Bosco et al., 2020; Huang et al., 2020; Irshad et al., 2020; Khanal et al., 2020; Lai et al., 2020; Nie et al., 2020; Salopek-Žih et al., 2020; Si et al., 2020; Xie et al., 2020. Yang et al., 2020). The characteristics of the main results and conclusions of each study can be found in Table 2.

Table 2
Objective, main results, and conclusions of each study included.

Source: Prepared by the authors.

The main symptoms presented were depression and discouragement (40%) (An et al., 2020; Dal’Bosco et al., 2020; Khanal et al., 2020; Salopek-Žih et al., 2020; Si et al., 2020; Yang et al., 2020), anxiety (53%) (Aksoy and Koçak, 2020; Dal’Bosco et al., 2020; Huang et al., 2020; Irshad et al., 2020; Khanal et al., 2020; Salopek-Žih et al., 2020; Si et al., 2020; Yang et al., 2020), concern (27%) (Cai et al., 2020; Chen et al., 2020; Huang et al., 2020; Nie et al., 2020), insomnia (13%) (Cotrin et al., 2020; Khanal et al., 2020), and stress (27%) (Nie et al., 2020; Salopek-Žih et al., 2020; Si et al., 2020; Xie et al., 2020).

Assessing nursing professional studies, some results demonstrated the depression symptoms are related to smoking habits, years of work, hospital characteristics, and the work sectors, and direct patient contact (An et al., 2020; Nie et al., 2020; Salopek-Žih et al., 2020; Si et al., 2020; Xie et al., 2020). Nurses presented anxiety more frequently than other health professionals, and this symptom was also more prevalent than others, such as depression and insomnia (Khanal et. al., 2020; Si et al., 2020). The closest contact of a COVID-19 zones, the strongest is the anxiety, anger, and other mental issues, which is more frequent to female participants (Irshad et al, 2020; Huang et al., 2020; Lai et al., 2020; Si et al., 2020). Difficulties to deal with family and personal life due to the COVID-19 pandemic were related to low and moderate anxiety symptoms (Aksoy and Koçak, 2020; Cai et al., 2020; Chen et al., 2020; Nie et al., 2020; Yang et al., 2020). Some studies showed the participants’ concerns about being infected with Coronavirus, as well as the risk of their families also being infected (Cai et al., 2020, Chen et al., 2020; Nie et al., 2020).

Based on our methodological criteria, we conducted meta-analyses just for psychological distress variables (Figure 2). Very low-quality evidence showed no association between psychological distress and being a frontline worker (OR 0.94; 95%CI 0.33-2.67) (Table 3).

Table 3
Grading of Recommendations Assessment, Development, and Evaluation Evidence Profile: association between frontline workers and psychological distress.

Source: Prepared by the authors.

As for work overload and professional evaluation, it has also been identified in studies of social and professional obligation to continue working long hours (Cai et al., 2020) and 74.7% of the professionals did not believe they have the right to refuse to treat certain patients (Sperling, 2020).

Regarding the systematic review, we included 25 studies with a cross-sectional design. The studies were carried out across 12 different countries, and the participants were mostly nurses or nursing teams. We submitted the studies to quality and bias analysis to identify their potentiality to be inserted in this review, although they had a cross-sectional design.

From the analysis of the studies, it was identified that the prevalence rates of depression, anxiety, and insomnia of healthcare professionals had increased in this pandemic scenario (Holmes et al., 2020, Pappa et al., 2020). Nursing professionals are the biggest part of the frontline workforce (Teixeira et al., 2020, Fawaz, Anshasi e Samaha, 2020), thus we decided to investigate the health impact specifically on this professional category. The main risks to be considered are exposure to the virus, long working hours, psychological impact, fatigue, professional burnout, stigma, and violence, both physical and psychological (WHO, 2020).

Nurses from the surgical units and those with good professional perceptions were more willing to participate in fighting the pandemic than those professionals who do not have a good perception of the profession (Woo et al., 2020). The psychological well-being and satisfaction of nursing professionals can also act positively in the inclusive leadership role and in fighting the pandemic (Zhao, Ahmed e Faraz, 2020), being another important characteristic of the profession. Another positive impact of the pandemic was the recognition of the profession worldwide (Missel et al., 2020). The year 2020 had been elected as the year of Nursing and several movements were being organized to give visibility to the profession, but it was the pandemic that made these professionals so notable (Treston, 2020).

However, according to our results, the mental health of nursing professionals was extremely affected by the COVID-19 pandemic, increasing depression, discouragement, anxiety, and other mental issues (An et al., 2020; Aksoya and Koçak, 2020; Cai et al., 2020; Chen et al., 2020; Cotrin et al., 2020; Dal’Bosco et al., 2020; Gan et al., 2020; Huang et al., 2020; Irshad et al., 2020; Khanal et al., 2020; Labrague and Santos, 2020a; Labrague and Santos, 2020b; Lai et al.; 2020, Li et al., 2020; Nie et al., 2020; Nienhaus and Hod, 2020; Salopek-Žih et al., 2020; -García-Sierra et al., 2020. Si et al., 2020; Sperling, 2020; Wu et al., 2020; Xie et al., 2020; Yang, Kwak e Chang, 2020; Zhang et al., 2021. Zhao et al., 2020). The results are reinforced by studies suggesting that medical and nursing staff were more suitable to present high levels of anxiety and depressive symptoms (Bohlken et al., 2020). Burnout syndrome, anxiety, and mental exhaustion were also described in healthcare workers (Cheung, Fong and Bressington, 2021).

This impact is not only felt by front-line workers, as was identified by our meta-analysis (Nie et al., 2020; Lai et al., 2020). Nursing professionals from other departments and healthcare workers from other specialties are also suffering from mental distress caused by the COVID-19 pandemic, including surgeons, anesthesiologists, and dentists (Cotrin et al., 2020; Xu et al., 2020).

Nurses had assumed several professional roles that encompass direct patient care, educational and epidemiological practices, and health services management (Treston, 2020). And situations already experienced by them worsened, leading to extreme fatigue and overload during the work process (Kang and Shin, 2020; Teixeira et al., 2020). They frequently feel overwhelmed and undervalued in their work environment, and the consequences of these factors are often severe, affecting the way people work and live, and because they account for a complex network of activities (Missel et al., 2020). The expected profile of the profession, even today, seems to be that of the early days of Nursing, with professionals feeling a social and professional obligation to continue working for long periods (Cai et al., 2020).

The increase in workloads may be linked to the precariousness and deficits in the work environment, materials, and equipment, added to the numerical deficit of the workforce and excessive demand for caring people (Biff et al., 2020). Overwork increases the risk of high rates of turnover, absenteeism, and burnout syndrome, which already affect a high parcel of nursing professionals (Silveira et al., 2016; Duarte and Pinto-Gouveia, 2017; Woo et al., 2020). It has also been associated with decreased job satisfaction (Labrague and Santos, 2020a). Job satisfaction is a complex phenomenon, and it can be influenced by several aspects related to work, such as aspirations, sadness, and happiness of the individuals, thus affecting their attitude towards themselves, their family, and the organization (Oliveira et al., 2019). It is also important to point out that there is a negative association between job satisfaction and work overload, that is, as one increases the other decreases (Dias and Furegato, 2016). Thus, being dissatisfied with work overload and its precarious conditions often leads to physical and mental exhaustion, influencing productivity, performance, absenteeism, turnover, organizational citizenship, health and well-being, life satisfaction, and user satisfaction (Suyantiningsih, Haryono and Zami, 2018).

As the pandemic progressed, access to adequate personal protective equipment (PPE) became a concern worldwide, which exposed healthcare workers to the imminent risk of contracting the disease in their workplaces (Silva et al., 2020; Khanal et al., 2020; Sperling, 2020). The rapid spread of the new coronavirus around the world has also increased the need for health services to be prepared to protect health workers in the performance of their duties since they are potential sources of disease dissemination (Edwards, Tomba and Blasio, 2016; Baker, Peckham e Seixas, 2020; Miranda et al., 2020, Teixeira et al., 2020). In Brazil, the situation of nursing professionals is worrying and may be related to the lack of structure of health services to face pandemic situations. The existence of public and free Sistema Único de Saúde (SUS) guarantees universal access to all levels of care and support in critical situations. However, the ceiling on public spending and management problems at the federal level have generated underfunding of SUS and caused a dire situation in the assistance of coronavirus. In addition to ever-increasing numbers of cases and deaths, lack of intensive care beds, the collapse of the SUS at all levels of care, illness, and lack of professionals (Noronha et al., 2020; Teixeira et al., 2020).

There is a need for commitment of the institutions with their workers. The organizational support offered by the institution can prevent anxiety, with the supply of materials, equipment, and training related to COVID-19 reducing stress and fear (Labrague and Los Santos, 2020b). Training to face moments of crisis is important to decrease anxiety and give greater satisfaction in the work environment (Labrague and Los Santos, 2020b; Li et al., 2020). And situational analysis would be a determining factor in preventing the illness of these professionals since it could help manage the risks for contamination by the new coronavirus (Baker, Peckham and Seixas, 2020).

It is necessary to conduct thorough planning, considering the mechanism of contamination, illness, and also mortality due to this exposure (Silva et al., 2020). This planning should consider serological screening, quarantine systems, guidance on the proper use of PPE, including in situations where asymptomatic patients are seen, and also organization for the reduction of horizontal transmission among workers, and also through their families (Silva et al., 2020). It must be emphasized that the safety of health care workers is critical to being able to serve people in need of health interventions (Huh, 2020). In situations of health crises like the ones we are experiencing, public health care policies should be considered as priorities, those professionals with an increased risk of becoming contaminated due to environmental exposure to the pathogen, especially health care professionals (Baker, Peckham and Seixas, 2020).

Although the results of the analysis provided good insight into the impacts of COVID-19 on nursing professionals during the pandemic, our study has some limitations. Some of them are related to the selection of only primary studies, in only three databases and with a final sample of publications in English (although they could be selected in Portuguese, Spanish and French).

In conclusion, the COVID-19 pandemic has negatively impacted the mental health of nursing professionals. The main symptoms presented were anxiety, depression, and discouragement. Moreover, many nurses felt obliged to work in the front line of fighting the pandemic; although they suffer from emotional impacts and work overload in the health services. The pandemic also revealed weaknesses in the organization and planning of health services in several countries around the world. The number of cases of infection and deaths may denounce the absence of planning, the lack of personal protective equipment, and the little investment in the qualification of nursing professionals.

The authors thank all healthcare workers, especially nursing professionals, for their valuable contribution and dedication in fighting to defeat this pandemic.