Nurses’ caring experiences in COVID-19 pandemic: A systematic review of qualitative research

Nurses, as front-line care providers, strive to offer adequate care to their clients. They have acquired valuable experiences during the COVID-19 pandemic that enhance the nursing profession. This study aimed to explore nurses' caring experiences in the COVID-19 pandemic. This is a qualitative meta-aggregative systematic review. Electronic databases (Google Scholar, PubMed, Web of Science, CINHAL) in English were searched to find out the meaningful subjective data on the COVID-19 pandemic. The inclusion criteria were studies published in English related to nurses' caring experiences in the COVID-19 pandemic. Seventeen qualitative studies with several approaches were included. Three key themes were identified from the studies: Weaknesses and strengths of nursing at the beginning of the pandemic, Nursing beyond challenges related to the pandemic, and Family and career challenges. Nurses face different challenges in caring for patients with COVID-19 that benefit the health and nursing professions. Governments, policymakers, and managers have to support nurses during and after the pandemic. Without enough support, nurses are likely to experience significant psychological issues that can lead to burnout and frustration.


Introduction
COVID-19 was first diagnosed in December 2019 in people with pneumonia in Wuhan, China [1] . COVID-19 began with a variety of symptoms, including respiratory and gastrointestinal symptoms, and symptoms ranged from mild to severe dyspnea, septic shock, and even defects in various organs of the body [2] . The disease was unknown, until March 11, 2020, the World Health Organization declared the disease as the COVID-19 pandemic. As of May 15, 2022, more than 520 million people in the world have been infected with this disease, and the death toll has exceeded 6 million people [3] . WHO estimates that between 80 and 180 thousand, with a medium of 115.5 thousand, health care providers have died from COVID-19 in the period between January 2020 to May 2021 [4] .
COVID-19 pandemic has severely shocked the health care systems in most countries. Nurses, as the front line in the fight against CVID-19, are involved in issues such as screening, collaboration in treatment,

Research question
What are the nurses' caring experiences for patients in the COVID-19 pandemic?

Design
In this qualitative meta-aggregative review, we polled, compared, and then summarized nurses caring experiences in COVID- 19. The steps were conducted as follows: developing the research question as "What are the nurses' experiences in caring for patients in the COVID-19 pandemic? ", searching the literature for the evidence systematically, doing a critical appraisal of included studies, aggregating the findings, developing categories, and further synthesizing the themes [16] .

Inclusion criteria
Qualitative studies were addressing nurses' caring experiences during the COVID-19 pandemic. No limits were placed on the year of publication. Only English publications were included. The article's title was on nurses' caring experience for patients with the COVID-19 pandemic. The nurses who participated in the reviewed studies were registered nurses at the front line of the COVID-19 pandemic, caring for COVID-19 patients for more than one month, and voluntarily participating in the studies.

Excluded criteria
Systematic reviews and quantitative as well as qualitative studies addressing the experiences of other health care professionals were excluded from the study.

Searching
In this systematic review, the eligible qualitative studies addressing nurses' caring experiences in COVID-19 in English were selected only. It was decided to review the studies of nurses' caring experiences published on reputable databases such as Google Scholar, PubMed, Web of Science, and CINHAL. The article search was conducted from the beginning of the COVID-19 pandemic in 2019 to the end of 2021. To maximize the search universality, the search was conducted for Latin and MeSH keywords including "coronavirus ", "qualitative research ", "nursing * ", "experience * ", "SARS-COV-2 ", "COVID-19 ", "caring ", and all possible combinations of words made by and/or operators in the introduced databases. The abstracts of studies were reviewed for inclusion and exclusion criteria. Then, the full texts were evaluated. After the search was carried out, all resultant studies were reviewed in the screening and selection process. In the next step, studies were processed considering the aim of the research. Search strings used in PubMed: (

Quality assessment, data extraction, and synthesis
The critical appraisal skills program (CASP) checklist was employed to assess the quality of qualitative studies. This 10-item instrument checks the results, validity, and usefulness of qualitative studies ( Table 1 ) [17] .
Information was extracted and compared by two of the authors. Data were technically extracted and observational characteristics were included research question, sampling and recruitment, observed population, statistics collection, and data analysis. We used a thematic evaluation technique to synthesize the qualitative statistics [18] . Thematic qualitative statistics were coded from the studies' findings, including costs from contributors and observing the authors' interpretations. The issues were inductively prepared under the headings for reporting. Data extraction, coding, and synthesis were achieved by two reviewers. MAXQDA was used for statistical control.

Risk of bias
We assessed the risk of bias using criteria developed by Hawker and colleagues [19] , which have been used in a range of reviews. Their critical appraisal tool allows for the methodological rigor of each empirical study to be assessed through assigning ratings (very poor, poor, fair, good) across nine categories: abstract and title, introduction and aims, method and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalizability, implications and usefulness [19] . The Hawker Tool was included in a full-text practice review by three authors. They discussed and resolved any disagreement about usage, performed the quality assessment on all included studies, and together clarified minor uncertainties at the end of the process.

Specifications of papers
Of 156 extracted papers from databases, 10 were redundant. After two research team members conducted the initial review, 120 papers were deleted because their titles and/or abstracts did not meet the inclusion criteria. In the second screening step, 17 of 26 full-text publications met the inclusion criteria ( Fig. 1 ).
The demographic characteristics of participants such as age, gender, and the number of participants (353 participants in all papers) varied from 5 to 43 participants. All articles were qualitative, mixed-method, and phenomenological, which applied content or thematic approach. The purposive sampling technique was used in all studies. The publications' data were collected through semi-structured interviews and were analyzed using the content and thematic analyses, and Colaizzi's method ( Table 1 ).

Results of data synthesis
Thirty findings were obtained from the eligible studies. All findings were checked in terms of validity or invalidity. Due to the similarities mentioned by citations in papers, 3 findings were categorized as 13 classes. Finally, three synthesized findings were obtained: Weaknesses and strengths of nursing at the beginning of the pandemic, nursing beyond challenges related to the pandemic, and Family and career challenges ( Table 2 ).
The studies were carried out in Asian countries with approximately the same history in socioeconomic, cultural, and health. Asia is the biggest continent with half of the world's population resides. The incidence of COVID-19 was very high in some less developed countries, leading to many deaths.

Discussion
This systematic review of qualitative studies explores nurses' caring experiences in the COVID-19 pandemic. There are three synthesized findings on nurses' caring experiences in the COVID-19 pandemic as follow: Weaknesses and strengths of nursing at the beginning of the pandemic, nursing beyond the challenges of the pandemic, and family and career challenges.
During the pandemic, nurses experience many issues such as changes in the workplace for offering care to the clients, therefore, nursing weaknesses and strengths emerge, and their medical care attempts for pa-tients are affected by governmental policies. In other words, the importance of nursing care is highlighted during the pandemic.
Nursing weaknesses and strengths emerge during the pandemic outbreak and nurses' intervention until the stabilization of work conditions. Nurses have experienced a knowledge deficit, a lack of preparedness to manage the pandemic, and shortages of staff, facilities, and equipment. Besides, people admire nursing services during the pandemic and realize the nursing profession is valuable to humanity. Moreover, positive aspects of nurses' work such as teamwork, compassion, and sacrificing themselves to save patients' lives are prominent in health systems. Considering the findings of a study consistent with the results of this study, nurses' lack of knowledge of the COVID-19 pandemic, shortages of personal protective equipment, and lack of managing protocols directly affect nurses' roles and result in problems in providing proper care [36] . Nurses mainly face challenges such as the risk of infection transmission, shortage of resources, workplace change, lack of knowl- edge, doubt, and fear which leads to low performance and quality of care services [37] . During the COVID-19 pandemic, nurses' responsibilities changed due to the increasing number of patients need intensive medical care. The shortage of nurses has prolonged working shifts and has increased nurses' duties [38] . In normal conditions, nurses experience workload and in a deadly pandemic, they are likely to face even more uncertain conditions is higher and the nursing profession is more highlighted than before [39] . Nursing beyond challenges related to the pandemic includes the following subcategories: The shortage of medical facilities and staffing, excessive expectation of nursing, and nursing in the treatment frontline. The COVID-19 pandemic places nurses on the treatment frontline and increases their managers' expectations. The managers and caregivers expect standard care from nurses despite shortages of safety equipment. Therefore, nurses have to stay a long time in the hospital to cover personnel shortages and save the existing protective equipment to compensate for further shortages. Protecting and maintaining the health of staff during the COVID-19 pandemic is crucial for health care institutions, particularly in Intensive Care Units, where high-qualified nurses and staff cannot effectively supplant [40] .
Given suitable conditions for nurses to work in the pandemic, one of the critical assignments of health policymakers is to control the infection chain. The staff's contamination and death seriously influence nurses' workload and the health care system [41] . Health care systems cannot fulfill the clients' needs unless enough facilities and staff are available [42] . Besides, during the pandemic, nurses experience workload, fear, high pressure, anxiety, helplessness [43] , sleep disorders, depression [44] , and many potential or actual problems [45] . The pandemic causes dangerous work environments for the medical staff, puts too much pressure on nurses, and threatens them. Nurses are a potential source of infection. Considering the high pressure, nurses experience psychological problems. The shortage of staff prolongs their working hours. As a result, they experience physical complications and occupational burnout. They also feel fearful and anxious when they take care of patients because of the risks of the disease. Nurses have experienced posttraumatic stress disorder [ 46 , 47 ], emotional fatigue, burnout, muscle aches, and mental problems after COVID-19 [48] .

Strengths and limitations
There were a few limitations in the interpretation of the current systematic review findings. First, probably, the main experiences or results might interpret incorrectly when qualitative data are synthesized from different sources. To minimize this possible error, a regular method was followed. Second, it is probable that the search strategy cannot identify all of the relevant papers because more results might be extracted by selecting other keywords. In addition, searching a larger number of more specialized databases can help find more relevant papers. Searching in other languages rather than English can also result in finding new papers.
The strength of this study is the specialty of the research team in qualitative studies. The extracted themes resulted from their intellectual integration, presumably including different areas of nursing, patients, and healthcare systems. The reviewed research results were aggregated into these areas.
Considering the COVID-19 pandemic conditions, the results of this systematic review can help increase our knowledge and provide authorities with information on nurses' experiences in other pandemics to benefit from the results in the current conditions. This study also shows appreciation to the nurses who are always serving those who need help on the frontline of crises, wars, and pandemics through sacrifice and bravery.

Conclusion
This systematic review of qualitative studies was conducted in different countries by providing an aggregated outlook of nurses' caring experiences in the COVID-19 pandemic. This study helps nurses provide better healthcare services and comply with safety instructions.
There are similarities and differences in nurses' caring experiences during the pandemic in countries. Nurses face many challenges and advantages in providing nursing services during the pandemic. At the same time, they try to take care of patients better by following healthcare protocols in addition to complying with safety and protection instructions.
This review extends the perception of nurses' experiences and can lay the foundations for expanding knowledge and developing the nursing profession by determining more research areas in the COVID-19 pandemic.
Governments, policymakers, and nursing managers are called upon to take an active part in supporting nurses, both during and after the pandemic. Without this, nurses are likely to experience significant psychological issues that can lead to burnout and loss of the nursing workforce.

Funding source
None.

Declaration of Competing Interest
No conflict of interest to declare.