Psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic - A qualitative systematic review

Background Frontline nurses have been directly exposed to the SARS-CoV-2 virus and come in close contact with patients during the COVID-19 pandemic. Nurses execute tasks related to disease control and face multiple psychosocial challenges in their frontline work, potentially affecting their mental well-being and ability to satisfyingly perform their tasks. Objectives To explore the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic. Design The qualitative systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Registered in PROSPERO (CRD42021259111). Data sources Literature searches were performed through PubMed, CINAHL, and the WHO COVID-19 database. Inclusion criteria were: All types of nurses having direct contact with or taking care of patients; Primary, secondary, and tertiary health-care services admitting and treating COVID-19 patients; Experiences, perceptions, feelings, views in psychosocial aspects from the identified population group; Qualitative studies; Mixed methods studies; Language in English; Published date 2019–2021. Exclusion criteria were: Commentaries; Reviews; Discussion papers; Quantitative studies; Language other than English; Published in 2018 or earlier; Studies without an ethical approval and ethical statement. Review methods The studies were screened and selected based on the inclusion and exclusion criteria. Quality appraisal was conducted according to the Critical Appraisal Skills Program qualitative study checklist. Data was extracted from included studies and a thematic synthesis was made. Results A total of 28 studies were included in the review. The experiences of 1141 nurses from 12 countries were synthesised. Three themes were constructed: ‘Nurses’ emotional, mental and physical reactions to COVID-19′, ‘Internally and externally supported coping strategies’, and ‘A call for future help and support’. Conclusion Nurses working frontline during the COVID-19 pandemic have experienced psychological, social, and emotional distress in coping with work demands, social relationships, and their personal life. The results pointed to a need for increased psychological and social support for frontline nurses to cope with stress and maintain mental well-being, which may subsequently affect nursing care outcomes.


Introduction
The World Health organisation (WHO) declared the outbreak of the SARS-CoV-2 virus that causes coronavirus disease  to be a Public Health Emergency of International Concern and to be characterised as a pandemic (World Health Organization 2020).Common symptoms of COVID-19 are fever, dry cough, and shortness of breath (World Health Organization 2020).Besides, the SARS-CoV-2 virus attacks the lungs, and can infect the heart, kidneys, liver, brain, and intestines (World Health Organization 2020).The virus is mainly spread through saliva droplets or discharged from the nose when an infected person coughs or sneezes (World Health Organization 2020) and by airborne transmission through aerosols (Klompas et al., 2020).Healthcare professionals are the main personnel involved in screening and treatment on the frontline of the COVID-19 pandemic (Spoorthy et al., 2020).Frontline healthcare professionals are here defined in line with Nguyen et al. (Nguyen et al., 2020) as individuals who reported direct patient contact.
As the major component of the hospital workforce in relation to the COVID-19 pandemic, nurses care for all types of patients and have most contact with COVID-19 infected patients (Schroeder et al., 2020, Gesesew et al., 2021).Frontline nurses are directly exposed to the SARS-CoV-2 virus and come in close contact with patients in care situations, undertaking most of the tasks related to the control of the COVID-19 pandemic (Hu et al., 2020).As such, nurses themselves are at high risk of being infected with COVID-19 (Fernandez et al., 2020, Liu et al., 2012).The COVID-19 pandemic has led to an unforeseen shift in nursing practice to meet the sudden increase in demand for pandemic-related care (Schroeder et al., 2020).Personal protective equipment (PPE) creates barriers to the efficacy of nurse-patient communication and physical contact, including restricted contact between patients and their family members (COVID-19: Changing the Face of the Nurse-Patient Relationship 2020).It means that frontline nurses are unable to provide adequate services to patients in the way they were taught and expected to, resulting in increased pressure for the nurses and dissatisfaction with their work (COVID-19: Changing the Face of the Nurse-Patient Relationship 2020).Studies show that nurses experience mental and physical stress at work, with subsequent negative health effects, when facing excessive workload, ambiguity in roles, and interpersonal conflict in their general work (Pisanti et al., 2015, Pisanti et al., 2016, Giorgi et al., 2016).Therefore, nurses working during the COVID-19 pandemic are both exposed to occupational hazards and psychosocial pressures at the same time (Pisanti et al., 2015).
Nurses are placed in unpredictable and high-risk situations which entail increased probabilities of physical, mental, and emotional distress (Lai et al., 2020, Huang et al., 2020, Rodríguez and Sánchez, 2020), while impacting the quality and safety of the care they deliver (World Health Organization 2020).Compared with the other health-care professionals, nurses had a higher prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) during and after pandemics (Martikainen et al., 2002, Maunder et al., 2004, Maunder et al., 2006, Chong et al., 2004, Bai et al., 2004, Verma et al., 2004, Barello et al., 2020, Grace et al., 2005).The WHO points out that healthcare professionals are facing multiple psychosocial hazards during the COVID-19 pandemic, such as long working hours and high workload, which can lead to fatigue, occupational burnout, increased psychological distress and/or decreased mental health (World Health Organization 2020).Psychosocial factors refer to the influences of social characteristics on psychological and mental health, as well as behaviours of a person (Martikainen et al., 2002, Macleod andDavey, 2003).Psychosocial factors consist of multidimensional domains encompassing mood status, cognitive behavioural responses, and social factors (Suzuki and Takei, 2013).Protecting the nurses' mental well-being by providing adequate psychosocial support during the COVID-19 pandemic has been identified as essential to ensure the long-term capacity of the health workforce (World Health Organization 2020).
Due to different responses to the pandemic, many countries and regions have repurposed and restructured hospitals to distribute the medical burden and prevent bed shortages (Her, 2020).The challenges and stress during the pandemic faced by nurses are significant (Cox, 2020, Kang et al., 2020), and varied task distributions and levels of experience among nurses may lead to various frontline work experiences.Understanding the psychosocial experiences of frontline nurses is essential to ensure that nurses are adequately supported and that the workforce and delivery of high-quality care during the period of increased health care need is maintained (Fernandez et al., 2020).Therefore, the aim of current study was to synthesize research literature about the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic.
H. Xu et al.

Methods
A qualitative systematic review was undertaken to synthesize the findings from qualitative primary studies to provide in-depth insights into frontline nurses' psychosocial experiences.Systematic reviews are regarded as the standard of evidence-based practice, and are increasingly used for policy decisions and research directions (Aromataris and Riitano, 2014).This article followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations (Moher et al., 2009, Liberati et al., 2009), see supplementary file 1 and 2. The review protocol is registered in PROSPERO (CRD42021259111).

Eligibility criteria
Study characteristics were identified by Population, Exposure, Outcomes (PEO) representing a framework to design research questions for qualitative studies and reviews, and to develop search strategies (Butler et al., 2016).P: frontline nurses that have been in contact with or taken care of patients during work in the COVID-19 pandemic, E: working during the COVID-19 pandemic, O: psychosocial experiences of nurses working during the COVID-19 pandemic.Psychosocial experience in this study is defined as the subjective experiences, perspectives, feelings, and views of the influences on mood status, cognitive behavioral responses, and social factors of a person (Suzuki and Takei, 2013).
Different keywords to be used were listed in Table 1, as well as types of studies to be included in the review.The population included all types of nurses involved in caring for patients, because the nursing role can vary due to needs associated with a pandemic (Hovan, 2020).The exposure included primary, secondary, and tertiary health-care settings that admit and treat COVID-19 patients.Depending on the country, its coping strategies, and its various circumstances or stages during the pandemic, the COVID-19 designated locations may differ.In view of the study's aim, only COVID-19 designated wards or primary health-care settings admitting and treating COVID-19 patients were included (World Health Organization, 2020).Given the special nature of nursing homes and any other health-care facilities that were non-designated for admitting and treating COVID-19 patients, studies conducted in those settings were excluded.Further, studies without an ethical approval and/or ethical statement were excluded.Outcomes included experiences, perceptions, feelings, views of psychosocial issues from the identified population group during the COVID-19 pandemic.

Literature search
The search was conducted in PubMed, CINAHL, and the WHO COVID-19 database on December 8, 2020 (Global research on coronavirus disease (COVID-19) 2020).A systematic search was conducted to identify all peer-reviewed and original empirical qualitative studies that answer the research aim (Bettany-Saltikov and McSherry, 2016).In each of the three selected databases, the search strategy consisted of a building block search carried out according to the PEO framework.The citation pearl search was conducted within Web of Science (WOS) to assess the importance and relevance of included studies, as well as to ensure that all relevant studies were included.WOS brings together all cited references for the citation search and contains citation indexes from each reference list.The years 2019-2020 were chosen to make sure that we did not miss any literature as the virus was first identified in humans in December 2019 in China, despite the fact that the outbreak was officially made public only in January 2020 (World Health Organization 2020).Table 2 shows the full electronic search strategy used to identify studies, including all the search terms and limits for all three databases.

Study selection
The initial search retrieved 897 studies, which were transferred to Covidence software for the following screening process (Veritas Health Innovation Covidence Systematic Review Software [computer program], 2020).The entire study selection process was conducted collaboratively by two authors (HX and SG).In case of disagreement in the screening or full-text review process, the two authors discussed until an agreement was reached.According to the inclusion and exclusion criteria, 16 eligible studies were combined through a final step with 12 additional studies that were retrieved through a citation pearl search.The additional studies from the citation pearl search were included through the joint decisions of all the authors.Finally, 28 studies that met the inclusion criteria were assessed for quality and included for synthesis (Arnetz et al., 2020, Eftekhar et al., 2020, Fan et al., 2020, N Galehdar et al., 2020, Gao et al., 2020, Góes et al., 2020, Hou et al., 2020, Jia et al., 2021, Kackin et al., 2020, Kalateh et al., 2020, Q Liu et al., 2020, YE Liu et al., 2020, Sheng et al., 2020, Sun et al., 2020, Tan et al., 2020, Zhang et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, Cos ¸kun and Günay, 2021, N Galehdar et al., 2020, Sethi et al., 2020, Fernández-Castillo et al., 2021, Ohta et al., 2020, Lee and Lee, 2020, Goh et al., 2020, Bennett et al., 2020, Vindrola-Padros et al., 2020, Okediran et al., 2020).The study selection process is presented in a PRISMA flow diagram (Fig. 1).The 28 included studies are marked with an asterisk * in the references.

Appraisal of study quality
The Critical Appraisal Skills Program (CASP) qualitative study checklist was used to appraise the quality of included studies (Critical Appraisal Skills Programme 2018).It consists of ten questions that assess a study's aim, methodology and design, recruitment strategy, data collection, data analysis, findings, and research value, see Table 3.No studies were excluded in this process.

Data extraction
Data extraction was performed to highlight the qualitative data of primary studies that was relevant to the review aim (Bettany-Saltikov andMcSherry, 2016, Noyes andLewin, 2011).Qualitative data referred to non-numerical or non-measurable information that captured a person's opinions or described the person's lived experiences (Tuckerman et al., 2020).The extracted data items were informed by the review's aim, including author(s), year, nation of publication, and setting(s); study aim(s) or research question(s); study design and theoretical framework; sampling strategy and participants characteristics; data collection methods; data analysis methods; ethical issues; and major findings, see Table 4.

Data synthesis
Initially, a descriptive summary analysis was supported by Table 4 and presented as 'Characteristics of the studies' in the result section.Considering that all studies used a qualitative analytical approach and most of them presented thematic findings, thematic synthesis, inspired by Thomas and Harden, was an appropriate approach to deliver key messages from primary data and to generate higher-level themes (Nicholson et al., 2016).First, the articles were read and re-read to develop a sense of the studies as a whole.The synthesis process was an inductive three-stages approach that began with collecting findings of each primary study and freely coding the texts line-by-line according to their meaning and content (Thomas and Harden, 2008).Following this stage came the development of descriptive themes which involved translating concepts from one study to another by combining codes, and then creating a hierarchical structure by considering similarities and differences between codes (Thomas and Harden, 2008).The final stage consisted of generating analytical themes from the content of the primary studies and determining key messages through descriptive themes according to the review aim (Thomas and Harden, 2008).The thematic synthesis led to the identification of three themes that describe the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic: 'Nurses' emotional, mental and physical reactions to COVID-19', 'Internally and externally supported coping strategies', and 'A call for future help and support'.
In addition to the fear of oneself being infected, nurses also expressed concerns about transmitting the infection (Arnetz et al., 2020, Eftekhar et al., 2020, N Galehdar et al., 2020, Góes et al., 2020, Kackin et al., 2020, Kalateh et al., 2020, Q Liu et al., 2020, YE Liu et al., 2020, Sheng et al., 2020, Sun et al., 2020, Tan et al., 2020, Cos ¸kun and Günay, 2021, N Galehdar et al., 2020, Sethi et al., 2020, Fernández-Castillo et al., 2021, Goh et al., 2020, Bennett et al., 2020).This potential risk increased the nurses' anxiety as they worried about being carriers of the virus and infecting their family members and loved ones.The nurses expressed a sense of guilt or self-blame for the infection or death of family members (Eftekhar et al., 2020, N Galehdar et al., 2020, N Galehdar et al., 2020).Nonetheless, the concerns regarding the nurses' safety and lack of familiarity with and understanding of the nurses' frontline work from family members increased the nurses' psychological stress (Fan et al., 2020, Kackin et al., 2020, Sun et al., 2020), and some nurses chose to hide the truth about working frontline from their family members (Kackin et al., 2020).
In the face of the COVID-19 surge, studies reported that nurses lingered with a sense of unknown and uncertainty (Arnetz et al., 2020, Eftekhar et al., 2020, N Galehdar et al., 2020, Kackin et al., 2020, Kalateh et al., 2020, YE Liu et al., 2020, Zhang et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, Fernández-Castillo et al., 2021, Ohta et al., 2020, Lee and Lee, 2020, Bennett et al., 2020).Early in the pandemic, since the disease was unprecedented and thus hardly known by the public and scientific authorities, nurses were working under stress resulting from the lack of scientific information available (N Galehdar et al., 2020, Góes et al., 2020).This ambiguous and unpredictable situation brought an unavoidable fear to frontline nurses (YE Liu et al., 2020, Tan et al., 2020).Information that differs from the nurses' understanding of COVID19 and over-information from the media were reported as some of the most stressful factors affecting the nurses' emotions (Arnetz et al., 2020, Eftekhar et al., 2020, N Galehdar et al., 2020, Góes et al., 2020, Fernández-Castillo et al., 2021, Ohta et al., 2020, Lee and Lee, 2020).They felt unable to disconnect from this awkward situation and were extremely anxious about the varied and uncertain content being spread (Fernández-Castillo et al., 2021, Ohta et al., 2020).Additionally, the nurses reported concerns about the future in relation to work and personal life as the pandemic continued (Lee and Lee, 2020), including concerns about neglecting patients with other diseases (Eftekhar et al., 2020), the ability to deal with COVID-19 patients (Ohta et al., 2020), the control of the current pandemic (YE Liu et al., 2020, Deliktas et al., 2021), and future financial situation of nurses and their families (Eftekhar et al., 2020).
Objective: To explore the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic.

Review Finding
Studies Contributing to the Review Finding

Assessment of Adequacy
Overall CERQual Assessment of Confidence

Explanation of Judgement
Frontline nurses experienced fear of infection and uncertainty during the COVID-19 pandemic.

High confidence
This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
The unfamiliarity in the workplace and psychological unpreparedness were the main occupational stressors that caused nurses psychological distress and negative physical impacts.

High confidence
This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.

Moderate confidence
This finding was graded as moderate confidence because of minor concerns regarding methodological limitations, relevance, and adequacy; and moderated concerns regarding coherence.
Despite the fact that nurses did their best to treat patients, there was a relatively high mortality rate and lower instances of improvement of patients' condition (Eftekhar et al., 2020, Q Liu et al., 2020, Sheng et al., 2020, Fernández-Castillo et al., 2021).Nurses felt that they were unable to provide patients with adequate support (Arnetz et al., 2020, Eftekhar et al., 2020, Fan et al., 2020, N Galehdar et al., 2020, Jia et al., 2021, Sheng et al., 2020, Sun et al., 2020, Muz and Erdogan, 2021, Fernández-Castillo et al., 2021).Accordingly, nurses, particularly those working in intensive care units, expressed a sense of helplessness and powerlessness (Arnetz et al., 2020, Eftekhar et al., 2020, Fan et al., 2020, N Galehdar et al., 2020, Q Liu et al., 2020, Sheng et al., 2020, Tan et al., 2020, Fernández-Castillo et al., 2021), as well as a sense of losing control over the patients' condition (Eftekhar et al., 2020).Nurses acknowledged an insufficiency in the psychological and emotional care they delivered to patients and their family members due to the lack of relevant knowledge and an inner fear of contagion (Jia et al., 2021, Sheng et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, N Galehdar et al., 2020).In addition, nurses retained hesitation in coming close to patients due to the fear of contamination (Jia et al., 2021, Kackin et al., 2020, Muz and Erdogan, 2021), and they reduced the frequency and speed of nursing activities to protect their own safety (Jia et al., 2021).This perceived inadequacy of care triggered moral distress in nurses, and nurses were under pressure due to the decline in quality of care (Kackin et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, Cos ¸kun and Günay, 2021, Fernández-Castillo et al., 2021).Besides, ethical dilemmas in care caused by COVID-19 also created frustration and moral distress for nurses (Hou et al., 2020, Jia et al., 2021, Fernández-Castillo et al., 2021).Patients' rights, such as the right to information, seemed to be neglected, and humanization of care could not be maintained due to the restrictions of PPE and strict isolation procedures (Fernández-Castillo et al., 2021).
H. Xu et al.

Internally and externally supported coping strategies
Nurses reported that, as a result of the pandemic-associated living and working conditions, their daily routines had changed significantly in terms of eating, sleeping, and outdoor activities (Eftekhar et al., 2020, N Galehdar et al., 2020, Sun et al., 2020, Deliktas et al., 2021, Sethi et al., 2020, Lee and Lee, 2020, Okediran et al., 2020).Nurses were actively seeking for knowledge (Hou et al., 2020, Jia et al., 2021), adjusting their attitudes towards the situation and being optimistic about the faced challenges (Sun et al., 2020), avoiding overthinking about the current pandemic and remarks on social media (Kackin et al., 2020, Sun et al., 2020), and developing interests to distract themselves (Kackin et al., 2020, Sun et al., 2020), many of them found their own method to relieve anxiety and to psychologically normalize the pandemic realities (Eftekhar et al., 2020, Sun et al., 2020).It was reported that the improvement of knowledge about the disease, nursing skills, and protective measurements had increased nurses' security and self-confidence in frontline work (Hou et al., 2020, Jia et al., 2021, Deliktas et al., 2021, Okediran et al., 2020), and greatly diminished their stress (Deliktas et al., 2021).Some nurses experienced changes to their perspectives on life, appreciating and cherishing life more than before (Q Liu et al., 2020, Deliktas et al., 2021).However, some nurses also expressed a sense of powerlessness in resisting stress and regulating psychological states (Jia et al., 2021).
Nurses viewed communication with family members as an additional psychosocial support that could encourage, motivate, and comfort them (Q Liu et al., 2020, Sun et al., 2020, N Galehdar et al., 2020, Goh et al., 2020, Okediran et al., 2020).Considering the potential risk of being a carrier, nurses restricted their social activities, and many of them had even isolated themselves from family members and friends (Eftekhar et al., 2020, N Galehdar et al., 2020, Kalateh et al., 2020, Muz and Erdogan, 2021, Cos ¸kun and Günay, 2021, Lee and Lee, 2020).As family members and friends used to be an important support system that nurses relied on (Arnetz et al., 2020), these new social restrictions and self-isolation suddenly and dramatically decreased nurses' social and emotional relationships (Arnetz et al., 2020, Eftekhar et al., 2020, Kackin et al., 2020, Muz and Erdogan, 2021, Sethi et al., 2020, Lee and Lee, 2020), which resulted in depression and loneliness for nurses during this adaptation process (Arnetz et al., 2020, Eftekhar et al., 2020, Muz and Erdogan, 2021, Sethi et al., 2020).Nurses with children expressed a sense of anxiety and guilt for being apart from their young children while they took care of patients at work, and not being able to explain the fact about the pandemic to their children exacerbated their worries and stress (N Galehdar et al., 2020, Cos ¸kun and Günay, 2021, N Galehdar et al., 2020).Nurses expressed additional stress related to the management of family-related issues, such as financial concerns due to the unemployment of family members (Arnetz et al., 2020, Sethi et al., 2020).Moreover, the adaptation of changed social dynamics brought additional challenges and difficulties to the nurses (Hou et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, Sethi et al., 2020, Ohta et al., 2020, Lee and Lee, 2020).Nurses who worked in COVID-19 wards reported experiences of being alienated from staff in the other departments and excluded by society, which felt disappointing and difficult to deal with (Deliktas et al., 2021, Muz and Erdogan, 2021, Ohta et al., 2020, Lee and Lee, 2020).People avoided approaching nurses and viewed them as potential threats (Hou et al., 2020, Deliktas et al., 2021, Muz and Erdogan, 2021, Ohta et al., 2020, Lee and Lee, 2020).On social media platforms, people criticised the professional competence of nurses who became infected at work, and the nurses were maliciously judged by people's comments based on unreasonable social standards (Arnetz et al., 2020, Sethi et al., 2020, Lee and Lee, 2020).These pressures created a substantial psychological burden for nurses to bear.Besides, nurses also worried about discrimination against family members because of their working conditions (Ohta et al., 2020).Therefore, it was difficult for nurses to physically and mentally adapt to a pandemic-related personal life and social conditions (Okediran et al., 2020).
During later stages of the pandemic, when nurses experienced pandemic fatigue, a study showed that the early fear, anxiety, and helplessness of nurses appeared to have been reactivated due to resurgences in the ongoing pandemic (Eftekhar et al., 2020).The possibility of care for COVID-19 patients becoming a long-term work requirement was a concern in many studies, thus not only compelling nurses to make psychological preparations, but also suggesting the need for adequate long-term material and psychosocial preparations to support nurses (Eftekhar et al., 2020, Lee andLee, 2020).

Confidence in cumulative evidence
The evidence was assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) Approach (Lewin et al., 2015).CERQual provides a systematic and transparent framework for assessing confidence in each review finding in terms of methodological limitations, relevance, coherence, and adequacy of data (Lewin et al., 2018).The levels of confidence in each individual review finding can be reported as high, moderate, low and very low (Lewin et al., 2018).Based on CERQual assessment, the confidence in two findings was high and in one finding was moderate (Table 5).

Summary of evidence
This study systematically reviewed 28 qualitative studies to synthesize the psychosocial experiences of frontline nurses working in hospital-based settings during the COVID-19 pandemic.The main findings that will be discussed in this section indicated that frontline nurses experienced fear of infection and uncertainty during the COVID-19 pandemic.Further, unfamiliarity in the workplace and psychological unpreparedness were the main occupational stressors that caused nurses' psychological distress and negative physical impacts.Moreover, nurses' coping strategies combined with external support contributed to improved coping abilities in terms of stress management and a strengthened sense of professional competence in nurses.
During the COVID-19 pandemic, nurses experience fear, anxiety, and psychological distress due to the risk of infection, concerns about family members, and the uncertainty of the disease.Compared with evidence from previous pandemics, such as severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) outbreak, it is consistent that nurses' concerns about their own safety heightened their anxiety level (Lam and Hung, 2013, Holroyd and McNaught, 2008, Kang et al., 2018, Koh et al., 2012).The fears of the unknown, virus infection and transmission are the prominent stressors related to the pandemic (Maunder et al., 2004, Bai et al., 2004, Chua et al., 2004, Ornell et al., 2020, Chan et al., 2005, Shih et al., 2007, Wong et al., 2005, Khalid et al., 2016, Khee et al., 2004, Wu et al., 2009).Although frontline nurses try to isolate themselves, they are concerned about the safety of their family members (Lam and Hung, 2013, Koh et al., 2012, Wong et al., 2005, LoGiudice and Bartos, 2021, Ives et al., 2009).The previous evidence indicates that quarantining resulted in adverse effects on nurses' mental health (Rossi et al., 2020), and social distancing deprives nurses of social support at work and added work-related stress (Halcomb et al., 2020, Labrague andde Los Santos, 2021).Social restrictions weaken nurses' social relationships yet trigger stigma towards nurses (Kim, 2018-(Xiang et al., 2020).During the SARS outbreak, nurses who experienced social avoidance and stigma developed higher levels of PTSD (Maunder et al., 2004).Evidence suggested that accurate messages from public health authorities could reduce underlying stigma and fear that is cultivated through media (Shih et al., 2007, Sirois andOwens, 2021).
The findings reveal that nurses experienced an inevitable sense of a loss of control when facing the suffering of patients combined with the perceived risks in contaminated environments, though having a sense of control is vital for nurses to resist distress and anxiety (Gallagher et al., 2014, Taylor et al., 2020).Evidence indicates that healthcare professionals frequently met ethical challenges in difficult work conditions (Mert et al., 2020, Cerit and Dinç, 2013, Amiri et al., 2019).Insufficient knowledge and resources, uncertainty with duties and procedures, and communication problems are the major causes of ethical issues and moral distress felt by nurses, and it is consistently noted that nurses are unable to provide adequate care when facing these challenges (Dehghani et al., 2015, Mert et al., 2021, Silverman et al., 2021).On the other hand, taking care of patients is a professional commitment that needs to be fulfilled (Kang et al., 2018, Koh et al., 2012).Consistent with the evidence, the fulfillment of professional duty brought a sense of pride and accomplishment to nurses.However, nurses experience moral distress pertaining to the maintenance of professional obligations and a sense of powerlessness in providing adequate care in a challenging environment (Silverman et al., 2021).Evidence emphasised that working with a high risk of infection due to professional obligation while having to work with insufficient protective measures creates ethical dilemmas and moral distress for nurses during pandemics (Mert et al., 2021, Silverman et al., 2021).
To cope with stress, frontline nurses used adaptive coping strategies, such as active learning, and maladaptive coping strategies, such as self-blaming, all while highlighting the need for psychological management at the leadership and organisational levels.Evidence indicates that adaptive coping strategies could effectively alleviate or prevent stress (Wang et al., 2020), while maladaptive coping strategies might lead to higher levels of burnout and PTSD as long-term impacts in previous pandemics (Maunder et al., 2006, Nie et al., 2020).Coping styles and perceived social support are associated with individual management of stress (Mariani et al., 2020).Social support is unanimously indicated to lower the level of distress and improve nurses' mental health (Spoorthy et al., 2020, Sirois and Owens, 2021, Taylor et al., 2020, Nie et al., 2020).Corroborating previous studies, organisational support diminishes the perceived fears and emotional exhaustion of nurses (Sirois andOwens, 2021, Ng andSorensen, 2008), particularly since nurses rely on organisational initiatives and expect to receive clear and adequate knowledge about the pandemic in a consistent manner (Fernandez et al., 2020).There has been increasing evidence supporting that the COVID-19 pandemic could be understood as a traumatic event (Bridgland et al., 2021).Studies report that frontline nurses developed PTSD after SARS and MERS outbreaks (Chan and Huak, 2004, Lancee et al., 2008, Lee et al., 2018, Kim et al., 2018).Therefore, trauma care might be crucial for nurses' psychological and mental well-being, and obtaining trauma-related knowledge can support nurses in coping with personal and occupational stressors (Eslami et al., 2015, Fowler andWholeben, 2020).

Strengths and limitations
This systematic review focused on the voices of frontline nurses regarding their psychological, social, emotional experiences during the COVID-19 pandemic.The results provide insights into nurses' perspectives on the challenges in frontline work management and barriers to the delivery of care.The included studies were from 12 different countries from five continents.Hence multiple perspectives from a diversity of countries are represented in the results, speaking for transferability of the results across different countries.This review corroborates previous pandemic research, and the results of this review contribute to the knowledge base about nurses' professional and personal stressors in frontline work during the COVID-19 pandemic, including nurses' psychosocial experiences in coping with work, social relationships, and personal life.
However, this systematic review has several limitations, which should be taken into consideration in light of the results' interpretation.Several limitations discussed below relate to the included studies' own prerequisites and limitations, but also to the current review's delimitations and limited time frame.First, the response to the pandemic in different countries may lead to various protocols and policies, which may influence frontline nurses' attitudes and work experiences.Second, the review did not take sociodemographic characteristics into consideration, though sociodemographic factors may have significant influence on frontline nurses' psychological experiences during a pandemic (Maunder et al., 2004).Third, nurses' work-related background information was not collected.A nurse's typical work position and department may influence transdisciplinary nurses' work experiences in COVID-19 wards (Fan et al., 2020).Furthermore, frontline nurses can be found in additional contexts not represented in the current findings, limiting the results' transferability to care contexts differing from the ones represented in the current review.Fourth, the review limited the language of published studies to those published in English.Studies published in other languages, and countries or regions where the COVID-19 pandemic was prevalent may have been excluded.Fifth, the citation search was limited to the database of WOS, which has a more limited number of journals than SCOPUS or Dimensions (Singh et al., 2021).It means that potentially relevant articles could have been overlooked.Lastly, the review only included peer-review studies published before February 2021.gray literature and pre-printed research which may contain relevant COVID-19 knowledge have been excluded.

Implications for nursing and health policy
This qualitative systematic review highlights the significance of frontline nurses' experience of psychological, social and emotional distress during the COVID-19 pandemic.Maintaining the mental health of frontline nurses is crucial to the quality of care and control over the pandemic (Mo et al., 2020).It is suggested that policymakers, health-care organisations, nursing managers, and nursing leaders engage in supporting frontline nurses during the pandemic.Nursing leaders should not only pay attention to the challenges that frontline nurses have experienced in their delivery of care, but aim to guide nurses in using adaptive coping strategies to prevent negative effects on their mental well-being.Nursing managers should provide safe and healthy working conditions for frontline nurses.It may also be helpful to offer corresponding financial subsidies or rewards and ensure professional equality as a way to mobilise the motivation and enthusiasm of frontline nurses (Mo et al., 2020).There is an evident need for health-care organisations to provide necessary resources and support to mitigate psychological and moral distress in frontline nurses.
Psychological interventions should be implementable and readily accessible for all frontline nurses to help them cope with psychological and emotional distress (Fernandez et al., 2020).Multidimensional social support is essential for frontline nurses in managing stress and maintaining mental well-being.Education aimed at nurses may be critical in lessening social stigma (Fernandez et al., 2020).Policy-makers should address the barriers that create ethical challenges for frontline nurses and consider multifaceted support to optimize working conditions (Mert et al., 2021), in order to help deal with wide psychosocial issues and promote nurses' professional identity.

Conclusion
Nurses working frontline during the COVID-19 pandemic have experienced psychological, social, and emotional distress in coping with work, social relationships, and their personal life.COVID-19 generates multiple challenges to the frontline nursing practice.The results speak of a need for psychological and social support for frontline nurses to cope with stress and maintain mental well-being, which may subsequently affect the outcomes and efficiency of nursing care.It is vital for nursing leaders, nursing managers, health-care organisations, and policy-makers to provide multifaceted support to increase professional satisfaction and ensure sustainability of the nursing workforce.Future research is needed to explore long-term psychosocial experiences of COVID-19 frontline nurses.Such evidence may serve as a guide for nurses' mental health management in response to future public health emergencies.

Declaration of Competing Interest
No conflict of interest has been declared by the authors.

H
.Xu et al.

Table 1
Inclusion and exclusion criteria.
OthersLanguage in English; Published date 2019-2021; Available full-text articles.Language other than English;Published in 2018 or earlier;Studies without an ethical approval and ethical statement.H. Xu et al.

Table 2
The full electronic search strategy for all three databases.

Table 3
CASP Study appraisal form.

Table 4
Study characteristics .
(Fan et al., 2020)  ChinaHospitalsTo collect the experiences and views of transdisciplinary nurses at the forefront of the COVID-19 outbreak and to evaluate their psychological stresses.Qualitative study• Purposeful sampling method• Nurses: N = 44 • 38 females, 6 males• Age range: 20-40 or older• Mean age: NR• Work experience range: 1-15 or more• Mean work experience: NR Semi-structured and face-to-face interviews Thematic Analysis method • Higher perceived stress levels and less perceived social support were detected in the transdisciplinary nurse (TN).•Ambiguous roles.• The transition of operating modes.• Unfamiliar work contents, the work environment and intensity, and the reversal of daily schedules.•Psychological problems.• Sense of powerlessness, incomprehension of parents, concern for family members and long-term isolation.(N Galehdar et al., 2020) IranHospitals To explore nurses' experiences of psychological distress during care of patients with COVID-19.Qualitative study • Purposeful sampling method• Nurses: N = 20• 15 females, 5 males• Age range: NR• Mean age: 31.95:• Work experience range: 1-22 years• Mean work experience: 7.25

Table 4
(continued ) • Resources to empower nurses to cope with the struggle.•Challenges during the coping process.• Affected nurses' views on lives, (continued on next page) H. Xu et al.

Table 4
(continued ) *N = Number of participants; NR = Not reported.H.Xu et al.