Introduction

On March 11, 2020, coronavirus disease (COVID-19) was declared by the World Health Organization [1] as a global pandemic and posed an extremely high risk, burden and negative impact on the physical and mental health especially of those frontline healthcare workers (HCWs) [1,2,3,4]. Healthcare systems in many countries at the time of the COVID-19 pandemic were on a brink of collapse, with HCWs exposed to unprecedented psychological strain [5] and experiencing an increased risk for infection and adverse physical health outcomes [3, 4, 6]. Work overload, social isolation, fear of infecting friends and family, physical exhaustion and the constant need for taking ethically difficult decisions were among the factors contributing to deteriorating mental health [2, 4, 5, 7]. HCWs were particularly at risk of experiencing increased symptoms of burnout, anxiety, depression, post-traumatic stress and insomnia [6, 8,9,10,11,12,13]. HCWs had to face several challenges during the COVID-19 pandemic including high workload, death of colleagues and patients, and being stigmatized by community members, whereas they reported needs for adequate rest, appreciation from management, and psychological support [3, 5, 9, 14, 15]. Therefore, their challenges and needs are multi-factorial influenced for example by work-related conditions (e.g., excessive workload) and individual-based cognitions and feelings (e.g., reduced mental health).

One of the earliest ecological models in psychology and public health is the Bioecological Model of Human Development [16]. According to the model [16, 17], an individual’s development is influenced by the microsystem (interactions with immediate environment like family), mesosystem (connections between different microsystems such as work and family), exosystem (indirect influence by an individual’s environment), macrosystem (cultural context of the individual) and chronosystem (changes in individual and environment across time). Socio-ecological models [18,19,20,21] such as the “Rainbow Model” [22, 23] are widely used in public health for mapping evidence (e.g., factors affecting mental health). They suggest that an individual’s behavior, emotions and relationships can be influenced by: (a) individual (i.e., choices, beliefs, attitudes, demographic characteristics), (b) interpersonal (i.e., formal or informal support systems such as family and friends), (c) organizational (i.e., organizational settings that exist outside home such as workplace), and (d) community factors (i.e., social interaction, political and psychological). It is of crucial importance to map the evidence from the literature on challenges and needs of HCWs caring for COVID-19 patients based on well-established socio-ecological models so as to possibly contribute to translating into policymaking actions and interventions.

A range of psychological interventions available to HCWs during COVID-19 were examined in previous reviews. They found that mindfulness training [14, 24], problem solving [24], Cognitive Behavioral Therapy (CBT) [6, 24], and Acceptance and Commitment Therapy (ACT) [6] were effective on improving mental health symptoms such as anxiety, depression, and post-traumatic stress. However, in order to maximize the effects of an intervention, the needs of HCWs at multiple levels (e.g., including contextual) should be addressed. The importance of conducting multi-level research was further supported by the guidelines proposed by the Task Force of the Association of Contextual Behavioral Science (ACBS) [25], which suggested that research should be more experimental, multi-level, process-based, and multi-dimensional.

Currently, there is an absence of reviews mapping evidence on the challenges and needs of HCWs caring for COVID-19 patients to different socio-ecological levels (e.g., individual, interpersonal, organizational, community). The aim of this rapid scoping review is to map and compile lessons learnt from the literature regarding the challenges and needs of HCWs caring for COVID-19 patients during the pandemic based on socio-ecological models. A secondary aim of this review is to investigate what type of psychological interventions were utilized and are effective for HCWs during the COVID-19 pandemic.

Method

The review followed the PRISMA guidelines for reporting scoping reviews [26]. The protocol of this study and the data supporting the findings are available in Open Science Framework (OSF; DOI: https://doi.org/10.17605/OSF.IO/5KBHD).

Eligibility criteria

Published and unpublished (e.g., dissertations) peer-reviewed studies were eligible for selection. The PICO method was used to determine the inclusion criteria for this review [27]: (a) P (Participants): Working as an HCW during COVID-19 that according to the World Health Organization [28] includes general medical practitioners, nursing professionals, psychologists, physicians, and physiotherapists. Students of any of these specialties and medical residents were also eligible; (b) I (Intervention): Report any psychological intervention available for or examine the challenges and needs of HCWs; (c) C (Comparison): Only studies examining psychological interventions had to compare an intervention group with control or, if no control group was used, the study should have utilized a design with pre–post intervention comparisons or examined the feasibility and acceptability of the intervention; and (d) O (Outcome): Examine either the challenges and needs or psychological interventions for HCWs caring for COVID-19 patients. Additionally, included studies examining the challenges and needs of HCWs had to utilize either qualitative (i.e., interview, focus groups) or quantitative (i.e., randomized controlled trial (RCT), correlational, and experimental) design. Challenges were defined as the problems experienced requiring great mental or physical effort in order to be done successfully during the COVID-19 pandemic whereas needs were defined as the conditions required for improved health and quality of life [29].

Studies were excluded if they were: (a) published in language other than English; (b) reviews, editorials, conference abstracts, or case studies; and (c) published before 2020 when COVID-19 was declared a pandemic.

Search strategy

Relevant studies published during the period of COVID-19 pandemic (2020–2024) were identified by searching the databases of PubMed, CINAHL and Scopus. Searches were conducted until end of March 2024. Existing relevant meta-analyses and reviews were also examined for additional eligible studies. A defined search strategy was undertaken using the following terms based on title and abstract: “COVID-19” or “COVID 19” or “SARS-COV-2” or “coronavirus” combined with the terms “healthcare professionals”, or “healthcare providers”, or “doctors”, or “nurses”, or “healthcare workers”, or “physicians”, and “need” or “challenge” or “intervention” or “treatment”. The full search strategy is available as Appendix.

Inter-rater reliability (IRR)

Articles were screened for eligibility at all screening stages by the first author. At all stages, an additional author (VT) screened 20% of the studies, independently. Inter-rater reliability (IRR) was calculated using the percent agreement and Cohen’s kappa [30]. An almost perfect agreement was observed between the two screeners in title-abstract (IRR = 90%; k = 0.95) and substantial agreement in full-text screening (IRR = 69%; k = 0.80). Any discrepancies were resolved in research team consensus meetings.

Data extraction and synthesis

A data charting form was used to extract the data. From all included studies, a mixture of general information about the characteristics of the study and population and specific information relating to the aims of this scoping review were extracted. A narrative synthesis approach [31, 32] was used to describe, analyze, summarize and interpret included study findings. Since we included both quantitative and qualitative studies, a mixed methods framework was used to synthesize the data, which is a convergent synthesis design where both types of data are collected and analyzed simultaneously [31]. Based on the data type provided by each study, the results-based convergent synthesis design was used in which both data types were analyzed and presented separately and then collated together. The themes reported by qualitative studies were extracted, whereas statistical data were extracted from the quantitative studies. The socio-ecological model was used to summarize and cluster the challenges and needs of HCWs into individual, organizational, interpersonal and community factors [18, 19].

Results

Study characteristics

A total of 16,633 studies were identified in initial search. After removing duplicates and screening the titles, 51 studies were screened for full text and 21 were included to examine the challenges and needs of HCWs, whereas 18 examined psychological interventions available for HCWs (see Fig. 1 for a detailed flow diagram including reasons for exclusion). The characteristics of the included studies examining the challenges and needs are presented in Table 1, whereas those examining psychological interventions are shown in Table 2.

Fig. 1
figure 1

Flow diagram of information detailing the database searches, the number of titles and abstracts screened and excluded, and the full texts retrieved and excluded

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Table 1 Characteristics of included studies for challenges and needs (N = 21)
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Table 2 Findings on the psychological interventions used for HCWs (n = 18)
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Studies were published between 2020 and 2024 and conducted in a range of countries. Specifically, studies examining challenges and needs of HCWs were conducted mainly in India (n = 4, 19.0%), USA (n = 2, 9.5%), Ireland (n = 2, 9.5%) and Africa (n = 2, 9.5%), whereas those examining psychological interventions were conducted in Iran (n = 2, 11.1%), Spain (n = 2, 11.1%), Turkey (n = 2, 11.1%), China (n = 2, 11.1%) and UK (n = 2, 11.1%). Studies examining challenges and needs implemented mostly a qualitative design utilizing interviews or focus groups (n = 18, 85.7%) or were cross-sectional studies utilizing quantitative methods (n = 3, 14.3%). In contrast, all studies examining psychological interventions implemented a quantitative design utilizing mostly a clinical trial (n = 12, 66.7%). Overall, in most studies the sample was comprised mainly by HCWs specialized in nursing (n = 26, 66.7%) or general physicians (n = 5, 12.8%). The challenges and needs were mapped into four ecological levels: individual, organizational, interpersonal, and community (see Table 3 for each study and Fig. 2 for a summary).

Table 3 Findings on the challenges and needs of included studies based on socio-ecological models (n = 21)
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Fig. 2
figure 2

Social-ecological framework of challenges and needs of HCWs caring for COVID-19 patients and potential psychological interventions to address them

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Individual-related

Individual-level challenges were reported by 18 studies conducted in India (n = 4, 22.2%), Africa (n = 3, 16.6%), Ireland (n = 2, 11.0%), USA (n = 2, 11.0%), Bangladesh (n = 1, 5.6%), China (n = 1, 5.6%), Indonesia (n = 1, 5.6%), Pakistan (n = 1, 5.6%), South Korea (n = 1, 5.6%), Turkey (n = 1, 5.6%), and UK (n = 1, 5.6%). Challenges included mainly fear (78%) and reduced mental health (78%) due to the COVID-19 pandemic [33,34,35,36,37,38,39,40,41,42]. Specifically, HCWs faced mostly the fear of contracting COVID-19 and transmitting it to their family members, and the uncertainty that comes with the disease (i.e., they were unaware of the nature and the consequences of the disease due to lack of knowledge about the novel virus), fear of alienation from society, and fear of death due to COVID-19, and experiencing loss and of experiencing loneliness [33, 35, 36, 38,39,40,41,42]. They also reported increased stress, burnout, emotional exhaustion, psychological and physical fatigue, sense of guilt due to the inability to save patients, and isolation due to the COVID-19 protective measures [33, 34, 36,37,38,39, 42]. In six studies (33%) conducted in Africa, Pakistan, India, Turkey, and USA, HCWs reported needing psychological support to manage their mental health [36, 39, 42,43,44,45]. To be specific, HCWs highlighted the need for counselling services to reduce the stress and anxiety they were experiencing due to the COVID-19 pandemic and to learn coping strategies for dealing with pandemic situations more effectively.

With respect to the psychological interventions being available for HCWs during the COVID-19 pandemic (Table 2), included studies addressed only individual-based challenges and needs, particularly to improve mental health symptoms. In all of the studies (n = 18), HCWs worked or lived in primarily urban areas (e.g., Zurich, Pavia, Istanbul, Ontario, Okayama). In the majority of studies (n = 15, 83.3%), interventions were administered for a period of two months or less with median duration in weeks being 4.0 (SD = 3.5). Interventions were mostly compared to a control group (n = 12, 85.7%), such as a waitlist or no-intervention control (n = 6 out of 12, 50.0%). In six studies (33.3%), individuals received a group psychological intervention with other HCWs [46,47,48,49,50,51], whereas in six studies (33.3%), individuals received 1:1 online or telephone counseling from a therapist [52,53,54,55,56,57]. Interventions were also delivered digitally through developed applications (n = , 16.7%) [58,59,60] including written and audiovisual psychological exercises (e.g., mindfulness, CBT techniques), a developed platform [61] with videos, interactive exercises with written information, a developed website [62] with psychoeducational videos and exercises and a web-based stress management intervention [63] based on ACT as developed by WHO including audiorecordings and illustrated exercises. With respect to the interventions provided, a range of psychological interventions was reported. Most studies delivered CBT (n = 4, 22.2%), mindfulness exercises (n = 4, 22.2%) and ACT (n = 4, 22.2%). A summary of findings of their reported effectiveness can be found in Box 1, whereas for each study in Table 2.

Interpersonal-related

Interpersonal-related challenges that HCWs faced were reported by four studies (19.0%) conducted in Africa [64], Bangladesh [40], India [36] and South Korea [65] including alienation by family members, being unable to spend time with family, having to choose work over family and reduced support that HCWs received by family, peers and friends. Interpersonal-related needs of HCWs were reported by two studies (9.5%) including family, spouse and friends providing emotional and instrumental support (e.g., by taking care of children, assisting in household chores), so as to motivate or support HCWs to go to work during COVID-19 [36, 64].

Organizational-related

Challenges at the organizational-level were reported by 13 studies (61.9%) conducted in Africa (n = 3, 23.05%), India (n = 3, 23.05%), Bahrain (n = 1, 7.7%), China (n = 1, 7.7%), Indonesia (n = 1, 7.7%), Ireland (n = 1, 7.7%), Nigeria (n = 1, 7.7%), South Korea (n = 1, 7.7%), and Turkey (n = 1, 7.7%). Challenges included unclear COVID-19 guidelines at the hospitals regarding protective measures taken, scarcity of protective equipment and limited medical supplies, suboptimal staff preparation for COVID-19, working beyond assigned role (e.g., physicians had to take nursing roles due to shortage of staff and absence of family caregivers), longer working hours, limited communication due to protective equipment, increased workload, lack of managerial support and wearing protective equipment every day for multiple hours [33, 36, 41, 42, 44, 45, 64,65,66,67,68,69,70]. Organizational-level needs were reported by 10 studies (47.6%) conducted in India (n = 3, 30.0%), Africa (n = 1, 10.0%), China (n = 1, 10.0%), Pakistan (n = 1, 10.0%), Spain (n = 1, 10.0%), Turkey (n = 1, 10.0%), UK (n = 1, 10.0%), and USA (n = 1, 10.0%). Specifically, needs reported by HCWs included feeling appreciated at work, support by superiors through listening to their fears and concerns and co-workers such as sharing experiences, flexible working hours, safe and secure working conditions such as administrative measures for better protection from COVID-19, improvement of protective equipment, paid night shifts, rest periods and holidays, and clear communication of policies related to risk, workload and sick leave [34, 36, 38, 39, 42,43,44,45, 68, 71].

Community-related

Community-level challenges were reported by 11 studies (47.5%) conducted in Africa (n = 3, 27.25%), India (n = 3, 27.25%), Bangladesh (n = 1, 9.1%), Nigeria (n = 1, 9.1%), Pakistan (n = 1, 9.1%), South Korea (n = 1, 9.1%), and Turkey (n = 1, 9.1%). Challenges included mainly poor societal support (e.g., community members did not recognize HCWs’ contribution during the pandemic) and stigma, isolation and discrimination from society as they had to work in COVID-19 wards, and community members feared that they will contract COVID-19 from HCWs [33, 36, 38,39,40, 42, 45, 64,65,66, 70]. Needs were reported by two studies (18.2%) with HCWs reporting support provided by the society by recognizing their contribution in providing support to people and following public protocols for controlling the spread of COVID-19 so as to reduce the burden on them [36, 38].

Discussion

In this review, 21 studies were included examining the challenges and needs of HCWs caring for COVID-19 patients, and 18 studies examining the psychological interventions available. The socio-ecological models, were used to synthesize the evidence [18, 19, 72]. A range of challenges and needs were identified with HCWs reporting mostly organizational-level factors such as flexible working hours. However, included psychological interventions addressed only individual-based challenges and needs (i.e., mental health symptom improvement), suggesting the importance of developing and administrating multi-level interventions targeting the various factors (interpersonal, organizational, community) influencing well-being [15, 73].

At the individual-level the most reported challenges were fears related to the COVID-19 pandemic such as being infected and transmitting COVID-19 to family members, as well as the uncertainty and mental health symptoms such as increased stress, burnout, fatigue and emotional exhaustion. This is not surprising, as HCWs were experiencing excessive workload, were under immerse pressure and were frequently exposed to infected individuals [3, 4, 6, 15]. However, in less than half of the studies (33%), HCWs reported needing psychological support to manage their mental health, suggesting thus HCWs might have wider needs than just individual. Psychological interventions that were found to be particularly effective on improving mental health symptoms such as anxiety, depression, and stress included ACT and CBT. Mindfulness-based exercises also appeared to be promising on improving depression symptoms. Our findings are in line to those of previous studies [6, 14, 24], suggesting that researchers and clinicians should use contextual approaches when intervening for the individual-based needs of HCWs to maximize and produce long-lasting effects.

Multi-level and multi-dimensional interventions should be preferred and based in accordance with reported guidelines [25]. Although there is a lack of studies implementing the socio-ecological framework when delivering interventions for improving the mental health of HCWs, some countries deliver socio-ecological interventions to non-HCWs populations (e.g., general population, families) for improving their mental health [74, 75]. For example, an ecological model of intervention for improving the mental health of individuals in Alberta [75], included educating individuals to manage their mental health (individual-level), group suicide intervention or mental health training (interpersonal-level), peer or social support groups (community-level) and suicide or mental health crisis lines (system-level). An additional example includes the combination of psychological interventions with medication use, that show promising results for managing mental health issues than using each of them alone [76, 77].

In addition, we found that although various apps and websites developed for HCWs resulted in improved mental health symptoms (e.g., PsyCovidApp, My Health too, Foundations, SH +, RECHARGE and RESTORE interventions) [56, 59,60,61,62,63], evidence is limited to a single study each. Thus, further evaluation of these digital-based interventions is required to strengthen their evidence base. Digital mental health applications are considered to be particularly effective for managing mental health problems such as depression, anxiety and schizophrenia, offering numerous benefits to the individuals (e.g., ease of habit, low effort expectancy) [78]. Additionally, the available interventions tend to be administered for a short duration, with the majority following HCWs for less than two months without concluding evidence on their long-term effectiveness. According to the American Psychological Association [79], on average, 15 to 20 sessions are required for 50% of patients to recover, suggesting thus the importance of administrating interventions for more than 2 months.

Importantly, HCWs reported that most of their needs were organizational such as flexible working hours, safe working conditions, paid rest periods, improvement of protective equipment, support by superiors and co-workers and clear communication of policies related to workload and sick leave. This suggests the important role that work environment plays in the mental health and well-being of HCWs and the crucial role of healthcare systems to provide adequate support to their employees [5, 6]. Workplace environment is also an important determinant of HCWs’ performance and productivity, with their satisfaction associated with high-quality care provision. For example, studies suggest that supervisor support, incentives, recognition and reward system could be used to improve HCWs’ experiences and their overall work satisfaction [80, 81]. Given the importance that workplace environment has to the mental health of HCWs [82, 83], improving only individual-based needs will result only in small and short-term improvements in HCWs’ well-being. During pandemic outbreaks, organizational support has been proven to be effective in protecting the mental health of HCWs by having a proper plan with supporting online platforms for HCWs to express and address their concerns and feelings [84]. If workplace needs of HCWs are not adequately supported, this may result in emotional exhaustion and thus possibly reduced quality care to their patients.

With respect to interpersonal-related challenges and needs, studies reported HCWs being unable to spend time and having to choose work over family, while expressing a need for support from their family, spouse, and friends. The need of support by family members was found to be a crucial factor for motivating HCWs’ to work during COVID-19, with reduced family support associated with HCWs’ reduced mental health and well-being [8, 14]. Due to the COVID-19 pandemic, HCWs had to stay away from their family to protect them and were forced to work long hours under pressure, leading then into reduced mental health and social isolation [5, 6]. Policies regarding the inclusion of family members in treatment could be promoted with provision of brief training or skills enhancement for family members [85].

Studies also reported that community-level challenges and needs included mostly stigma and discrimination from society while expressing a need for support from community members. Societal stigmatization of HCWs during COVID-19 is not surprising as previous research [2, 5, 9, 15] suggests that since the beginning of the COVID-19 pandemic, social prejudice and stigmatization was directed to HCWs as they were exposed to COVID-19 and community members feared that they would contract them COVID-19. Possible interventions at the community-based level might include educational campaigns on the measures required to control the spread of the virus. Acknowledging the significant contribution of HCWs by community members is crucial as providing support to HCWs during pandemics might enhance their resilience and possibly reduce their burnout. Although some efforts were deployed during the COVID-19 pandemic to recognize the contribution of HCWs [86, 87], more support is needed as it can improve the functionality of the healthcare system and the overall resilience of communities during health crises.

Limitations

The results of this scoping review should be interpreted considering for its limitations. First, due to the rapid need for a review in this area, only three databases were searched, and a single reviewer extracted the data of the articles. However, the databases were chosen for their comprehensive coverage of health and psychological research, representing the main topic in a sufficient way. Furthermore, this review was limited to English language studies, thus, we might have missed some relevant studies especially from non-English speaking countries or journals. It should also be considered, that 51% of the included studies were conducted in non-English speaking countries (e.g., Pakistan, Bangladesh, Iran, Africa, India, Indonesia). In addition, some countries that were highly affected by the COVID-19 (e.g., Brazil, China) [88] were either underrepresented (e.g., only three studies included that were published in China) or no studies were identified (e.g., Brazil). No quality assessment was conducted as this study was a scoping review and therefore the evidence could be influenced by the studies’ methodological shortcomings.

Implications for researchers and clinicians

This rapid scoping review is the first mapping of the challenges, needs and psychological interventions for HCWs caring for COVID-19 patients based on the socio-ecological models. Given that behavior change and mental health improvement entails an interaction of factors [72], multi-level and multi-dimensional interventions are needed addressing not only individual-based factors, but also the multiple socio-ecological levels with a variety of interventions (e.g., societal, workplace, family, group and individual). However, expecting any single intervention to focus on three or more ecological levels may be unrealistic, but given that HCWs are the first to be infected and that they are the key to a healthcare system’s ability to respond to pandemic outbreaks, it is crucial to implement interventions that incorporate at least the individual and organizational key members [89] while encouraging health care systems to adopt a stepped care approach to services [90, 91]. Adopting a stepped care approach to delivering of interventions might be particularly useful, with the degree of support that HCWs will receive being stepped up based on their needs or presence of psychological symptoms [90, 92]. Digitally delivered interventions hold promise for effectively improving mental health and well-being, and can be used when HCWs are socially isolated and for targeting the limited available time due to excessive workload [14].

Psychological interventions were only delivered in HCWs working in primarily urban areas (e.g., Ontario, Zurich, Istanbul, Okayama). Although interventions are suggested to be more impactful in urban areas [93, 94], it is important to examine their effectiveness for HCWs working in rural areas as rural residents were found to be less likely to adapt preventive COVID-19 measures than those in rural areas [95]. Future studies are suggested to utilize interventions based on the socio-ecological framework additionally in rural areas and examine whether regional differences exist on interventions’ efficacy [93].

Community psychology interventions might be also effective as individuals’ behavior is influenced by the interaction with their context [96, 97]. Specifically, including community members (e.g., co-workers) in treatment is essential. Community interventions that focus on community-level change rather than individual usually integrate social, cultural, economic, political, and environmental to achieve empowerment at individual and systemic levels. For example, an intervention approach for HCWs based on community psychology might include group prevention trainings with other HCWs to address fears and reduced mental health related to the COVID-19 pandemic, problems experienced at work, and social action strategies such as community education. By addressing the multiple levels of influence on HCWs’ needs, interventions are more likely to be effective and to possibly better cope with future pandemic situations.