Introduction

The nursing workforce forms more than 60% of the healthcare workforce and it is reported to be the backbone of the healthcare industry, therefore their safety and welfare should be a priority for all players in the health sector [1]. Nurses are found everywhere, in the communities and health facilities both rural and urban delivering care. During the peak of the COVID-19 pandemic, nurses from all sectors of the profession played various roles which have resulted in the successes seen in the fight against the pandemic. While public health nurses and community health nurses were doing contact tracing and follow-up of cases [2], mainstream clinical nurses were found at the emergency units and isolation centres handling suspected and confirmed cases [3]. Critical care nurses were found in the intensive care units (ICUs) helping to revive those with respiratory distress, and the seriously ill assisted in feeding and taking care of their hygiene needs [4]. Furthermore, nurses handled dead bodies before their conveyance to the mortuary and gave psychosocial support to family members [5].

The roles nurses continue to play in combating the COVID-19 pandemic are enormous. The COVID-19 outbreak has strained the global healthcare system, with conditions getting worse as a result of overcrowding and caring for several patients in the hospital with proven or suspected COVID-19 infections and a lack of supplies, beds, and the workforce. Nurses have been confronted with numerous work-related challenges ranging from physical (injury/musculoskeletal problems) to psychosocial (stigma/verbal abuse) [6, 7]. These challenges have resulted in many nurses developing mental health disorders, quitting the profession, and some losing their lives [8, 9]. For these reasons, international nursing organisations, for example, the International Council of Nurses and the American Nurses Organisation have issued statements and envisaged that the future of the nursing profession is gloomy if nothing is done about the situation [10].

Previous pandemics caused mental health decline in people; however, the COVID-19 pandemic came with lockdowns, the mandatory wearing of PPEs, and movement restrictions in many countries that compounded the problem. Though there were limitations in healthcare, such limitations and stringent observation of protocols in healthcare have been incomparable globally due to differences in the availability of resources. Though there were issues with PPEs availability and space for patients, nurses in less endowed countries and health facilities suffered more. Hence, there were worries that nurses experienced anxiety due to concerns about the possibility of getting infected with COVID-19 [11].

The demanding working conditions nurses found themselves in made them develop serious psychological issues like insomnia, depression, and anxiety. In addition to the stress brought on by their core duties as nurses, their mental health got worse as a result of restrictions on their daily activities including bans on going out in public. Therefore, identifying risk and resilience characteristics linked to mental health issues related to COVID-19 is essential. This could assist those at risk and boost their resilience. COVID-19 did not only affect nurses’ emotions, but it also changed the way they cope [2].

It is therefore critical to ascertain stress management strategies that can aid nurses in coping with the extraordinarily trying conditions brought on by COVID-19 as well as for use in similar pandemics. Techniques for coping with stress and other psychosocial challenges during the 2002 SARS outbreak have been shown to enhance psychological symptoms and overall health. Further studies have revealed that during previous pandemics, nurses were able to handle the situation by controlling their emotions and adjusting to them. Therefore, using coping mechanisms under pressure may prevent a mental health catastrophe. Additionally, suggesting coping mechanisms for healthcare professionals will be crucial in reducing the detrimental impacts of COVID-19 [12].

Instituting holistic psychosocial support will help nurses continuously build resilience, thereby improving a safe working environment to promote quality of life, increase work output, and push towards the achievement of the Sustainable Development Goals (SDGs) and the Universal Health Coverage (UHC) by 2030 [13].

This review, therefore, sought to assess the various work-related psychosocial challenges nurses encountered during the pandemic, noting the major contributors to the challenges and the coping strategies nurses adopted to deal with them.

Methods

Design

A scoping review was performed as it aims at determining the range and extent of research activity, appraising key research outcomes, and finding gaps in the literature. A scoping review is usually undertaken to establish the need for a systematic review and to guide future research [14]. Scoping review approach was used because the researchers wanted to assess the extent of the body of literature on work-related psychosocial challenges of nurses associated with COVID-19, and the coping strategies. Investigating such a topic calls for an exploratory yet thorough mapping of essential concepts, evidence, and research gaps which is ideally suited for scoping review method [15,16,17]. A study protocol was developed but this was not published in the public domain. In this study, the six [6] stages of Arksey and O’Malley’s scoping review methodology were followed [15]: [1] specifying the research goals and identifying research questions, [2] establishing the inclusion and exclusion criteria for the search, [3] identifying the search strategies, [4] charting the results, [5] discussing the results, and [6] providing conclusions and recommendations were followed. For the current review, details of the six stages are provided as follows:

Stage 1: specifying goals of the research and identifying research questions

The following questions guided the review:

  1. 1.

    What work-related psychosocial challenges do nurses encounter in the COVID-19 pandemic?

  2. 2.

    What coping strategies do nurses use to deal with work-related psychosocial challenges in the COVID-19 pandemic?

The study results were clearly and comprehensibly summarised. Through an iterative process of charting and analysing the data, extra pertinent result associated with the work-related psychosocial challenge was identified and presented below:

  1. 3.

    What factors account for the work-related psychosocial challenges among nurses?

Stage 2: inclusion and exclusion criteria

From each database, only peer-reviewed literature published from December 2019 to December 2021 was searched. In addition to the peer-reviewed literature, grey literature published within the specified period mentioned earlier was considered. The inclusion and exclusion criteria are presented in Table 1.

  1. i.

    Population: nurses involved in the care of COVID-19 patients in the clinical setting.

  2. ii.

    Exposure: working with COVID-19 cases, either confirmed or suspected.

  3. iii.

    Intervention: coping strategies that helped to reduce or prevent work-related challenges.

  4. iv.

    Outcome: psychosocial challenges that resulted from the COVID-19 pandemic.

  5. v.

    Study design: grey literature and peer-review publications comprising qualitative, quantitative, and mixed-method designs were included in the review (primary studies/ original articles).

Table 1  A comprehensive description of the eligibility of articles
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Stage 3: identifying relevant studies

The search was conducted in the following electronic databases: PUBMED, CINAHL, SCOPUS, and Google Scholar for articles published between December 2019 and December 2021. To guide the review, the PCC tool was used to separate the concepts: [1] Population/Problem (Nursing Workforce); [2] Concept (Work-Related Psychosocial Challenges and Coping Strategies); [3] Context (during the COVID-19). The keywords included challenges, nurses, pandemic, COVID-19, SAR-CoV2, work-related, and coping strategies. The search string (Nurs* OR Midwi*) AND (“Work-related” OR occupational OR “job-related”) AND (challenges OR problems) AND (“COVID-19” OR “SARS-COV-2”) AND (“Coping-strateg’’ OR Resilience) was compiled and first used for PUBMED and later adapted for the other databases. In addition to the search string, the following MESH terms were employed: nurse, nurse clinician, midwife, midwives, and midwifery, which were used to search for the population. The concept of work-related psychosocial challenges and coping strategies were searched using MeSH terms separated by BOOLEAN operators AND/OR: job-related OR occupational OR work OR professional OR work-related OR hospital-related AND psychosocial AND challenges OR factors OR problems OR coping strategies OR coping behaviour OR resilience. The context was searched using COVID OR Covid-19 OR COVID-19 OR SARS-COV-2, as MeSH terms. All remaining terms were free terms. Google Scholar was also searched using the terms nurse AND work-related challenges AND coping strategies in SARS-COV2 OR COVID-19 pandemic. The references to the included articles were also hand-searched to see if any studies were missed in the initial search. The following grey literature sources were also searched: MedNar, Open Grey, and Trove. Articles were considered for the analysis if they reported both or separate results for work-related challenges and coping strategies among nurses.

The title, the abstract, and the full text of the articles were independently assessed by the three reviewers. On the occasion of differences in opinion, an agreement was reached through discussion and consensus. Stage 4 is detailed in the results section of this study followed by stages 5 and 6 in the discussion and conclusion segments respectively.

Results

Data charting process and synthesis

The results from the selected databases generated 7,334 articles. Articles with abstracts were exported using Zotero software (5.0.96), and data were entered into a standardized data chart using Microsoft Word. Information on author(s), year of publication, title, study purpose, study location, study design, and findings were recorded. After duplicate articles were removed, two reviewers critically read the abstracts of 271 articles. An additional 192 articles were then excluded after reviewing the abstracts as they did not meet the inclusion criteria of the population being nurses and primary articles. In all, 79 articles related to the research questions were included in the review but only 45 fully met the inclusion criteria of attaining their full text and also discussing the psychosocial challenges of nurses and/or coping strategies. Figure 1 details the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for selecting the articles. Based on the review aim, further data were extracted to be able to answer the review question. To synthesize the extracted data, we used the review aim as a heuristic guide to formulating codes across the included studies following which similar codes were aggregated to formulate sub-categories. Finally, similar sub-categories were merged to develop categories that formed the basis of undertaking a narrative synthesis.

Fig. 1
figure 1

PRISMA ScR Flow Diagram depicting the study selection process

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Out of the 45 studies, there were 39 quantitative studies; 38 cross-sectional designs [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55], a longitudinal study [56], and six [6] qualitative studies [57,58,59,60,61,62]. All studies were conducted in a hospital setting, with the sample size for the quantitative studies varying between 91 [24] and 7542 [35]. The qualitative studies had sample sizes of 12 [58], 15 [61], 17 [62], 20 [60], 26 [57], and 55 [59]. Eight [8] of the studies were undertaken in China [26, 45, 51,52,53,54,55,56], six [6] studies in the United States [18, 23, 47, 48, 59, 63] and two [2] each from Iran [58, 61], Italy [30, 41], Lebanon [19, 20], Philippines [38, 62], Poland [24, 37], South Korea [32, 39], Spain [40, 46], and the UK [43, 44], a study each from Canada [60], Cyprus [29], Ecuador [28], Egypt [49], Germany [35], Indonesia [42], Israel [31], Jordan [57], Malaysia [25], Norway [50], Saudi Arabia [22], South Africa [27], and three multi-country studies [33, 34, 36] as presented in Table 2.

Table 2 Characteristics of Included Studies
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Work-related psychosocial challenges among nurses

The results on psychosocial work-related challenges among nurses and their coping strategies were descriptively summarized. The challenges identified were categorised into psychological and social with a brief description given under each. The factors accounting for the challenges and the coping strategies used have been provided in Table 3.

Table 3 Data synthesis
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Psychological challenges

The psychological problems came in the form of a higher level of burnout, higher levels of depression, intense anxiety, post-traumatic stress disorder (PTSD), sleep disorders, low quality of life, and fear of infection and death. These problems arose because nurses saw a lot of people dying including their colleagues and loved ones. They felt hopeless, helpless, and inadequate in their caregiving roles. In addition, false information gotten from social media and television made nurses uncertain about the viral dynamics because of the different variants that kept coming up (18, 20, 22, 23, 25,26,27, 29,30,31,32, 34, 35, 37,38,39,40,41,42,43,44,45, 47,48,49,50,51,52,53,54,55,56,57, 59, 60, 62,63,64).

Social challenges

Front-line nurses were separated from their families because of the virulent nature of the virus. In addition to the various lockdowns that were imposed on countries with higher case fatalities and infection rates also affected them. Business closures affected nurses with financial insecurities. Nurses had uncertainty about their job and work output (30, 42, 62).

Factors accounting for work-related psycho-social Challenges among nurses

In the present review, immense challenges were identified in the work environment of nurses which contributed to their psychosocial problems. These factors include the inadequate supply of resources and uneasiness associated with the use of personal protective equipment (PPEs), lack of fixed guidelines on case management, infection prevention protocols, and low inter-shift recovery. The inadequate PPEs supply put nurses at higher risk of contracting the virus [18, 21, 23, 28,29,30,31, 49, 59, 60, 62].

Other factors included the severity of patients’ conditions and working in COVID-19 centres as a frontline nurse. Frontline nurses were worse in depression, anxiety, and stress levels than non-frontline nurses. Increased workload and hours per week, and the tedious shift system contributed to insomnia, fatigue, low inter-shift recovery, burnout, and PTSD, though the frequency of 30-minute breaks was significant in reducing some of the challenges. The stress level of nurses was attributed to fear of exposure to infections from COVID-19, and fear of illness/death of the patient, co-workers, and/or loved ones. Additionally, nurses felt inadequate and helpless in the care of COVID-19 patients at the workplace, especially in the event of the high incidence of false information about COVID-19 in the media [23, 30, 34, 35, 40, 45, 47, 48, 56, 57, 62]. Cai et al. [56] and Coffré and Aguirre [28] on the other hand indicated that watching colleagues cry at work, induced stress among nurses, and was associated with the age of the nurse, as younger nurses were more worried about the health of their families, patients, and colleagues compared to experienced nurses. Similarly, being single or divorced, the female gender and the position of nurses in their families (being the only child in their families) influenced the work-related psychosocial challenges. Higher levels of contemplation resulted from increased job stress and increased job demand. The lack of specific treatment for COVID-19, vaccines unavailable, financial hardship, social rejection, and stigmatization of nurses, all contributed to various work-related challenges [30, 42, 48, 51, 52].

Coping strategies

The strategies used to resolve work-related challenges were either nurse-specific or an institutional-established plan to cope with the challenges of the pandemic. First, nurses used emotion-focused coping (EFC) or problem-focused coping (PFC) such as avoidance, religion, emotional support, planning, active coping, substance use, self-blame, venting, and reframing depending on the nature of the challenge. While EFC was used to improve the resilience of nurses (lack of support, insufficient preparation, and fear of infection), PFC was more helpful in dealing with psychological stress (fear of infection and work overload). Most nurses, however, combined both coping strategies [19, 25, 27,28,29, 33, 37, 40, 44, 46, 51, 54]. The exhibition of a positive attitude among nursing team members and assurance of nurses that COVID-19 cases improve was also helpful in dealing with the challenges.

Accessing online psychological information had a protective impact factor for anxiety, insomnia, and PTSD symptoms [51, 56, 64]. Most nurses reiterated that sticking to the same or even reduced hours in a shift at work or a flexible work schedule helped them cope with the stresses [59, 61]. Coping strategies related to the safety of nursing practice: strictly following personal protective measures, for example, maintaining separate clothing for the street and work, constant use of masks, and COVID-19 knowledge acquisition were listed as activities undertaken. Other measures included effective communication with relatives and friends; positive thinking and attitudes, and improved nutrition, exercise, and recreational activities were helpful coping measures [22, 25, 28, 34, 39].

Rest breaks, daily self-health monitoring, vaccination, and the use of anti-viral sprays and thymus injections to enhance immunity were also effective for most nurses in COVID-19 centres [65]. Online counselling, advice hotlines, and online chat rooms for frontline nursing staff were explored in handling psychological distress. Mindfulness-based intervention is aimed at reducing stress through mindful meditation practices [26, 28, 36, 39, 40, 44, 56]. Management-related strategies designed by facilities to support nurses with work-related challenges: continuous guidance and psychological assistance by management, training schedules for staff including orientation to general ward work and nursing responsibilities, infection control and self-protection, mental health guidance to orient younger and less experienced nurses during the pandemic response and provision of sufficient work resources including PPEs, benefits such as financial and non-financial incentives and promotions packages to engage in volunteer workforces to support frontline during shortage and work overload [59, 61]. Others included the introduction of flexible work schedules through rearrangement of the workforce, thus relocating high-risk staff, e.g., aged, pregnant, and lactating nurses and nurses with underlying medical conditions to work areas of low-risk of COVID-19 [24, 25, 28, 34, 37, 46, 48, 61].

Discussion

It is essential to synthesize evidence to improve practice and inform policy in nursing care and workforce management. This review identified studies that aimed to determine work-related psychosocial challenges nurses faced while caring for COVID-19 patients and summarised the most common work-related psychosocial challenges, factors accounting for the challenges, and coping strategies nurses use in dealing with them across the globe. The impact of the pandemic, which places in perspective the challenges on healthcare facilities and the nursing workforce is enormous [66, 67].

The commonest psychosocial work-related challenges included stress, anxiety, depression, sleep difficulties, burnout, PTSD, fear of infection and death, and stigmatization. These work-related psychosocial stresses resulting from COVID-19 are likely to have more repercussions on nurses even after the pandemic [68] as past episodes of pandemics have demonstrated similar findings. According to Xiao et al. [69], nurses who provided care during SARS experienced stress and psychological discomfort which accounted for 68% and 57%, respectively. Likewise, between 29 and 35% of nurses reported experiencing a significant level of distress, and the pertinent contextual characteristics were working with SARS patients, being a nurse, and being a parent.

The death of people including nurses is alarmingly causing a lot of fear, depression, and anxiety [5, 70, 71]. Aside from the fear of death, anxiety, depression, and PTSD, nurses also experience burnout due to excessive workload and psychological distress. Likewise, stigmatization has resulted from working as a frontline in a stressful environment [72]. Similar findings have been reported in the past by Bernaldo-De-Quirós et al. [73] and Donnelly and Siebert [74] while occupation and other sociodemographic factors are major contributors to burnout [75, 76]. COVID-19 has been a major significant challenge confronting nurses and, therefore advocacy to better the psychological well-being of nurses is essential through the various waves of the pandemic.

Coping strategies were aimed at insulating nurses from both physical and psychological challenges. Though rest break has been mandatory in most public organizations, their impact has not been adequately reported concerning nursing care outcomes. In the past, most nurses did not consider the significance of rest breaks as a means of coping with the challenges of the stressful work environment. Findings from the current review demonstrated the need to institute compulsory rest breaks in the daily schedule of the nurse as physical restitution, decreased feeling of being sick, improved safety-related decision-making, and the general well-being of nurses is associated with rest breaks during work [77, 78]. Again, the usefulness of problem-focused and emotion-focused coping strategies in reducing the psychological burden on nurses has been explored in the past. Emotion-focused coping has been demonstrated to be effective when dealing with emotional trauma associated with work. Nurse managers responsible for policymaking in the healthcare system should consider developing culturally sensitive coping strategies. Resilience among nurses can be empowered by integrating coping strategies in the educational and orientation programs for nurses [19, 20].

Though much cannot be said about the use of online social support such as chat rooms, counselling and advice by healthcare providers facing work-related stresses, such coping strategies have been used to provide support [79, 80]. The opportunity created through these media enhanced the ability of nurses to share their emotions (sadness and fear). These findings are consistent with other studies that saw a positive association between the use of technological support and the reduction of fear and depression among the health workforce [81,82,83]. The role of online advice, chat rooms, and counselling in reducing psychological stress among nurses is promising and calls for further studies on it.

Meanwhile, major difficulties encountered during the pandemic were increased workload and the shortage of PPEs which is similar to reported cases of health commodity shortages during the Ebola outbreak [84, 85]. Due to the highly contagious nature of the COVID-19 pandemic, all facets of the health system including health financing and human resource have been challenged, and the effect is global shortages of PPEs. Safeguarding the judicious supply of quality and quantity health commodities is germane to the emergency response systems globally. Measures at increasing the training of such cadres of the nursing workforce will help reduce the workload on these few specialist nurses, thereby improving efficiency in the provision of delicate but complex nursing care to patients. Implementing a scientifically arranged shift system through rational allocation of the nursing workforce and flexible duty roster can reduce the physical and psychological challenges associated with the pandemic [86].

The subject has been a great concern in managing human resources in health services, and therefore it is essential to fully appreciate and ease its effects on patients and workforce safety. This position is supported by Ramaci et al. [87] and Schubert et al. [88] who reiterate that supportive strategies against stigma are recommended at workplaces to promote nurses’ well-being, as stigmatization can impact nurses’ work ethics in the management of COVID-19 patients. Policy measures on the work environment are, therefore, needed to ensure the motivation and job satisfaction of nurses. This will go a long to reducing turnover associated with the COVID-19 pandemic [89].

Challenges of physical and psychological stress are resolved through a flexible shift system for experienced and inexperienced nurses. The support system at work from nurse managers also contributes immensely to the coping of nurses [90, 91]; these are similar to findings from the review. This review supports findings of management-instituted support through building a strong nursing workforce teamwork, provision of psychological counselling units for nurses, incentives packages, and other external support for nurses during the pandemic [2, 92, 93]. These strategies help motivates nurses, and also reduce the infection- and death-induced fear associated with the provision of care to patients. As a way of building resilience, developing an optimistic attitude towards life is helpful in psychosocial work-related challenges, and enhances the overall well-being of the workforce. Again, our review demonstrated the establishment of programmes designed to educate nurses on COVID-19 and also on how to deal with stress at work through emotion-focused and problem-focused coping, and this was recommended in past studies [94,95,96].

Furthermore, while some nurses experienced social isolation due to being separated from loved ones and friends, others experience stigmatization. Congruent with other studies, nurses also go through the ethical dilemma and are found battling with either quitting their job as their families mount pressure on them to quit the job due to stigma or fulfilling professional goals and values [71, 97]. This calls for the attention of all stakeholders to find a lasting solution to these problems endangering the lives of nurses across the globe.

Conclusion and implications

The final stage of the scoping review dealt with the conclusion of the findings. The studies reviewed were mostly from China, with a few from other parts of the world. Meanwhile, the literature indicates that Africa, as a resource-constrained continent, will have serious consequences from COVID-19 for the healthcare workforce, especially the nursing workforce. However, the authors came across only one primary study done in Africa specifically on nurses’ work-related challenges as frontline health workers. We, therefore, recommend that more studies concentrated on African nurses so that their unique concerns can be brought to bear. Again, 39 out of the 45 studies reviewed were quantitative studies, and six qualitative studies were reviewed. We also recommend more qualitative studies be done to gain a deeper understanding of the challenges nurses faced from their perspectives. Finally, it was observed that most of the psychological challenges were more pronounced in the female gender, which is also predominant in the nursing profession. Policy decisions could be made to increase the intake of male nurses, who seem to be more resilient and can withstand pressure to provide support in fluid situations like the current pandemic. In the future and subsequent waves, nurse managers should select experienced staff who are not too old and can withstand the virulence of the virus. This study’s findings are not surprising because of the nature of the pandemic, the dominance of the female gender in the nursing profession, and the roles of the female gender in homes and society. What is worrying therefore is the fact that nurses are dying, and some have depression and PTSD. This invariably is going to affect the nursing profession, the overall quality of life of the nurses, and ultimately, the realisation of UHC and SDGs. The WHO, health institutions/hospitals, and nursing organisations both international and local should plan activities to give universal psychotherapy to nurses across the globe to help them recover fully from the effects of the pandemic. It is also recommended that healthcare facilities prioritize the following steps in the event of a future pandemic institute more psychological support systems at the workplace for nurses and also enhance coping skill training. Again, to create a safe environment to minimise the spread of infectious disease in hospitals, suitable medical protective equipment must be installed, and there must be a commitment from all stakeholders to building resilient healthcare to withstand any unforeseen events in the future. This would foster a positive atmosphere and ensure the nurses’ safety, enabling them to continue providing the highest standard of patient care to defeat this disease.

Limitations

Despite the interesting findings obtained, some limitations are noteworthy. Firstly, only studies with a full article were considered for inclusion, which led to the exclusion of studies with only the abstract. Secondly, the quality of the included primary studies was not assessed due to the scoping nature of the study. Thus, the findings may be interpreted with caution. Again, a critical appraisal of the sources of evidence was not conducted and, as such, was not reported.