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\def\RunningAuthor{Aruna Jothishanmugam et al.}
\firstPage{1905}
\articleType{Review Article}
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\title{Psychological impact of COVID-19 outbreak on nurses: A systematic review}
\author{Aruna~Jothishanmugam\textsuperscript{*}\textsuperscript{1},  
            Sithara~Begum\textsuperscript{2},  
            Amani~Abdelgader~Mohammed~Abdelgader\textsuperscript{3},  
            Hawa~Ibrahim~Abd~AllaHamid\textsuperscript{1}, 
            Nagla~Abdelmonim~Abdelrahim~Abdalghani\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Nursing, Aldair University college, Aldair, Jazan university, Saudi Arabia}~\\{\textsuperscript{2}Department of Respiratory therapy, Jazan, Jazan University, Saudi Arabia}~\\{\textsuperscript{3}Department of Nursing, Sabya University college, Sabya, Jazan University, Saudi Arabia}}

\begin{abstract}
The sudden exposure of COVID-19 has affected more than one hundred million people live and heath across the world. COVID-19 pandemic not only affected the lives of people, and it also affected the functions of Health care systems and also produced an overburden to the Health care systems. During the COVID-19 period, health care workers are affected by psychological problems, especially nurses working in the hospital and protecting the lives of everyone affected with COVID -19 infections. It is important to identify the issues that producing psychological problems among nurses, and it is necessary to support the nurses during their struggle. The researcher considering these issues, did a rapid systematic review to identify the percentage of nurses affected with psychological impact and causes for psychological impacts among nurses during COVID19 outbreaks. The researcher searched Google scholar and Science direct for selecting relevant research articles. The searched the studies based on the title, Study design, population, psychological problems of the nurses like anxiety, depression, fear, stress, sleeping problems, key words of nursing, psychological problems, and COVID-19. A PRISM protocol was used for selecting relevant research articles. According to the systematic review, the result shows that 26\textit{.}4\% of the nurses had depression, 40.8\% had anxiety, and 42.7\% had somatic symptoms\textit{, }50.5\% had stress, and 91.2\% had fear. The nurses are at risk of psychological problems and physical problems as being due to Covid-19. Effective intervention should be planned on nurses' issues, and it helps to strengthen the mental health of nurses. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Coronavirus,\newline COVID-19,\newline Nurses,\newline Depression,\newline Anxiety,\newline Stress
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Aruna~Jothishanmugam~\\ Phone:\ ~\\  Email:\ arunamsnhod@gmail.com
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\section{Introduction}
Coronavirus is an infectious disease. The infection was first identified in Wuhan City, China. The information about the infectious diseases was communicated to WHO on December 31st, 2019. But in 2020, January 30th, The World Health Organization declared that Covid -19 is a world pandemic health emergency. All the counties were taken preventive measures to control the spread of infection.

The covid-19 pandemic produced an impact on economic and psychological problems among the public. It also produced a massive impact on the health care system and health care workers. Health care workers are affected with psychological problems like depression, anxiety, stress, emotional distress, and sleeping problems, especially among front-line life supporters such as nurses, are affected extensively \unskip~\citep{1020102:21539438}. It was supported by the findings of the American Nurses Association survey. It was done from March to April 2020 among 32,000 nurses. The results show that 87\% of nurses were fear going to work, 36\% of the nurses said they were taken care of Covid -19 infected patients without PPE, and 11\% of the nurses said they can take care of COVID-19 patients \unskip~\citep{1020102:21539572}.

There are some other factors that also contributed to increase the psychological problems among nurses. They are, lack of knowledge and skills to take care of patients produced physical and mental exhaustion and negative emotion and psychological distress among nurses \unskip~\citep{1020102:21539566}. It implies an urgent need and importance to provide psychological support for nurses with psychological distress. Hence, the Researcher did a rapid systematic review to find out the proposition of nurses faced psychological problems during COVID -19 pandemic period and the factors that contributed towards psychological problems among nurses. 
    
\section{Methods}
The researcher chosen systematic review methods to find out the percentage of nurses affected with psychological problems and the factors that produced psychological problems among nurses during outbreaks of COVID-19. The researcher followed PRISM guidelines to select a research article for a systematic review \unskip~\citep{1020102:21539493}, Figure~\ref{f-050c868401d7} shows,

\textbf{Eligibility criteria} \textbf{\space }

\textbf{Exclusion Criteria}


  
  \begin{enumerate}
  \item \relax The studies are done to assess the psychological problems among health care workers during COVID-19 outbreaks.
  \end{enumerate}
  \textbf{Inclusion Criteria}


  
  \begin{enumerate}
  \item \relax Studies published to identify the psychological problems among nurses during COVID-19 were added.
  \item \relax The studies published in the English language from March to October 2020 were taken for the study.
  \item \relax The studies done to find out the percentage of nurses affected with psychological problems among nurses and factors that producing common psychological problems. 
  \end{enumerate}
  \textbf{Data extraction from includes studies:}

The studies were selected based on the criteria. After selecting the studies, the following information were extracted and presented in Tables~\ref{tw-b32551ebb613}, \ref{tw-de766ee50c32} and~\ref{tw-a83664544155}. Tables~\ref{tw-b32551ebb613}, \ref{tw-de766ee50c32} and~\ref{tw-a83664544155} consist of the following information like, the date of the review, the title of the article, study design, study setting, outcome, and name of the journal and findings were summarized.
    
\section{Results}
\textbf{The information about studies}

According to the search, 19 researches were done to assess the psychological impact on COVID-19 outbreaks on nurses. Out of 19, only 9 articles met the inclusion criteria and the data and information was complete.

\textbf{Psychological impacts among nurses}

A study among 2014 nurses shows that 545 (27.1\%) had mild Anxiety, 221 (11\%) had moderate, and 67(3.3\%) had severe Anxiety. Similarly, 661 (32.8\%) had mild. Depression, 194 (9.6\%) had moderate and 23 (1.1\%) depression. According to the findings, the nurses (41.5\%) suffered with high emotional exhaustion, 27.6\% of nurses experienced high depersonalization, and 771 (38.3\%) were not able to complete their goal. It's showing that the nurses are suffering from high burnout during work \unskip~\citep{1020102:21539436}.

They are also data identified that 50\% of the nurses and 46.8\% of the midwives were selected as a sample for the study. According to the analysis, (36.3\%) felt Anxiety, (31.3\%) experienced uneasiness and 19.4\% felt fear due to COVID-19. The participants were having fear, anxiety, depression and 49.7\% of said that they experienced remorse about their profession \unskip~\citep{1020102:21539434}.

Study 4692 nurses who completed the survey, it was observed that 442(9.4\%) were experienced depressive symptoms, 379 (8.1\%) of nurses had anxiety, and out of 4692 nurses, 42.7\% had a somatic symptom, and about 306(6.5\%)participants had suicidal ideation \unskip~\citep{1020102:21539570}. A similar finding was found in another research done among 325 nurses. 123 (37.8\%) were had dysfunctional levels of Anxiety with a mean score of 8.440 \textit{(\textit{SD}} = 4.32). The finding shows that the nurses suffered with 'tonic immobility'(mean score 1.779, SD of 1.029) and dizziness (mean value of (1.726) with SD of 1.02) \unskip~\citep{1020102:21539469}. 

A similar manifestation was experienced by the nurses in ICU. According to the findings, 59\% of nurses were suffered from appetite or indigestion 


\bgroup
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\caption{\boldmath {PRISM flow diagram for database search of studies}}
\label{f-050c868401d7}
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\egroup

\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.04360000000000001\linewidth-2\tabcolsep}p{\dimexpr.11309999999999999\linewidth-2\tabcolsep}p{\dimexpr.14070000000000004\linewidth-2\tabcolsep}p{\dimexpr.16699999999999996\linewidth-2\tabcolsep}p{\dimexpr.1834\linewidth-2\tabcolsep}p{\dimexpr.3521999999999999\linewidth-2\tabcolsep}}
\caption{\boldmath {Study Details} }
\label{tw-b32551ebb613}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} \hline \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}S, NO & Author, Country and year & Study Title & Study Design & Intervention and Outcome & Key findings\\
\tblmidrule 
1 &
  \unskip~\citep{1020102:21539436} &
  Frontline nurses' burnout, anxiety, depression, and fear statuses and their associated factors during the COVID-19 outbreak in Wuhan, China: A large-scale cross-sectional study &
  A large-scale cross-sectional, descriptive, correlational study design \mbox{}\protect\newline N-2014 &
  Socio-demographic and background data, a set of valid and reliable instruments were used to measure outcomes of burnout, anxiety, depression, fear, skin lesion, self-efficacy, resilience, and social support via the online survey. &
  About half of the nurses reported moderate and high work burnout, as shown in emotional exhaustion (n = 1,218, 60.5\%), depersonalization (n = 853, 42.3\%), and personal accomplishment (n = 1,219, 60.6\%). The findings showed that 288 (14.3\%), 217 (10.7\%), and 1,837 (91.2\%) nurses reported moderate and high levels of anxiety, depression, and fear, respectively..\\
2 &
  \unskip~\citep{1020102:21539434} &
  Psychological effects of nurses and midwives due to COVID-19 outbreak: The case of Turkey &
  Descriptive study \mbox{}\protect\newline n-758 &
  Personal Information Form, State-Trait Anxiety Inventory and Intolerance of Uncertainty Scale were used as data collection tools. &
  Participants who attended the study were 56.9\% of nurses and 43.1\% of midwives. Approximately half of the nurses and midwives (48.8\%) participating in our study contacted the patient with suspected COVID-19, and 29.8\% provided care to the patient diagnosed with COVID-19. Nurses and midwives were scored 52.75 \ensuremath{\pm} 9.80 for State Anxiety, 44.87 \ensuremath{\pm} 7.92 for Trait Anxiety Inventory and 35.16 \ensuremath{\pm} 9.42 for Intolerance of Uncertainty Scale. It has been determined that 54.5\% of nurses and midwives have been making their lives worse since the outbreak started, 62.4\% had difficulties in dealing with the uncertain situation in the outbreak, 42.6\% wanted psychological support, and 11.8\% had alienated from their profession\\
3 &
  \unskip~\citep{1020102:21539570} &
  Immediate psychological impact on nurses working at 42 government-designated hospitals during COVID-19 outbreak in China: A cross-sectional study &
  Cross-sectional Study, \mbox{}\protect\newline N-4692 &
  A structured self-administered questionnaire was used to collect the data. demographic data, Perceptions and Attitudes Toward COVID-19, COVID-19-Related Experience, job-related stress severity scale was used to collect the data &
  4,692 nurses who completed the survey, 9.4\% (n = 442) were considered to have depressive symptoms, 8.1\% (n = 379) represented anxiety, and 42.7\% (n = 2,005) had somatic symptom. About 6.5\% (n = 306) respondents had suicidal ideation.\\
4 &
  \unskip~\citep{1020102:21539469} &
  COVID-19 anxiety among frontline nurses: predictive role of organisational support, personal resilience and social support &
  cross-sectional study \mbox{}\protect\newline n-325 &
  Four standardized, self-reported scales were used for data collection: the COVID-19 Anxiety Scale, the Brief Resilient Coping Scale (BRCS), the Perceived Social Support Questionnaire (PSSQ) and the Perceived Organizational Support (POS) questionnaire. &
  Of the 325 nurses in the study, 123 (37.8\%) were found to have dysfunctional levels of anxiety. Using multiple linear regression analyses, social support (\ensuremath{\beta } = \ensuremath{-}0.142, p = .011), personal resilience (\ensuremath{\beta } = \ensuremath{-}0.151, p = .008) and organisational support (\ensuremath{\beta } = \ensuremath{-}0.127, p = .023) predicted COVID-19 anxiety. Nurse characteristics were not associated with COVID-19 anxiety\\
5 &
  \unskip~\citep{1020102:21539571} &
  Measuring the extent of stress and fear among Registered Nurses in KSA during the COVID-19 Outbreak &
  cross-sectional study,n-314 &
  The survey was divided into five sections: demographic information, exposure to the COVID-19 outbreak, job stress related to the COVID-19, fear of infection, and factors that might contribute to stress. &
  The survey was divided into five sections: demographic information, exposure to the COVID-19 outbreak, job stress related to the COVID-19, fear of infection, and factors that might contribute to stress friends and colleagues (mean \ensuremath{\frac14}  7.61, SD (2.72).\\
\tblbottomrule 
\end{longtable}
\endgroup
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\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.0645\linewidth-2\tabcolsep}p{\dimexpr.12\linewidth-2\tabcolsep}p{\dimexpr.1393\linewidth-2\tabcolsep}p{\dimexpr.12110000000000003\linewidth-2\tabcolsep}p{\dimexpr.26509999999999998\linewidth-2\tabcolsep}p{\dimexpr.29\linewidth-2\tabcolsep}}
\caption{\boldmath {Study Details (\textit{Continued from Table 1})} }
\label{tw-de766ee50c32}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} \hline \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}S, NO & Author, Country and year & Study Title & Study Design & Intervention  and Outcome & Key findings\\
\tblmidrule 
6 &
  \unskip~\citep{1020102:21539565} &
  The psychological stress of ICU nurses in the time of COVID-19 &
  Descriptive Study design,n-85 &
  Self-administering Questionaire &
  We surveyed 85 ICU nurses in our ward and found that the main manifestations were decreased appetite or indigestion (59\%), fatigue (55\%), difficulty sleeping (45\%), nervousness (28\%), frequent crying (26\%), and even suicidal thoughts (2\%). Especially, young nurses with no experience of caring for critically ill patients face a greater psychological crisis\\
7 &
  \unskip~\citep{1020102:21539438} &
  Emotional responses and coping strategies in nurses and nursing students during Covid-19 outbreak: A comparative study &
  A comparative study,n-850 &
  Demographic data, positive and negative emotion (PANAS) scale, The tool for measuring the coping strategies during the outbreak of COVID-19 was revised based on the Brief COPE)scale &
  Independent sample t test found that anxiety in professional nurses (t\ensuremath{_{(799.33)}} = 3.05, \textit{p} = 0.002, Cohen's d = 0.220), fear (t\ensuremath{_{(799.33)}} = 3.05, \textit{p} {\textless}0.0001, Cohen's d = 0.326), sadness (t\ensuremath{_{(799.33)}} = 4.59, \textit{p} {\textless}0.0001, Cohen's d = 0.565), and anger (t\ensuremath{_{(802)}} = 4.56, \textit{p} {\textless}0.0001, Cohen's d = 0.322) was significantly higher than the emotional level of nursing college students. Women experienced significantly higher anxiety than men (t\ensuremath{_{(802)}} = -3.62, \textit{p} {\textless}0.0001, Cohen's d = 0.08) and fear (t\ensuremath{_{(314.44)}} = 5.17, \textit{p} {\textless}0.0001, Cohen's d = 0.427). Participants from rural areas experienced more sadness (t\ensuremath{_{(584.85)}} = -3.85, \textit{p} {\textless}0.0001, Cohen's d = 0.285) than participants from urban areas, while participants from urban areas experienced more anxiety (t\ensuremath{_{(679.52)}} = 2.55, \textit{p} = 0.009, Cohen's d = 0.192) and anger (t\ensuremath{_{(802)}} = 3.04, \textit{p} = 0.002, Cohen's d = 0.226) than participants who lived in rural areas.\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 

\begin{table*}[!htbp]
\caption{\boldmath {Study Details (\textit{Continued from Table 2})} }
\label{tw-a83664544155}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.05900000000000001\linewidth-2\tabcolsep}p{\dimexpr.1918\linewidth-2\tabcolsep}p{\dimexpr.1725\linewidth-2\tabcolsep}p{\dimexpr.1116\linewidth-2\tabcolsep}p{\dimexpr.20700000000000003\linewidth-2\tabcolsep}p{\dimexpr.2581\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S, NO & Author, Country and year & Study Title & Study Design & Intervention and Outcome & Key findings\\
\tblmidrule 
8 &
  \unskip~\citep{1020102:21539564} &
  Impact of COVID-19 on the psychology of nurses working in the emergency and fever outpatient: A cross-sectional survey &
  :A cross-sectional survey,n-453 &
  Data were obtained by self-administered online questionnaires, which consisted of a general questionnaire, the Self-Rating Anxiety Scale, Perceived Stress Scale-14 and Simplified Coping Style Questionnaire. &
  Results Among the participants, 281(62.03\%) had no anxiety symptoms, 154(34.00\%) had mild anxiety, 16(3.53\%) had moderate anxiety, and 2(0.44\%) had severe anxiety. There were 146(32.23\%) participants with scores greater than 25 in the PSS, indicating excessive stress.\\
9 &
  \unskip~\citep{1020102:21539435} &
  Psychological impact of COVID-19 outbreak on frontline nurses: A cross-sectional survey study  &
  Cross-sectional study,,n-263 &
  The survey included six main sections: the General Health Questionnaire, the  Perceived Social Support Scale, the Simplified Coping Style Scale, the   \mbox{}\protect\newline Impact of Event Scale-Revised, socio-demographic, occupation and work history \mbox{}\protect\newline  &
  According to the Results, 263 frontline nurses,  \mbox{}\protect\newline  66 (25.1\%) were identified as psychological  \mbox{}\protect\newline  distress.  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
problems, 55\% from fatigue,45\% of nurses suffered with sleeping difficulties, 28\% nurses with nervousness, 26\% had felt like crying and 2\% nurses had suicidal thoughts (2\%). Especially, newly joined nurse's experienced psychological crisis because they were provided care to the COVID-19 patients with the critical condition without previous experience in ICU \unskip~\citep{1020102:21539565}.

A study to find out the impact of COVID-19 on the psychological condition of nurses who is working in emergency and fever outpatient was conducted. According to the findings, out of 453 participants, 281(62.03\%) of the nurses had no anxiety symptoms, 154(34.00\%) had mild Anxiety, 16(3.53\%) had moderate Anxiety, and 2(0.44\%) had severe Anxiety. The findings also show that nurses were experienced stress, along with Anxiety. Out of 453 nurses, 146(32.23\%) participants experienced excessive stress with scores greater than 25 in the Perceived Stress Scale \unskip~\citep{1020102:21539564}. The same findings was reported by another research; out of 263 nurses, 66(25.1\%) nurses working in the frontline had a psychological impact. According to the researcher's findings, more than 60\% of nurses were affected with psychological problems during COVID-19 outbreaks  \unskip~\citep{1020102:21539435}.
    
\section{Discussion}
According to a systematic review, nurses are faced with psychological problems during the COVID-19 period. The most common psychological problem is anxiety, depression, stress, fear, sleep disturbance, and suicidal thoughts. It also indicates that nurses in a psychological crisis. 

There are a vast number of factors associated with psychological problems. The main issues are inadequate PPE supplies, not having adequate preparedness to care for patients with Covid-19. It was supported by the survey study done by the American Nurses Association (ANA; 2020). The survey study was done with 32,000 nurses from March to April 2020. Out of 32,000, 87\% of nurses were feared going to work, 36\% have provided care to the COVID-19 patients without having adequate Personnel Protective Equipment, and only 11\% of the nurses said that they are had adequate training and confidence to care for patients with COVID-19. It indicates that there is a need to train the nurses for personal safety and the procedure of using PPE.

According to American nurses were not prepared for the coronavirus pandemic. It is not the fault of nurses; it is because of lack of workforce preparedness even after exposure to pandemic infectious diseases like H1NI in the year 2009-2010 and Ebola Outbreak in the year 2013-2016 \unskip~\citep{1020102:21539572}.

The other factors related to nurses' psychological problems are workload, the continuous wearing of PPE, and the constant wearing of PPE issues of work-related emotional support. The same findings was highlighted by Deying Hu et al., 2020. According to the analysis, most of the participants were felt uncomfortable by wearing PPE throughout the shift. According to the findings. 94.85\% of the participants had skin lesion because of wearing PPE continuously. It added the psychological discomfort among nurses. Moreover, many nurses did not manage and treat their skin lesions due to a lack of related knowledge or no medicine available at hand.

The reasons for psychological problems among Frontline nurses were fear of infecting her family (71.9\%), not meeting with her family (7.1\%). Missing her family (21.\%5), decreased work efficiency due to Fear of transmission (75.9\%), reduced care of patients due to fear of communication (9.1\%), Tiring, and inadequate productive work because of no protective equipment (5.0\%) \unskip~\citep{1020102:21539434}. The similar reasons for psychological problems nurses was identified and discussed by another study in that 60\% of the registered nurses felt they were not personally well-prepared to handle the outbreak, and it could be the additional causes for producing fear and stress among nurses \unskip~\citep{1020102:21539571}. 

Nurses were experienced psychological problems because most of the patients on a mechanical ventilator with advanced life support, such as extracorporeal membrane oxygenation, continuous renal replacement therapy, and ventilation in the prone position. The other factors induced psychological problem among nurses are huge workload, long-term fatigue, infection threat, and frustration with the death of patients whom they cared and also due to anxiety, many nurses had misunderstanding among patients and their family members \unskip~\citep{1020102:21539565}.

According to the researcher's findings, more than 50\% of nurses were affected with psychological problems during COVID-19 outbreaks. It implies that early identification of psychological distress and supportive intervention to be given based on the associated factors. It can help to prevent severe psychological problems and mental health impact among nurses.
    
\section{Conclusion}
As per the findings of the study, providing an adequate number of nurses, hospital supplies, strict infection control practices, shorter shift length, ensuring sufficient rest time, timely updating the nurses with the latest information about COVID 19, organizing training programme about how to use of PPE, and also about how to provide care for COVID 19 patients with ventilator and also the leader should do a regular inventory to identify and assess the availability of resources and supplying the adequate amount of resources without delay. It can reduce the psychological problems among nurses.

In conclusion, it is a right time, all nursing personnel like nursing researchers, manger, leader, educator and nurses, who provided care of COVID-19 patients should join together and prepare a protocol, policy and pandemic preparedness guidelines for nurses to face a future pandemic situation effectively without any impact.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study. 
\section*{Acknowledgements}All researchers, who has taken the initiation to find out the psychological problems among nurse during COVID-19 outbreaks. It provided extensive information for us to complete this article. 
    

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