key: cord-0960065-m6rg1u5m
authors: Rony, Moustaq Karim Khan; Islam, Kanika; Alamgir, Hasnat M.
title: Coping strategies that motivated frontline nurses while caring for the covid‐19 patients during the pandemic: A Scoping Review
date: 2022-04-28
journal: J Nurs Manag
DOI: 10.1111/jonm.13644
sha: e22deab89a44996fde2e15e506af9765ebbfcc50
doc_id: 960065
cord_uid: m6rg1u5m

BACKGROUND: The world faced a great health crisis during the covid‐19 pandemic. Consequently, the healthcare providers struggled and faced tremendous difficulties in treating high‐load critical patients. This was particularly true in low‐ and middle‐income countries where the work and patient loads are always higher and nurses at the forefront must deal with emergencies while being at high risk of exposure. However, little is known about the survival strategies of frontline nurses as dealt with the pandemic. OBJECTIVES: This study catalogued the coping strategies of frontline nurses to deal with caring for the covid‐19 patients during the pandemic. METHODS: The Arksey O'Malley framework was followed to conduct a scoping review. A systematic literature search was conducted using three databases: Google Scholar, Scopus, and PubMed and out of the 192 studies, 12 met the inclusion criteria set for this review study. RESULTS: A total of 44 strategies were identified that motivated nurses to deal with the covid‐19 situation, and these strategies could be categorized into five main themes: nurses’ self‐strategies, nurses’ strategies at the ethical level, employers’ strategies, nursing leaders’ strategies, and supplementary strategies. CONCLUSIONS: The findings of this study will provide guidance for healthcare workers, employers, policy makers, regulators and other stakeholders to adopt and promote different strategies in managing difficult emergency situations in future. IMPLICATIONS FOR NURSING MANAGEMENT: This study emphasizes the importance of learning how to deal with adversity by healthcare workers and organizations in an emergency.

The covid-19 outbreak has highlighted the tremendous vulnerability of health care workers (HCW), especially direct patient caregivers like nurses all across the world. Patient handling and transferring; sharp injuries and spills exposure to blood or body fluids that may carry human immunodeficiency virus (HIV), hepatitis B and C virus among others; exposure to chemical agents; work-related anxiety and depression; workplace harassment and violence are more frequent occupational stressors for nurses (Koehoorn et al., 2015) . These challenges are more acute for the low-and middle-income countries (LMIC) where healthcare delivery system operates in less than ideal conditions and healthcare workers including nurses work in often compromised work environment (Workie et al., 2020) . There is also huge shortage of nurses around the world (Lopez et al., 2021) particularly so in LMIC. Moreover, nurses deal with high level of work stress (Mo et al., 2020) , manage complex patient care situations (Combrinck et al., 2020) , and come across emergency situations on a regular basis (Fjällman et al., 2021) .

The provisions or supply of basic necessities such as food, clothing, shelter, healthcare, education, and so on were all in jeopardy in most countries as covid-19 impacted almost all spheres of individual lives and all national level delivery systems suffered because of a lack of preparation, expertise and resource support to deal with a pandemic of this massive scale in severity, nature and extent (Ramsari, 2020) . Brickell et al. (2020) revealed that most countries struggled to provide healthcare services given the risk, uncertainty and fear associated with delivery of care for the covid-19 patients. Moreover, healthcare facilities in developed and developing countries battled to provide adequate care during the pandemic as these were overburdened with patients that created many organization level limitations AL-Abrrow et al., 2021) . Inadequate supply of personal protective equipment (Cohen & Rodgers, 2020) , and insufficient human resource staffing (Harrington et al., 2020) were some of the challenge's healthcare facilities faced. In addition, hospital capacity in terms of number of beds, oxygen supply/ICU supports (Bonnet et al., 2021) were not adequate to admit covid-19 infected patients (De Nardo et al., 2020) . Unfortunately, according to ICN (2020) an estimated 20,000 frontline nurses died worldwide in this pandemic.

Access to health care has always been considered to be one of the most important human rights (Brunelli, 2021) . The gains of medical advancement and the digital revolution happened in health care since the nineteenth century seemed to have vanished in thin year as a pandemic of this magnitude and severity with so high case fatality rate afflicted the humanity (Keesara et al., 2020) . No one could imagine that the huge population size infected with corona virus would face extreme difficulty in receiving timely, adequate and appropriate health care (Kumar et al., 2020) . Different waves of corona virus came up and afflicted the population en masse that further complicated the already strained healthcare delivery system and inflicted moral wounds on nurses and other direct care providers (Magnusson et al., 2020; Solmi & Correll, 2021) . However, the world witnessed the great dedication of health workers who risked their lives to help the infected and suffering patients. Nurses were the major frontline fighters in this war because they spent a large number of their working hours caring for these patients at their bedsides. Therefore, it is critical to explore, understand and describe how nurses responded to less than ideal work environments using various coping strategies. This review study looked into the various techniques adapted by frontline nurses while caring for covid-19 patients during this pandemic.

The scoping review was conducted using five steps Arksey O'Malley framework (Arksey & O'Malley, 2005) to determine the strategies employed by nurses in handling covid-19 cases during this difficult pandemic situation. This study employed the following steps: I) Formulation of the research questions, II) Finding relevant research, III) Selection of studies, IV) Charting the data, V) Collating, summarizing, and reporting the findings. Scoping reviews were used to uncover knowledge gaps, develop research agendas, and determine decision-making implications (Tricco et al., 2016) .

This research question was formulated after extensive discussions among the authorreviewers: "what are the coping strategies that motivated frontline nurses while caring for covid-19 patients during this pandemic?''

From three databases (Google Scholar, Scopus, and PubMed), the relevant original articles were selected between September and October 2021, for which the full texts were available and written in English. The keywords included "strategies OR techniques AND nurses OR healthcare workers AND covid-19 OR pandemic AND Experiences OR caring COVID patients AND coping OR survival strategies OR techniques''. The term "experience" was used because some nurses had a positive experience in coping with pandemic situations. Also, the term "healthcare worker" was used because nurses are part of the healthcare worker team.

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The following types of articles were searched for I) original research published in the covid-19 era from 2020 to 2021, II) the study involved nurses who had experience caring for patients with covid-19, III) studies available in English with full text, IV) studies explored nurses' coping strategies. At the end, 12 articles met all the inclusion criteria. The exclusion criteria were short reports, commentary, editorials, review article, magazine articles, perspectives and letters to editor.

All authors searched the literature independently following the guideline and objectives of this study. All authors conducted independent literature searches. After that, the duplicate articles were removed.

Charting the data After the article selection process, data were extracted on a Microsoft excel sheet, which consisted of the authors' names, date of publication, country, study sample, sample size, data collection time, study design, objectives, and finally identified coping techniques/strategies.

After screening 192 identified articles (Figure-1), 12 articles were finally selected (Table-2 ). The five articles reported qualitative studies (41.67%), two articles of mixed-method type (16.67%), two were grounded theory studies (16.67%), one comparative study (8.33%), one longitudinal (8.33%) and one cross-sectional study (8.33%).

Analytical findings A total of 44 strategies (Table-4 ) were identified and categorized under five themes: 1) nurses' self-strategies, 2) nurses' strategies at the ethical level, 3) employers' strategies, 4) nursing leader's strategies, 5) supplementary strategies.

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Nurses' self-strategies Nurses adopted self-strategies to deal with the covid-19 emergency according to majority of studies. Nurses felt they were in the position of patients, and nurses' resilience in emergency situations aided them in handling work stress (Rony et al., 2021) . Pogoy & Cutamora (2021) discussed that several nurses realized that life is short and they should value it; thus, nurses united together to minimize work burden. LoGiudice & Bartos (2021) revealed that nurses expressed their pride in being on the front lines as a nurse. Being a nurse gave them a sense of pride, which motivated them to stay confident and feeling heroic (Demirci et al., 2021) . Also, the sympathy (Ohta et al., 2021) and positive perspectives (Demirci et al., 2021) of the nurses encouraged them to communicate closely with their patients and to have enough affection for them to help them manage difficulties. Moreover, nurses were able to maintain emotional control during pandemic crises by convincing themselves that fighting the deadly virus was a normal part of their job in the COVID-19 era (Pogoy & Cutamora, 2021) . Nurses' emotional coping skills included providing emotional support to the patients, accepting any worsening circumstance optimistically, and performing nursing tasks without becoming confused . Besides, nurses were self-aware in managing covid-19 patients by wearing PPE, cleaning their hands often . Although the PPE supply of healthcare organizations was limited during the pandemic crisis, nurses showed their creativity by making masks from clothes and gowns from raincoats (Tosepu et al., 2021) . As frontline fighters, they were able to focus on the work without fear. When corona patients and deaths were on the upswing, nurses rarely saw corona-related news to reduce their own anxiety, had a tendency to avoid unfavorable situations at all costs, and were always ready to work in any situation . Zhang et al. (2020) also said that the nurses were mentally prepared to the point and that is why they ran campaigns in various locations to raise awareness of coronavirus infections among the general people. In addition, the nurses were grateful to God (Allah) for giving them the opportunity to serve Corona patients. Because they believed that it was a nurse's responsibility to carry out clinical tasks truthfully (Manik et al., 2021) . A few nurses surrendered to God (Allah) after realizing that He is in charge of everything and that they must try their best in order to please Him (Tosepu et al., 2021) . Thus, nurses used prayers, meditation, and other techniques to improve their emotional responses (Rony et al., 2021) .

Nurses were professionally vigilant about offering proper nursing activities, coordination with other staff, managing workload situations, and so on (Manik et al., 2021) . In an emergency, nurses felt it was their professional obligation to be by the critical patients' side (Pogoy & Cutamora, 2021) . Also, nurses were passionate about their work and realized how important it was to fight illnesses at any moment. They highlighted the necessity to be always on the patient's side as a frontline caregiver (Demirci et al., 2021) . Moreover, nurses were more focused on establishing standard approaches and practices to relieve work stress (Ohta et al., 2021) .

Healthcare organizations used a variety of techniques to facilitate healthcare providers to deal with the coronavirus disaster. Demirci et al. (2021) found that several healthcare organizations were able to manage enough personal protective equipment (PPE) before the outbreak of a pandemic. In addition, numerous healthcare organizations also supplied nutritious food, healthcare facilities for employees, and lodging for nurses on duty (Zhou et al., 2021) . In particular, through proper planning and engaging nursing decision-makers in inpatient management, certain healthcare institutions have been able to successfully overcome patient load challenges . One of the key tactics used by healthcare organizations was to manage nursing services by combining the skills of new nurses and experienced nurses (Catania et al., 2021). These techniques encouraged new nurses to learn how to adapt to unexpected situations. Various government and nongovernment organizations also provided additional allowances to nurses , which helped to raise their spirit.

One of the most crucial aspects of a healthcare institution's strategies is the nursing leadership and management it offers. That was especially noticeable while dealing with corona scenarios. Zhang et al. (2020) revealed that a competent nursing team leader was essential in maintaining the work-life balance of professional nursing practice. Similarly, Catania et al. (2021) explained that one of the nursing team leaders' key strategies was to keep in touch with the nurses frequently. Also, nursing supervisors or nursing team leaders played a vital role in assisting nurses to work normally, in controlling pressure, increasing sincerity of the nurses, increasing team spirit, and how to focusing on work when there was a high work stress.

To adapt to diverse situations, the nurses practiced different new and other strategies. Positive attitudes from coworkers, families, organizations, and society all played a part in motivating nurses to continue to work. They received the most assistance from family members in particular (Manik et al., 2021) . Colleagues were also supportive on an emotional and psychological level (Kackin et al., 2021) . Demirci et al. (2021) revealed that the unlimited sacrifices of nurses further increased the social status of nurses during the pandemic, which encouraged nurses to do more work.

During this pandemic, healthcare organizations across the world battled to deal with covid-19 affected patients due to the very high prevalence of coronavirus cases. In this scoping review, we explored how nurses were able to adapt to the challenging situations. Most of the studies uncovered nurses' self-strategies to deal with difficult situations Rony et al., 2021; Zhang et al., 2020; LoGiudice & Bartos, 2021; Tosepu et al., 2021; Ohta et al., 2021; Zhou et al., 2021; Pogoy & Cutamora, 2021; Demirci et al., 2021; Manik et al., 2021) . Rony et al. (2021) described how nurses imagined themselves in the patients' position and how nurses controlled patients' emotions. Lin et al. (2021) revealed that nurses' self-strategies helped them become more professional and inspired them to practice mindfulness. Besides, every nurse has unique self-strategies for dealing with stressful situations (Ausar et al., 2021; Hofmeyer & Taylor, 2021) and providing appropriate nursing care (Mintz-Binder et al., 2021) , This enables nurses to avoid burnout by reducing the severity of job stress (Eder & Meyer, 2022; Shahzad et al., 2021) . Additionally, it plays a significant role for nurses to develop advanced skills and to utilize their nursing knowledge and abilities at the appropriate time (Zeb et al., 2021) . However, a remarkable revelation by Pogoy & Cutamora (2021) was that nurses learned that working as a front-line warrior is normal for a nurse at any time. Another significant part of this study is the adoption of professional strategies by nurses to ensure nursing commitment from ethical concerns. In particular, Manik et al.'s (2021) unique statement was that nurses were professionally and intellectually conscious of the need to reduce medical errors and that nurses, as healthcare personnel, should always be by the patient's side. Supporting Manik et al.'s (2021) opinion, Kim et al. (2021) defined that nurses' moral sense enables them to fulfill nursing responsibilities effectively in healthcare environments. Markey et al. (2021) also mentioned that nursing ethics greatly assisted in the provision of standard nursing care, patient rights, and the establishment of a facilitative environment for patients. Demirci et al.'s (2021) notable finding was that nursing philosophy was present among the nurses and this philosophy says that nurses should devote themselves to the patients. This review explored how employers used a variety of strategies to manage the covid-19 pandemic. The strength of employers is to develop and provide comprehensive healthcare management to meet the needs of employees and patients (Gebreheat & Teame, 2021) . Moreover, providing adequate staff, retaining employees, and providing high-quality service all depend entirely on the employers' strategy (Copeland, 2021) . On the other hand, outlined a variety of techniques employed by employers to deal with less-thanideal situations. One of the most interesting observations was that healthcare organizations provided a variety of incentives (money, medals, cars, dresses, etc.) to nurses. At times, incentives positively encouraged healthcare professionals to work more effectively and efficiently to bridge clinical gaps (Jang & Chang, 2021) . In addition, Catania et al. (2021) mentioned employers' strategies and leadership strategies that healthcare organizations used a combination of experienced and novice nurses, in order for new nurses to be able to adapt to a variety of challenging scenarios. In particular, Catania et al. (2021) gave more importance to leadership strategies in dealing with the situation because a good leader is very important to motivating the nursing staff. But Demirci et al. (2021) discovered several strategies other than leadership tactics. However, Richard-Eaglin (2021) urged that nurse leaders be responsible for guiding nurses to ensure nursing care planning and create positive patient outcomes.

Only the original research studies published in English were selected in this study, which revealed the real scenarios of the coping strategies of the nurses. It also highlights how other variables, along with nurses' self-strategies, have positively impacted nurses' coping strategies, which are fundamental for managing a well-organized healthcare system. After searching the literature, a few studies met the inclusion criteria. There has been little research on nurses' coping strategies; the majority of research has been conducted on other healthcare workers. Even though nursing leadership is crucial in developing future expert nurses, only two research studies have covered leadership strategies. Although the prevalence of deadly coronavirus was high in many countries, we found limited research on nurses' coping strategies in low-and middle-income countries.

This study shows how nurses at hospitals dedicated themselves to patients by adapting to awful situations created by corona pandemic. This study findings will inspire all nurses and healthcare professionals around the world in dealing with challenging situations. Also, this study highlighted the many coping/survival techniques used by nurses in various situations, which will motivate healthcare personnel to work harder. Nurses' strategies at the ethical level will encourage healthcare organizations and policymakers to comprehend the nursing profession's perspective, motivating them to participate in making quality of nursing care environments in developing countries. Also, all healthcare organizations around the world can benefit from organizational strategies that make nurses' tasks more efficient. Moreover, nursing leadership strategies will also play an important part in developing the next generation of nursing leaders (Al-Yateem et al., 2021) . Finally, this study enables nurse managers to better understand how nurses responded to stressful conditions during this devastating pandemic situation. This study encourages nurse managers and organizations to increase nurses' coping strategies to ensure self-sufficiency in healthcare. In addition, this study provides novel and distinctive data on nurse resiliency from the viewpoints of individuals, nursing teams, and nursing leadership.

Healthcare providers including nurses acted by adapting different strategies to continue taking care of patients in hostile environments and these strategies helped them maintain emotional stability while doing their duty in difficult situations. Coping strategies motivated the nurses to provide appropriate nursing care. Therefore, healthcare institutions must always be ready to operate optimally during any emergency situation. Health workers have to be ready, available and motivated at all times. It is important to know about how they adopt various coping strategies. Additional research of qualitative nature on frontline nurses should be undertaken to explore these strategies further to assess their relative effectiveness. 

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The authors are very pleased to Abdullah Al Saki (Noakhali textile engineering college); Mst. Rina Parvin (Captain of Bangladesh Army, Combined Military Hospital, Sylhet, Bangladesh).

This article is protected by copyright. All rights reserved.(