Introduction

The outbreak of coronavirus disease 2019 (COVID-19) caused by the new SARS-CoV-2 coronavirus was first reported on December 31, 2019, in Wuhan, China, and has been spread to 188 countries becoming in a pandemic¹. As of June 29, 2020, a total of 10.199.798 cases and 502.947 deaths have been confirmed worldwide. COVID-19 is characterized by clinical manifestations such as fever, non-productive cough, dyspnea, myalgia, fatigue, normal or decreased white blood cell counts, radiographic evidence of pneumonia, organ dysfunction (shock, acute respiratory distress syndrome- ARDS, acute heart or acute kidney damage) and death can also occur in severe forms of the disease². However, other manifestations such as headache or abdominal pain, diarrhea, loss of taste, or smell have been added to the clinical spectrum, during the course of the pandemic³. Public health emergencies such as those faced with COVID-19 require accurate and real-time information to guide effective responses⁴.

A part of the timely response is led by nursing professionals who, not only from the clinical area but also from management, epidemiological analysis, and public health carry out interventions to reduce the individual and collective impact of the pandemic. However, there is concern about the invisible work performed by nursing staff, who have been called the “silent heroes”. This can be partially explained by the 19th-century Christian concept of self-denial which is still present in the profession. Additionally, nursing is still considered an almost natural "female job" and probably due to its social devaluation, characterized by gender hierarchies, the performance of professional nurses in the fight against epidemics and pandemics has been poorly documented⁵.

Officially, 2020 has been declared the “International Year of the Nurse and Midwife” by the World Health Organization (WHO) and it's also with the bicentennial of the birth of the nursing mother, Florence Nightingale and the “Nursing Now” campaign, which pretend to generate global awareness of the nurses' value. The above, added to the COVID-19 pandemic, should be a powerful combination of forces to ensure greater visibility of nursing in health systems and society worldwide⁶. Therefore, this study aimed to review and synthesize the trends on COVID-19 and nursing research, identifying the main journals, country of origin, language, topics, type of design, and area of applicability of the results.

Material and Methods

Results

We identified 560 citations and after a title and abstracts screening, 325 articles were selected for a detailed full text evaluation. Of these, 38 articles met our inclusion criteria and were included in the review (Figure 1).

Figure 1 Flow chart of the articles included in the systematic review 

Most articles were “narrative reviews”, accounting for 23.68% of the total (n=38), followed by “cross sectional study” (n=8, 21.05%) and, “experience” (n=7, 18.42%). We also identified other types, such as “qualitative study” (n=3, 7.89%), “quasi-experimental” (n=3, 7.89%), “clinical guidelines” (n=2, 5.26%), among others. The results of the research subject provide insight into the trends, frequency of use, and distribution of topic categories. The most frequent topics were: mental health (n=10, 26.32%), management (n=7, 18.42%), prevention and training program (n=4, 10.53%), clinical care and aging (n=3, 7.89%), education and working conditions (n=2, 5.26%) with the same proportion for each category. Besides, subject as palliative care, policy and health travel were studied. There was a low geographic reach, representing 11 countries. Most studies conducted in China (n=18, 47.37%), followed by the United Kingdom and the United States with the same contributions (n=5, 13.16%), Brazil (n=3, 7.89%) and the other countries such as Australia, Canada, Italy, Japan, New Zealand, Singapore and Switzerland (n=7, 18.42%). Thirty-four (89.47%) articles were published in English followed by Portuguese and Chinese with the same proportion (n=2, 5.26%) (Table 2).

We identified five areas of application of the results in this review. The most frequent was “clinical” setting with 47.0% in research topics as management, prevention, clinical and palliative care, following by the area “Nursing Professionals” with 26.0% mainly studied mental health issues, “Health Care Workers” area with 11.0% also mostly focused on mental health, “Community” area with 11.0% including aging care and travel health topics, and finally “Academic” area with 5.0% (Figure 2). The general characteristics of the included articles are shown in Table 3.

Source: Compilation based on the information of articles

Figure 2 Area of application of the results found in this review 

Discussion

In the present review, we summarize the research patters on COVID-19 and nursing, identifying that most articles were published in the International Journal of Nursing Sciences. As expected, China was the country with the highest number of publications. Furthermore, most articles have been published in English language and narrative reviews were the most frequent type of documents, followed by cross-sectional studies, and experiences. The highlighted topics and application setting of the results, were mental health and clinical area, respectively.

Regards journals, only four nursing journals were in Q1 and two of them had h-index higher than 80. The above allows evidence of the nursing development achieved in the last years about the quality of scientific production in terms of writing, evaluating, and editing research articles⁴⁸. Additionally, it is necessary to publish in nursing-specific journals, which allow greater visibility by nurses' staff worldwide. It is also important to highlight that English is the official language in scientific research, and that was reflected in our review, with 89.47% of articles published in this language.

On the other hand, it is important to recognize the role of countries such as China (center of the pandemic), the United States and the United Kingdom, which had the greatest contribution to nursing publications. In Latin America, most studies were performed in Brazil, where the pandemic came first, and has one of the most advanced nursing research networks in the region with the established Virtual Library on Nursing Health (BVS, by its acronym in Spanish) with the support of the Latin American and Caribbean Center in Health Information (BIREME/PAHO/WHO)⁴⁹. Further, according to the PAHO report entitled "Doctoral training in nursing in Latin America and the Caribbean", Brazil is the country with the highest offer of nursing Ph.D. programs (n=37) and an important proportion (25%) have a long history and recognition. Also, 92% of nurses have been trained in the research field which has supported the country's leadership in nursing research⁵⁰.

In order to analyze the type of scientific publications, it is necessary to mention that, nursing is a young profession that has mainly depended on knowledge developed by other health disciplines. Indeed, nursing training in research is recent, and also the lack of time for research activities in most professional settings has limited the type of designs used in nursing studies^51),(52. Despite undeniable progress, there are important challenges to face. Among those, the most important is the gap between nursing research and practice, especially in developing countries where the proportion of nurses with postgraduate training is low and most of them work in the education field⁵³. Following the publication types, we found a huge number of editorials, reflections, and narrative reviews focused on challenges established by the pandemic. Despite, these are important, they are mainly based on personal opinions and lack of scientific methodology⁵². From included articles, one of the most frequent was the report of experiences, which has the lowest evidence level and does not allow making clinical recommendations⁵⁴. Given the pandemic and their unexpected trends, the report of experiences has been a frequent publication useful in implementing effective actions to decrease the COVID-19 contagion and its consequences^{26),(32),(36),(38),(43}.

The main type of study was the narrative review^{12),(14),(16),(17),(24),(28),(34}, which is appropriate for the initial phase of the pandemic due to its high accessibility and easy interpretation, especially in an unprecedented acute condition with no previous scientific evidence⁵⁵. Following the same argument, cross-sectional studies were also frequent because their main objective is to describe a health condition⁵⁶. They are relevant to understand the patterns of COVID-19 under different conditions of public and clinical health. In this review, we identify that cross-sectional studies were used to describe the mental health status of health care professionals, especially nurses because they are in the front line of clinical attention^{10),(20),(21),(23),(30),(33),(37),(39).}

We also found qualitative studies, which have achieved greater visibility in research because of their usefulness in understanding human behavior and social interactions. They have also been valuable to identify the feelings and concerns of people about the pandemic in both, community and clinical areas^{25),(39),(40),(46}. Otherwise, there is a lack of experimental designs in the field of nursing and COVID-19 research, identifying only three quasi-experimental studies^22),(35),(39 y one experimental⁴⁷, mainly focused on the evaluation of educational models and adherence to preventive measures by healthcare professionals. Although they are studies with a higher level of evidence and their results can be translated into clinical recommendations, a limited number of those were expected because of their high cost and logistic⁵⁶.

Regarding the main topics researched by nursing in the COVID-19 pandemic, mental health and management stand out. A high percentage of articles as focused on mental health and mainly researched in health care workers (HCWs)^{20),(21),(23),(25),(28),(37),(40),(45),(46} The antecedents of previous influenza A/ H1N1 and severe acute respiratory syndrome (SARS) pandemics could explain this, where it was documented that HCWs experienced high levels of stress, anxiety, and low mood. Additionally, these psychological problems in HCWs have negative consequences for organizations as the extreme pressures experienced during a pandemic may increase the risk of burnout, generating adverse outcomes at the of individual well-being, in patient care and the health system, so during the SARS outbreak, the emotions expressed by health workers were associated with resignations and poor work performance, therefore, the mental health status in HCWs has picked up interest during the COVID-19 pandemic^57),(58. In this way, a study on the factors associated with mental health outcomes in health workers in China treating patients with COVID-19 found that women, nurses, people in Wuhan and front-line workers had a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions⁵⁹. Similar results were found by Huang JZ et al. where the incidence of anxiety in female medical personnel was higher compared to men, and the incidence of anxiety in nurses was higher than that of doctors⁵⁸.

On the other hand, nursing boards and their leaders play a key role in the management and quality of care provided to patients with COVID-19. They usually work as part of a multidisciplinary team and lead the implementation of care based on the best available evidence and promote patient and health care worker's safety. The above implies active nursing participation in new initiatives and clinical interventions according to the high healthcare demand and the new epidemiologic patterns established by COVID-19⁶⁰. In consequence, it is important to highlight the nursing participation in the development of a rapid advice guideline is suitable for the first frontline doctors and nurses, managers of hospitals and healthcare sections, community residents, public health persons, relevant researchers, and all person who are interested in the 2019-nCoV¹⁸. Likewise, there were four studies where nursing staff describe their experience about human resources and supplies management, as well as, prevention and control actions in non-isolated areas, offering some usefulness advice^{26),(32),(41),(44}. Finally, we found some studies focused on considerations for nephrology nursing and the effect of optimization of intravenous infusion therapy in isolated patients with COVID-19^16),(39.

By contrast, there were a few published studies related to nursing care plans despite nursing theories have been incorporated into the habitual clinical practice⁶¹. Just three studies were identified in this field; one of them describe nursing care in patients with COVID-19, who were not candidates to mechanical ventilation (palliative care)¹³. In another study, twenty nursing experts from China developed a consensus about holistic care in patients with severe COVID-19, including clinical evaluation, care priorities, and 13 key points to guide the interventions⁴² and finally in the last article, the authors propose a biopsychopharmacosocial approach to evaluate the impact of social distancing and isolation in the mental health the elderly population¹¹.

Another finding that is striking is the underrepresentation of the community applicability area, during the initial phase of the pandemic, despite the importance of nursing actions focused on the home and the community to control the contagion. The scarce evidence applicable to community settings is consistent with the call made by nursing associations worldwide, highlighting the importance of interventions in “wards without walls”⁶¹, who have lost care despite being essential to release hospital occupation, avoiding complications through individualized home care for people with mild forms of the disease. Additionally, the nursing role is essential to maintain the physical and mental health of people who remain in confinement¹¹. Taking into account the above, the community health area constitutes a priority scenario to focus on scientific research and its findings to make visible and intervene in the main problems that have arisen with the pandemic.

Finally, it is important to highlight that there is coherence between the main topics studied (where health care workers mental health was the most important) and the area of application of the findings, which was mostly clinical. This response to the new challenges that nursing professionals face in clinical settings due to the pandemic, which include: the admission to hospital of a high number of critically ill patients which have increased care demands on nurses and these demands must be met by an already depleted nursing workforce. Indeed, nurses are not only experiencing an increase in the volume and intensity of their work but are having to accommodate new protocols and a very ‘new normal' which includes they have to provide end-of-life care more frequently and closer interaction with family members who cannot be at the bedside because of isolation rules^28),(62.

Strengths and limitations

The main strength of our study is the application of a highly sensitive search and the systematic methodology used in this review, which allowed us to control or decrease selection bias, a critical assessment, and synthesis of all relevant studies on COVID-19 and nursing. However, this research study did have some limitations. First, unpublished studies were not searched and publication bias may exist. Second, aspects that do not depend on the authors, such as the rapid outdated that this review may have due to the acute nature of the event of interest (COVID-19) and for the need to generate literature on this topic that provides help in managing the pandemic. Finally, it is essential to mention that the scope of this review was limited to the initial phase of the pandemic and do not reveal the current evidence in the field.

Conclusions

During the first phase of the pandemic, nursing research was focused on mental health topics, and the clinical area was the main setting investigated. These findings are aligned with the challenges faced during this period. It is essential to mention that nursing research was visible and valuable from the beginning of the pandemic until the current situation, contributing to understanding care phenomena typical of the pandemic. Future research should explore the current state of evidence in the main topics identified in this review and continue to give visibility to work carried out by nursing in the emergency of the COVID-19 pandemic.