The COVID-19 pandemic has exposed nursing home (residential long-term care home) residents and staff to a diverse set of challenges affecting their physical, psychological, and social well-being [1,2]. Evidence from the 2003 severe acute respiratory syndrome outbreak and emerging COVID-19 studies suggest that there will be global phenomena such as increased anxiety, depression, and trauma experienced by health care workers, which will likely have long-term impacts [3-9]. An analysis conducted in February 2021 of national data sets for 22 countries reported that nursing home deaths accounted for 41% of the total COVID-19 deaths (9%-64%) [10]. Concerted action to address the needs of staff working in nursing homes is needed to prevent and manage the impact of COVID-19 [11]. Therefore, a systematic review to synthesize all empirical evidence on the effects of COVID-19 on regulated and unregulated frontline nursing staff (registered nurses [RNs], licensed practical nurses [LPNs], and care aides) working in nursing homes is warranted.

Frontline nursing staff (RNs, LPNs, and care aides) working in nursing homes routinely experience challenges that are known to have negative effects on work-life. Prior to the COVID-19 pandemic, both regulated and unregulated direct care staff (RNs, LPNs, and care aides) experienced higher levels of burnout and mental health issues than the general population and difficulties meeting the daily care needs of residents [1,12-14]. Most nursing home residents have Alzheimer disease or another age-related dementia (~90% have cognitive impairment), multiple chronic diseases, recurrent medical problems, and complex emotional and social needs. The increasing complexity and dependency of resident populations, in the absence of commensurate resources, has led to unmanageable workloads for nursing home staff [12].

In the context of a COVID-19 outbreak, witnessing extreme suffering and the loss of residents with whom staff had long-term relationships has led to emotional exhaustion, which is a component of burnout [15]. Frontline nursing staff have also been subjected to substantial pressure from health authorities, who have introduced additional infection control and monitoring measures; from family members [16] who are concerned about residents’ well-being; and from the public and media. Despite a general acknowledgment that the challenges observed during the COVID-19 crisis in nursing home settings, particularly those that have contributed to severe resident outcomes, are symptoms of more systemic issues [1], the media has highly scrutinized nursing home staff. Additionally, nursing home staff have received little recognition for caring for persons infected with COVID-19 compared to hospital staff [16-18].

Emerging evidence from nursing home settings across regions has generally reported higher rates of mental health symptoms, somatic symptoms, burnout, and reduced quality of work-life [15,19-21]. One study reported 71.3% (211/296) of the respondents had medium to high emotional exhaustion, and 64.2% (190/296) of the respondents had medium to high depersonalization [19]. The current and anticipated need for psychological or psychiatric support was 21.6% (64/296) and 41.0% (141/296), respectively [19]. Reports of job satisfaction vary. Two studies reported worsened job satisfaction [20,21], one of which compared nursing home staff data from COVID-19 to data from 2013 and noted an increase in burnout syndromes. In contrast, Blanco-Donoso and colleagues [15] found that 98.2% (329/335) of the participants agreed or totally agreed with the single item—I feel satisfied to be able to help people.

A descriptive study among Spanish nursing home staff reported 71% (149/210) of respondents had clinical stress, 29% (n=61) had clinical insomnia, and rates of clinical depression and anxiety were 49% (n=102) and 59% (n=124), respectively [16]. Riello and colleagues [22] found 44% (471/1071) of respondents passed the set threshold for moderate to severe anxiety and 44% (471/1071) of respondents passed the set threshold for moderate to severe symptoms of posttraumatic stress disorder (PTSD) [22]. A high risk of suicidality was found in 25% (10/40) of participants working in 2 nursing homes in Italy [23]. Previous COVID-19 infection was associated with a higher risk of suicidality [23].

Other studies examining individual and organizational risks and protective factors of mental health and work-life outcomes identified several modifiable and nonmodifiable characteristics. Factors influencing the rates and severity of mental health symptoms include access to personal protective equipment [15,22,24], professional support in the workplace [15,21,25], safety guidelines [24], psychological support [24], changes to work activities [25], increased workload [15,21], and direct contact with patients or colleagues who are COVID-19 positive [14,15,22]. Other factors increasing the risk of adverse outcomes include younger age [26], female sex [22,26], less education [22,26], and less work experience [26]. Shift workers, such as frontline nursing staff, have also been found to have higher rates of somatic symptoms [24]. Staff resilience has been associated with lower rates of anxiety, depression, insomnia, and stress [26].

Several reviews have been conducted during the COVID-19 pandemic in general health care worker populations. To date, however, only one review conducted by Gray and colleagues has synthesized a portion of the nursing home-specific evidence from 14 studies published between March 2020 and March 2021. This review reported a high prevalence of anxiety, PTSD, and depression among direct care staff in nursing home settings based on quantitative studies [27]. The synthesis of qualitative studies suggested various personal experiences among nursing home care staff, including psychological and mental health concerns, feeling undervalued and abandoned, fear of contagion, poor working conditions, lack of skills and knowledge, and support and the positive impacts of COVID-19 [27].

The number of studies on the impact of COVID-19 on nursing home staff has rapidly accumulated since the publication of Gray’s [27] review. An updated review is warranted to capture emerging studies and, most importantly, the enduring effects of COVID-19 as a sustained extreme stressor and potential effective interventions. This review is an important first step toward supporting the mental health of frontline staff during and after the COVID‐19 crisis and during other disease epidemics and pandemics. This is important for the health and well‐being of individual health care staff as well as nursing home residents.

The purpose of this systematic review is to synthesize the empirical evidence on the effects of COVID-19 on frontline nursing staff who provide direct resident care, which includes RNs, LPNs, registered psychiatric nurses, and health care aides (HCAs), also called personal support workers (PSWs), direct care assistants, or nursing assistants, who worked in nursing homes during the COVID-19 pandemic. This systematic review will combine and synthesizes both quantitative and qualitative evidence. Its specific objectives are as follows: (1) to assess the impact of the COVID-19 pandemic on mental health (eg, stress, distress, depression, anxiety, PTSD, well-being, and somatic symptoms) and work-life outcomes (eg, burnout, job satisfaction, responsive behaviors directed toward staff, moral injury, distress, and working short-staffed) of frontline nursing staff (regulated and unregulated) working in nursing home settings (residential long-term care home); (2) to identify specific risks and protective factors; and (3) to examine the types and feasibility of strategies or interventions that have been developed to improve the outcomes of interest.

This protocol is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) checklist (Multimedia Appendix 1) [28,29]. This protocol is registered with PROSPERO (CRD42021248420). Any amendments to this study protocol will be documented and filed with PROSPERO.

All empirical study designs reporting the outcomes of interest for frontline nursing staff (regulated and unregulated) working in a nursing home setting and providing direct care during the COVID-19 pandemic will be considered for inclusion, without restriction on publication language. Articles published in languages other than English will be translated by authorized translators. We will exclude review articles; however, original studies included in reviews will be sourced and screened for inclusion. Articles that do not report primary study results, such as editorials, commentaries, opinion papers, theoretical papers or discussions, and anecdotal evidence will also be excluded.

A preliminary search of PubMed, Cochrane Library, Google Scholar (pages 1-10) and PROSPERO was conducted to ensure that no similar review is underway. The index terms and text words contained in the titles and abstracts of relevant papers were used to develop a full search strategy in consultation with a university health sciences librarian. We will conduct the search using combinations and synonyms of the core concept keywords for “COVID-19 pandemic,” “direct care staff,” “frontline staff,” and “nursing home.” We will search MEDLINE, CINAHL, Embase, Scopus, and PsycINFO databases, as well as sources of gray literature. These will include health discipline colleges and associations (eg, Registered Nurses Association of Ontario) and relevant conference programs (eg, Gerontological Society of America Annual Conference).

Additional sources of data will be identified by reviewing reference lists of relevant publications and reports, and contacting authors of relevant publications and reports to clarify published and seek unpublished information. The search strategy, including all identified keywords and index terms, will be adapted for each included database and information source. If reviews are identified, the citation list will be screened to ensure all relevant studies are included. To ensure all emerging intervention studies are included in our synthesis, we will repeat our search prior to publication. The results of the search will be reported in full and presented in a PRISMA flow diagram [28]. The search strategy is shown in Multimedia Appendix 2.

This review will be conducted in accordance with Cochrane’s principles for systematic reviews [45], with adaptations for observational and qualitative study designs, which are frequently used in studies of staff mental health and quality of work-life outcomes. We will follow the PRISMA statement [46], a checklist of 27 essential items for transparent reporting of systematic reviews (Multimedia Appendix 1). We will also use the AMSTAR-2 tool, a 16-item checklist (developed as a quality appraisal tool for systematic reviews) to ensure our review meets quality standards and to avert any possible deficiencies in the conduct and reporting of our review [47].

Ethical approval is not required as this project does not involve primary data collection.

This study was funded in 2021. As of December 2022, full-text screening is complete and data extraction is underway. The expected completion date is June 30, 2023. Our preliminary search identified approximately 10 studies published in 2020, over 40 studies in 2021, and approximately 15 studies published in the first 4 weeks of 2022 that meet our eligibility criteria. These are primarily observational studies; however, 4 intervention studies, including 1 randomized controlled trial conducted in nursing homes, were identified. Most studies sampled frontline staff from nursing homes only; however, a portion include staff from multiple settings (eg, hospital, home care, and intensive care).

Findings will be disseminated through conference presentations and publication in a peer-reviewed journal. Additionally, we will produce a plain-language summary of the findings for informing users on what is known on this topic and recommendations for use in practice. Any amendments made to this protocol when conducting the study will be outlined in PROSPERO and reported in the final manuscript.

To date, there have been numerous COVID-19 studies of the impact on frontline nursing home staff with varied methods and, in some cases, disparate findings—leaving knowledge users with uncertainty. Therefore, a robust evaluation is required to gain a broader understanding of the impact of the sustained effects of COVID-19 on the nursing home workforce. This systematic review will uncover gaps in current knowledge to inform future research exploring how nursing homes can be more proactive in supporting the health and psychological needs of frontline nursing staff amid extreme stressors such as the pandemic and within the wider context of prepandemic conditions.

Findings from the preliminary search suggest that nursing home workers have worse mental health outcomes than staff working in other health care settings [6]. Studies comparing outcomes by service setting (eg, nursing home, hospital, and primary care) report higher rates in one or more of clinical depression, anxiety, stress, PTSD, and insomnia among nursing home staff [12,14,44,48]. One study found that nursing home staffs’ risk of extended sick leave (<3 weeks) was almost 2-fold higher, while groups working in other health care had no elevated risk of sickness absence due to COVID-19 [49]. For frontline staff working in nursing homes, preexisting stressors may partially explain the increased risk of developing negative mental and physical health symptoms due to pandemic-related work conditions [12,16,50].

We identified 4 heterogeneous intervention studies in nursing home settings [36,51-54]. The first study aimed to prove the feasibility and effectiveness of treating anxiety and depressive symptoms among nurses who were highly mobilized during the acute phase of COVID-19 using a web-based (remote) Eye Movement Desensitization and Reprocessing (EMDR) protocol [36]. The authors concluded that web-based EMDR was both feasible and effective [36]. However, this study did not include a control group and all participants had received prior EMDR treatments from the therapist who provided the study intervention. This limits the ability to draw conclusions on the effectiveness of the EMDR protocol [36]. The second study was a randomized control trial that examined the effectiveness of self-help plus in reducing anxiety and posttraumatic symptomatology [51]. No difference in self-reported anxiety or posttraumatic symptomatology was found postintervention [51]. The third study used a mixed methods approach to evaluate the effectiveness of a web-based education program delivering just-in-time learning and best practices to improve staff confidence and comfort level when working with residents who were at risk, confirmed, or suspected of having COVID-19 [52]. The results indicated that the intervention effectively delivered time-sensitive information and best practices to support nursing home staff [52]. Lastly, Lathren and colleagues [53] explored the feasibility and effects of self-compassion training for certified nursing assistants working in nursing homes (n=34). Self-compassion training was found to be feasible and beneficial for the stressors that certified nursing assistants experienced during the COVID-19 pandemic [53].

While there is significant interest in this topic, a preliminary search of the literature indicates that there is limited research available specifically focused on nursing home settings. Our inclusion of all designs will ensure that we provide the best evidence possible on the effects of the COVID-19 pandemic on frontline nursing staffs’ mental health and work-life outcomes that are protective and those that increase risk, as well as the effects of interventions to limit negative outcomes.

Second, the heterogeneity between study designs, outcomes of interest, and how these are measured may limit our ability to statistically compare results. Therefore, our analysis will include descriptive analysis, which will synthesize all available and potentially actionable evidence. We will also conduct a subgroup analysis if sufficient data are available to compare results when different measures are used to capture the same outcomes.

A third potential challenge we may face is that an insufficient number of intervention studies will be captured based on the timing of this review. The search will be repeated before synthesis to ensure all available intervention studies are included. Finally, as with all reviews, misinterpretation of the original research or data extraction errors is possible. To minimize this risk, 2 team members will independently engage in these activities, and discrepancies will be discussed to reach consensus. Should we encounter unforeseen circumstances where we need to deviate from our protocol, we will document and report the change in the completed review.

Systematic reviews have a central place in informing decision-making from the level of individual patient care to health care policy makers [45,54]. To better understand the impact of the COVID-19 pandemic on frontline nursing staff health and work-life outcomes, identify the risks and protective factors, and determine which interventions are feasible and effective, a comprehensive synthesis of all existing evidence is needed. To date, there have been numerous COVID-19 studies related to its impact on frontline nursing home staff with varied methods and disparate findings, leaving knowledge users with uncertainty. This systematic review will inform the interpretation of the disparate findings to date and uncover gaps in current knowledge; doing so will guide future research exploring how the health care system can be more proactive in improving quality of work-life and supporting the health and psychological needs of frontline staff amid extreme stressors such as the pandemic and within the wider context of prepandemic conditions. Future research may examine specific interventions and policies to support nursing home staffs’ well-being, ultimately promoting better work-life and optimizing nursing home staffs’ ability to provide optimal quality of care to residents.