Caregivers' experiences and perspectives on caring for the elderly during the COVID‐19 pandemic: A qualitative systematic review

Abstract

Aims

The goal of this study was to explore caregivers' experiences, perspectives, emotions, knowledge and needs in caring for older people during the COVID‐19 pandemic. These included, but were not limited to, experiences in hospital care, home care and nursing home care.

Background

Because of the high mortality rate associated with the COVID‐19 pandemic, senior care is critical. During the COVID‐19 pandemic, caregivers caring for older people have had unique experiences potentially affecting the quality of care provided. This topic has received substantial attention since the start of the pandemic and has been studied by numerous researchers. However, experiences may differ among countries and time periods. In addition, no qualitative systematic reviews on this topic appear to have been published.

Evaluation

In this systematic review of qualitative studies, data were collected from the following electronic databases: PubMed, Web of Science, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Science Direct and PsycINFO. Titles and abstracts were screened according to the inclusion and exclusion criteria, full texts were screened and the methodological quality of included studies was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research by two independent reviewers.

Key issue(s)

A total of 141 findings were extracted and aggregated into 20 categories; 6 synthesized findings were identified.

Conclusion

This review indicates caregivers' experiences and perceptions regarding caring for older people during the COVID‐19 pandemic. The results of a qualitative systematic review show that caregivers' emotions, cognitions and knowledge have affected the quality of caregivers' senior care services during the pandemic. Caregivers caring for older adults should practise self‐awareness, understanding their knowledge and attitudes to improve the quality of senior care. Moreover, health care administrators and policymakers should make concerted efforts to cultivate a better working environment.

Implications for Nursing Management

Managers should formulate timely and effective management strategies. During the COVID‐19 pandemic, the workload of caregivers has increased, thus requiring better scheduling by managers. Furthermore, managers should consider the negative emotions of caregivers and prevent negative emotions from affecting their work. Besides, virtual technology should be applied to senior care and psychological support be provided for caregivers in this special care setting.

1. INTRODUCTION

The COVID‐19 pandemic has negatively affected health care, caused disruptions in daily life and prompted concerns globally. It has infected approximately 516 million individuals worldwide, and 6.25 million people had died as of May 2022 (Our World in Data, 2022). The COVID‐19 death rate for people 18–29 years of age was 0.7%, whereas the mortality rate for those 65 years and older was approximately 25%, according to the CDC (Centers for Disease Control and Prevention, 2022). Furthermore, older people are more likely than younger people to become very ill from COVID‐19. Experts expected that this pandemic would not be rapidly controlled (Telenti et al., 2021). There is no doubt that prevention, treatment and nursing care for older people are critical. Caregivers can draw insights into providing better quality care for older people during COVID‐19.

Some recent studies (Lasater et al., 2021; Walton et al., 2020) have demonstrated that caregivers may experience negative emotions such as anxiety and sadness, which may affect normal care during the pandemic. As the pandemic continues, health care workers require mental health support, encouragement and a sense of purpose (Walton et al., 2020). Furthermore, treatment and care is more complex for older adults than other populations, particularly during a pandemic. The work of caregivers involves continual contact with older adults, which can lead to different experiences and emotions (Ortega‐Rodríguez & Solís‐Sánchez, 2019).

Many researchers have conventionally conducted quantitative research and interventional systematic reviews to assess the experiences of caregivers caring for older people (Blanco‐Donoso et al., 2021; Greene et al., 2020; Lanièce Delaunay et al., 2020; Tan & Seetharaman, 2020). The literature most similar to our study is a systematic review (Gray et al., 2021) examining the experiences of home care staff to better understand how to support them during the ongoing pandemic and in the future. However, limitations exist regarding the study years, methods and results. First, 14 articles were included, but most were quantitative studies published in 2020. The relevant literature has since been updated with the development of the COVID‐19 pandemic. Second, their systematic evaluation has attached importance to quantitative literature but lacks in‐depth analysis of qualitative research, which provides more information summarizing the experiences and emotions of the participants. Using a qualitative method to investigate caregivers' experiences and perspectives on caring for older people during the COVID‐19 pandemic can help gain a better understanding of the challenges. Consequently, integration of qualitative research findings (qualitative systematic review) has become a major research area. Qualitative systematic reviews have the benefit of combining qualitative research with a systematic method, thus aiding in the development of more comprehensive and general theories; moreover, they add breadth and depth to the research question by focusing on the views and feelings of the participants in interventions. Finally, their results lack the summary and guidance of management.

To our knowledge, no prior qualitative systematic review has examined caregivers' experiences in managing older people during the COVID‐19 pandemic. By consolidating these unique experiences, this review has the potential to guide care practice and management in senior care settings or any area of senior care in the context of the COVID‐19 pandemic or other infectious diseases. This review aimed to synthesize the best available evidence in exploring caregivers' experiences, perspectives, emotions, knowledge and needs in caring for older people during the COVID‐19 pandemic. These included, but were not limited to, experiences in hospital care, home care and nursing home care.

2. METHODS

2.1. Design

This systematic review was based on the Joanna Briggs Institute methods for qualitative systematic reviews to explore caregivers' experiences and perspectives on caring for older people during the COVID‐19 pandemic. This approach is grounded in pragmatism and phenomenology to aid in synthesis of qualitative studies (Lockwood et al., 2015). A protocol was developed and registered on PROSPERO (CRD42022325933), the international prospective register of systematic reviews relevant to health and social care. During the synthesis of this review, the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement was used as guidelines (Tong et al., 2012). The research work was performed between February 2022 and July 2022.

2.2. Eligibility criteria

This review considered studies including caregivers of older people (≥65 years of age) during the COVID‐19 pandemic. Caregivers were defined as personnel who take care of older people, particularly nurses and other medical staff. The topics of interest in this review were the experiences, perceptions, emotions, knowledge and needs of caregivers caring for older people during the COVID‐19 pandemic. These included, but were not limited to, experiences in hospital care, home care and nursing home care. The topics of interest also included experiences in senior care management from the beginning of the pandemic to the present. Only literature from December 2019 to May 2022 was considered. This review considered full‐text studies in English with qualitative designs, such as phenomenology, grounded theory, ethnography, qualitative descriptive studies and mixed research. Unpublished studies were excluded (Table 1).

TABLE 1.

Eligibility criteria

Criteria	Inclusion	Exclusion
Population	Caregivers who take care of older people during the COVID‐19 pandemic.	Caregivers who take care of older people before the COVID‐19 pandemic.
Phenomena of interest	The phenomena of interest for this review were experiences, perceptions, emotions, knowledge and needs of caregivers caring for older people during the COVID‐19 pandemic. These included, but were not limited to, the experiences of hospital care, home care and nursing home care.	Studies that do not reflect experience of caregivers when caring for older people during the COVID‐19 pandemic.
Context	Primary, secondary and tertiary health care contexts or at home.	—
Type of study	Qualitative studies and the qualitative part of mixed studies. Studies published in English.	Systematic reviews. Studies in which the patient was not the primary participant. Unpublished literature.

2.3. Search strategy

A three‐step strategy was used in this review. First, databases such as PubMed and the PROSPERO (international prospective register of systematic reviews) were searched to confirm that no similar review had been conducted or registered. An initial search was conducted in PubMed to identify index terms and keywords of relevant articles. Second, on the basis of a preliminary search of the literature, key terms were identified to generate a full search strategy, which was structured by using the PICoS (Population, phenomena of Interest, Context and type of Study) framework. Six databases were searched (PubMed, Web of Science, Scopus, CINAHL [Cumulative Index to Nursing and Allied Health Literature], Science Direct and PsycINFO) with a publication date between December 2019 and May 2022. Grey literature was also searched to decrease publication bias and provide a more balanced understanding of the topic of interest (Paez, 2017). For PubMed as an example, with combined index terms and keywords, the following terms or closely related expressions were used along with the Boolean operators OR and AND: (‘COVID‐19’ OR ‘Coronavirus’ OR ‘Sars Covid’) AND (‘caregiver’ OR ‘nurse’ OR ‘nursing’ OR ‘staff’ OR ‘practitioner’) AND (‘Experience’ OR ‘Experiences’ OR ‘Feeling’ OR ‘Feelings’ OR ‘view’ OR ‘emotion’ OR ‘perspective’) AND (‘old’ OR ‘older’ OR ‘elderly’ OR ‘seniors’ OR ‘geriatrics’). Finally, the reference lists of eligible articles and systematic reviews were manually searched to identify additional studies.

2.4. Study selection

After the search, the retrieved articles were imported into the bibliographic software Citavi 6, and duplicates were removed. Titles and abstracts were screened against the eligibility criteria, and studies meeting the inclusion criteria were sourced and exported for full text review. The entire screening process was conducted by two independent reviewers using a standardized set of eligibility criteria. After screening of the titles and abstracts, the full texts of potential studies were retrieved to confirm their eligibility. Articles with full text screening that did not meet the inclusion criteria were excluded. To search the literature as comprehensively as possible, we reserved more relevant documents for the next full‐text search. Finally, the reviewers read the remaining full‐text articles and retained the articles relevant to the topic of this article. Any disagreements between reviewers were resolved through discussion or with a third reviewer. The inter‐rater reliability test was aimed at achieving at least moderate agreement, with Cohen's kappa statistic (κ) > 0.4 (McHugh, 2012). This literature search was conducted according to a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram (Figure 1).

FIGURE 1.

Flow diagram for study selection: Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA). CINAHL, Cumulative Index to Nursing and Allied Health Literature

2.5. Quality appraisal

The principal author summarized the characteristics of each study to provide contextual information on the first author, year of publication, country of study, participants, setting, aim, design, data collection/analysis and main findings. They were recorded and entered into a table (Table 2).

TABLE 2.

Summary of main characteristics

First author, year of publication	Country of study	Participants	Setting	Aim	Design	Data collections/analysis	Main findings
(Morley et al., 2022)	England	23 Advanced Clinical Practitioner volunteer participants	Across England	This study aimed to capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID‐19 pandemic.	Qualitative research design	Interpretative qualitative study; part of 3 focus groups using Zoom video communication.	‘Experiencing different work’—extending flexibility and adaptability in advanced practice ‘Developing attributes’—building autonomy and leadership in advanced practice ‘Negotiating barriers’—bargaining and diplomacy in advanced practice ‘Changing future provision’—transformation of advanced clinical practice
(Sun et al., 2020)	China	20 nurses who provided care for COVID‐19 patients	The First Affiliated Hospital of Henan University of Science and Technology	The aim of this study was to explore the psychology of nurses caring for COVID‐19 patients.	A phenomenological approach	Face‐to‐face or by telephone from 20 January to 10 February 2020.	Significant amount of negative emotions in the early stage Coping and self‐care styles Growth under pressure Positive emotions occurred simultaneously or progressively with negative emotions
(Ter Brugge et al., 2022)	Dutch	Physicians	Dutch nursing homes	This study aimed to explore how physicians in Dutch nursing homes practised advance care planning during the first wave of the COVID‐19 pandemic and to explore whether and how it changed during the first wave of the pandemic.	Qualitative analysis of an online	Mainly open‐ended questionnaire on ACP among physicians working in nursing homes in the Netherlands.	Reasons for ACP discussions Discussing ACP, topics discussed in ACP and decision making in ACP
(Sizoo et al., 2020)	Dutch	Elderly care physicians	Dutch nursing homes	The aim of this study was to explore the dilemmas experienced by elderly care physicians as a result of the COVID‐19‐driven restrictive visiting policy.	A qualitative exploratory study was performed using an open‐ended questionnaire	A thematic analysis was applied. Data were collected between 17 April and 10 May 2020.	Dilemmas as a result of the general strict visitor restriction Dilemmas as a result of the exception in the dying phase Impact on elderly care physicians Diversity calls for tailored solutions
(Sarabia‐Cobo et al., 2021)	Spain	24 interviews were conducted with geriatric nurses	Nursing homes in four countries (Spain, Italy, Peru and Mexico)	The aim was to explore the emotional impact and experiences of geriatric nurses working in nursing homes and caring for patients with coronavirus disease 2019 (COVID‐19).	A qualitative study with phenomenological method	Via video conference, using a semi‐structured interview guide. Data were gathered through in‐depth interview.	Fear of the pandemic situation The sense of duty and professional commitment Emotional exhaustion
(Krok‐Schoen et al., 2021)	The United States	Eligible health care providers of older adults were recruited by emails	Four professional organizations' listservs (ACCC, CARG, Association of Oncology Social Work, and Social Work Hospice and Palliative Care Network) as well as social media messaging (e.g., Twitter and Facebook)	This study sought to examine health care providers' clinical barriers, patient questions and overall experiences related to care delivery for these patients during the pandemic.	A qualtrics survey	The responses to the three open‐ended questions were analysed using qualitative content analysis by two separate reviewers.	Clinical barriers during the COVID‐19 pandemic Questions asked of health care providers by older adults with cancer during COVID‐19 Experiences as a cancer care team member during the COVID‐19 pandemic: (1) worry about their patients' mental health; (2) feelings of crisis and fear of personal safety; (3) frustration and anger at multi‐level institutions; and (4) contrarily positive feelings regarding their health care system leadership, colleagues and communication
(Sweeney et al., 2022)	Ireland	1. Owners/managers and staff of residential care settings for older people 2. Residents and/or their family members	Residential care settings	The aim of this study was to explore the COVID‐19 pandemic as it was experienced by people on the front line in residential care settings for older people in the Republic of Ireland.	A two‐phased mixed methods study	The qualitative data were recorded on Zoom and transcribed by a transcription company. The data were transferred to NVivo and analysed by thematic analysis to generate overall themes.	Mental health/social health Physical health Impacts on family members Staffing levels Impacts on staff: (1) Trust and responsibility/blame and (2) role of the media
(Castaldo et al., 2022)	Italy	A total of 31 nurses who cared for dying patients during the COVID‐19	Hospitals and nursing homes in the Northern and Central Italian regions	The aim was to explore nurses' experiences of caring for and accompanying patients dying without the presence of family during the COVID‐19 pandemic.	A qualitative descriptive design was used	Focus group interviews.	Unprecedented deaths in the time of COVID‐19 Ensuring physical, emotional, interpersonal and spiritual care for dying patients and supporting their family despite the difficulties Ensuring care procedures for patients' bodies after death Psychological consequences of caring for dying people during the COVID‐19 pandemic
(Jia et al., 2021)	China	18 nurses	Chinese hospitals	This study aimed to examine the ethical challenges encountered by nurses caring for patients with the novel coronavirus pneumonia and to provide nurses with suggestions and support regarding promotion of their mental health.	A qualitative study was carried out using a qualitative content analysis	They were purposively sampled, and structured, in‐depth interviews were performed. Data were iteratively collected and analysed from February to March 2020.	Ethical challenges (people with COVID‐19, inequality, professional ethics and job competency) Coping styles (active control and planning, seeking support as well as catharsis and staying focused) Impacts on career (specialized nursing skills, scientific research ability and management skills)
(Lingum et al., 2021)	Canada	Health care providers who participated in 12 weekly, 60‐min sessions; 21 participants provided qualitative comments	Elderly long‐term care homes primarily in Ontario, Canada	This study aimed to determine whether Project Extension for Community Health care Outcomes Care of the Elderly Long‐Term Care: COVID‐19, a virtual education programme, was effective at delivering just‐in‐time learning and best practices to support LTC teams and residents during the pandemic.	Mixed methods evaluation	Responses to open‐ended questions were deidentified and imported into NVivo for analysis. A deductive coding approach was adopted where the codes and subsequent themes derived from the topics were explored in the open‐ended survey questions.	Reflections on experience Impact of ECHO COE‐LTC: COVID‐19
(Nyashanu et al., 2022)	England	40 research participants who took part in the research study	Care homes and domiciliary care setting	The study explored the triggers of mental health problems among frontline health care workers during the COVID‐19 pandemic.	An exploratory qualitative approach	The data were collected using semi‐structured interviews and analysed through interpretive phenomenological analysis.	Fear of infection and infecting others Lack of recognition/disparity between National Health Service and private health care conditions Lack of guidance Unsafe hospital discharges Loss of professionals and residents through deaths Unreliable testing and delayed results Staff shortage
(Bilal et al., 2020)	Pakistan	27 caregivers	Three care homes in Karachi, Pakistan	This study aimed to explore the perceptions and experiences of staff providing direct caregiving services to the elderly residents at three care homes.	A qualitative approach	Semi‐structured, face‐to‐face interviews were performed with current and former caregiving staff members. The data were analysed through qualitative content analysis.	Living in anxiety and fear Forces affecting decision to work Decision to work
(Marshall et al., 2021)	England	Ten managers	Care homes in the East Midlands of England	The aims were to inform more effective responses to the ongoing pandemic and to improve understanding of how to work with care home staff and organizations after the pandemic has passed.	Interviewed by video conference or phone about their experiences	Analysis used an adapted organizational framework analysis approach with a focus on social ties and interdependencies between organizations and individuals.	Interdependencies of care processes and practices Interdependencies of resources Interdependencies of governance

Abbreviations: ACP, advance care planning; ECHO COE‐LTC, Extension for Community Healthcare Outcomes Care of the Elderly Long‐Term Care; LTC, long‐term care.

The JBI Critical Appraisal Checklist for Qualitative Research was used to assess the rigour of the qualitative research (JBI, 2020). The Mixed Methods Appraisal tool (Hong et al., 2019) was used for mixed method studies. The two reviewers appraised the findings independently, and any disagreements were resolved through discussion with the third reviewer. The results of the critical appraisal are reported in a table (Table 3). All studies, regardless of their methodological quality, underwent data extraction and synthesis, to present a complete systematic review of all existing findings regarding this topic of interest (Butler et al., 2016).

TABLE 3.

Results of the critical appraisal of included studies

Citations	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10
(Morley et al., 2022)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
(Sun et al., 2020)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y
(Ter Brugge et al., 2022)	Y	Y	Y	Y	Y	U	Y	Y	U	Y
(Sizoo et al., 2020)	Y	Y	Y	Y	Y	Y	U	Y	Y	Y
(Sarabia‐Cobo et al., 2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
(Krok‐Schoen et al., 2021)	Y	Y	Y	Y	Y	U	Y	Y	U	Y
(Sweeney et al., 2022)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
(Castaldo et al., 2022)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
(Jia et al., 2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y
(Lingum et al., 2021)	Y	Y	Y	Y	Y	U	U	Y	Y	Y
(Nyashanu et al., 2022)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
(Bilal et al., 2020)	Y	Y	Y	Y	Y	Y	U	Y	Y	Y
(Marshall et al., 2021)	Y	Y	Y	Y	Y	U	Y	Y	Y	Y
Total (%)	100	100	100	100	100	53.8	76.9	100	84.6	100

Note: Q1: Is there congruity between the stated philosophical perspective and the research methodology? Q2: Is there congruity between the research methodology and the research question or objectives? Q3: Is there congruity between the research methodology and the methods used to collect data? Q4: Is there congruity between the research methodology and the representation and analysis of data? Q5: Is there congruity between the research methodology and the interpretation of results? Q6: Is there a statement locating the researcher culturally or theoretically? Q7: Is the influence of the researcher on the research, and vice versa, addressed? Q8: Are participants, and their voices, adequately represented? Q9: Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body? Q10: Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Abbreviations: U, unclear; Y, yes.

2.6. Data analysis

Data analysis and synthesis consisted of four steps (Sandelowski & Barroso, 2003): coding, sorting, synthesizing and theorizing. The first process of data analysis was conducted by two authors and began with reading and re‐reading the articles. All qualitative data were extracted from the original articles and grouped by identification of topically similar codes. At this stage, subjective categories were generated by sorting. The articles were then subjected to thematic analysis, which yielded a final set of interpretive themes (Table 4) (van Grootel et al., 2020).

TABLE 4.

Synthesized findings and categories

Synthesized findings	Categories	Description of category	Findings	Number of findings
Caregivers protect older people against COVID‐19 infections (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Sizoo et al., 2020; Sweeney et al., 2022; Ter Brugge et al., 2022).	Strict visitor restriction	The visitor restriction contributed to limiting the further spread of COVID‐19.	The general strict visitor restriction (Sizoo et al., 2020) Being the liaison between patient and family (Castaldo et al., 2022) Visitor/staff movement restrictions (Sweeney et al., 2022) Help residents cope with lockdown (Marshall et al., 2021)	4
	Advance care planning for older people	Older people are more likely to be infected with the virus; advance care planning for older people is essential.	Advance care planning had to be completed rapidly (Morley et al., 2022) Make definite decisions (Morley et al., 2022) COVID‐19 pandemic served as an advance care planning discussion (Ter Brugge et al., 2022) Diversity calls for tailored solutions (Sizoo et al., 2020) Being adequately prepared (Sweeney et al., 2022)	5
	Increasing use of virtual technology and telemedicine	Caregivers note a significant development in the use of technology and telemedicine with the older people.	Significant development in the use of technology with the older person (Morley et al., 2022) Telephone triage moved to the use of video (Morley et al., 2022) Increased use of technology (Morley et al., 2022) More experienced in making decisions by phone or online (Ter Brugge et al., 2022) Last goodbyes between patient and family member via telephone (Castaldo et al., 2022) Telehealth challenges (Krok‐Schoen et al., 2021) Using mobile phones/smartphones for video calls (Sweeney et al., 2022) Speaking through Perspex or glass or using technology (Sweeney et al., 2022) Digital media (Marshall et al., 2021) Online counselling and courses (Marshall et al., 2021)	10
Caregivers are concerned about older people's mental and physical health (Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sun et al., 2020; Ter Brugge et al., 2022).	Concern for older people's mental	Many caregivers worry about the mental health of the older people.	Worry about their patients' mental health (Krok‐Schoen et al., 2021) Empathizing with patient and family (Castaldo et al., 2022) Providing emotional support to patients and their families (Castaldo et al., 2022) Concern for patients (Sun et al., 2020) Caring for those who are most vulnerable and defenceless (Sarabia‐Cobo et al., 2021)	5
	Concern for older people's physical	Caregivers pay attention to the physical health of the older people and prevent infection.	Geriatric syndrome (Krok‐Schoen et al., 2021) High‐risk status (Krok‐Schoen et al., 2021) Symptom discernment (Krok‐Schoen et al., 2021) Encouraging the patient to eat (Castaldo et al., 2022) Daily exercise programmes (Marshall et al., 2021) Healthy eating regimes (Marshall et al., 2021) Daily activities (Marshall et al., 2021)	7
	Arrange hospice care for dying older people	Caregivers provide hospice care for the older people.	Assessing the dying phase (Sizoo et al., 2020) Dilemmas as a result of the allowed exception in the dying phase (Sizoo et al., 2020) Providing end‐of‐life nursing care to patients (Castaldo et al., 2022) Replacing the family in the last farewell (Castaldo et al., 2022) Ensuring care procedures for the patients' bodies after death (Castaldo et al., 2022)	5
Caregivers show various emotions and mentality (Bilal et al., 2020; Castaldo et al., 2022; Jia et al., 2021; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sun et al., 2020; Sweeney et al., 2022).	Fear of contagion	They fear the older people being taken care of and their families infected with the COVID‐19 pandemic.	Fear of viral infections (Sun et al., 2020) Fear of the pandemic situation (Sarabia‐Cobo et al., 2021) Fear about death of residents and self (Sweeney et al., 2022) Fear for personal safety and exposing their family to the virus (Bilal et al., 2020) Fear of infection and infecting others (Nyashanu et al., 2022)	5
	Pressure increase	Pressures were elicited from communication, death, workload and other negative events.	High‐intensity work (Sun et al., 2020) The feeling of being overburdened with work (Sarabia‐Cobo et al., 2021) Staff shortages (Sarabia‐Cobo et al., 2021) Loss of income (Krok‐Schoen et al., 2021) Staff shortages arising from self‐isolating (Sweeney et al., 2022) Unreliable testing and delayed results (Nyashanu et al., 2022) Overload (Sweeney et al., 2022) Great pressure (Morley et al., 2022)	8
	Negative emotions	Sadness, frustration, powerlessness, depression, anger and so forth.	Encountered dilemmas had profound emotional impact on caregivers (Sizoo et al., 2020) Feeling of social stigma (Sarabia‐Cobo et al., 2021) Anxiety (Sarabia‐Cobo et al., 2021) Depression (Sarabia‐Cobo et al., 2021) Suffering from moral distress (Castaldo et al., 2022) Sense of frustration (Castaldo et al., 2022) Sense of inadequacy (Castaldo et al., 2022) Sense of helplessness (Castaldo et al., 2022) Unexpressed pain (Castaldo et al., 2022) Unsupported (Morley et al., 2022) Isolated (Morley et al., 2022) Professional knowledge disrespected (Morley et al., 2022) Discomfort (Sun et al., 2020) Frustration and anger (Krok‐Schoen et al., 2021) Living in anxiety and fear (Bilal et al., 2020) Emotional pain of death (Marshall et al., 2021)	16
	Emotional exhaustion	Multiple emotional distress and untreated grief, leading to emotional exhaustion.	Emotional exhaustion (Sarabia‐Cobo et al., 2021) Mental exhaustion (Sweeney et al., 2022) Emotional burnout (Sarabia‐Cobo et al., 2021) Suffering in remembering (Castaldo et al., 2022) Experiencing unprocessed grief (Castaldo et al., 2022) Fatigue (Sun et al., 2020)	6
Caregivers display preference in their learning needs (Bilal et al., 2020; Castaldo et al., 2022; Jia et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sun et al., 2020; Sweeney et al., 2022).	Optimization technique	They realize they need to learn more sophisticated techniques.	Lack of knowledge and skills (Jia et al., 2021) Lack of recognition/disparity (Nyashanu et al., 2022) Anxiety caused by lack of knowledge (Sun et al., 2020) Specialized nursing skills (Jia et al., 2021) The broad knowledge base and training (Morley et al., 2022) A shift to technology would continue post pandemic (Morley et al., 2022) Intent to change behaviour, resident care and knowledge sharing (Lingum et al., 2021) The expertise in managing death and bereavement (Marshall et al., 2021) Knowledge increased confidence in clinical (Lingum et al., 2021) Knowledge dissemination (Lingum et al., 2021)	10
	Different work and self‐care	Caregivers have changed roles since COVID‐19 and feel a need for more capacity for self‐care.	Experiencing different work (Morley et al., 2022) Redeployment (Morley et al., 2022) Anxiety caused by environmental changes (Sun et al., 2020) Self‐prevention ability (Sun et al., 2020)	4
	Communication skill	Their jobs require communication skills, dealing with patients, families and colleagues.	Facilitating last communications between patients and their family (Castaldo et al., 2022) Lack of communication with staff (Sweeney et al., 2022)	2
	Emotional support	They are prone to negative emotions during this pandemic and need emotional support.	Lack of ancillary/psychosocial support (Sweeney et al., 2022) Lack of emotional support (Jia et al., 2021) Inability in psychological adjustment and stress resistance (Jia et al., 2021) Psychophysical symptoms (Bilal et al., 2020) Workplace phobia (Bilal et al., 2020) Active or passive psychological adjustment (Sun et al., 2020)	6
Difficulties of management (Bilal et al., 2020; Jia et al., 2021; Krok‐Schoen et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sweeney et al., 2022).	Difficulties brought by the government	Government's incompetence troubles caregivers and managers.	The government policy is not pleasant (Sizoo et al., 2020) Governments lacked foresight (Sarabia‐Cobo et al., 2021) Being abandoned by the authorities (Sarabia‐Cobo et al., 2021) Angry and frustrated at multiple institutions' response to the pandemic (Krok‐Schoen et al., 2021) Slow implementation of infection control measures/government guidelines (Sweeney et al., 2022) Insufficient response to urgency requirements of the situation (Jia et al., 2021) Difficult to work without specific guidance from central government (Nyashanu et al., 2022) Government furlough scheme (Marshall et al., 2021)	8
	Financial strain	Financial strain has increased the pressure on caregivers and made management difficult for managers.	Lack of adequate personal protective equipment (Sarabia‐Cobo et al., 2021) Did not receive the recognition and state benefits they deserved (Bilal et al., 2020) Financial difficulties in the face of extra running costs (Marshall et al., 2021) Supply chains (Marshall et al., 2021) Required to cover sick leave (Marshall et al., 2021) Topping up wages (Marshall et al., 2021) Paying staff during shielding or self‐isolation (Marshall et al., 2021) Stretched staff resource (Marshall et al., 2021) Resource shortages (Marshall et al., 2021)	9
	Competence of manager	The competence of managers is beneficial to improve the job confidence of caregivers.	Limiting advanced clinical skills of the staff (Morley et al., 2022) Uncertainty and doubts concerning the strategies adopted (Sarabia‐Cobo et al., 2021) Complaints on the initial lack of adequate personal protective equipment as well as clear guidelines (Sarabia‐Cobo et al., 2021) Organizational challenges in care provision (Krok‐Schoen et al., 2021) Poor management and leadership (Sweeney et al., 2022) The lack of medical support (Sweeney et al., 2022) Management skills (Jia et al., 2021) The attitude and behaviour of the care home administration (Bilal et al., 2020) Leadership style towards a more hierarchical ‘military’ style of command (Marshall et al., 2021)	9
	The sense of danger brought by nature of the job	The occupational nature of caregivers is that they are exposed to the risk of contagion, which makes management more difficult during the COVID‐19 pandemic.	Helplessness caused by self‐protection (Sun et al., 2020) Feelings of crisis and fear of personal safety (Krok‐Schoen et al., 2021) Unequal exposure to the infectious environment (Jia et al., 2021) Unknowingly catching the coronavirus through interaction with coworkers and residents (Bilal et al., 2020) High‐risk caregiving (Bilal et al., 2020) Left job (Bilal et al., 2020) Loss of professionals through deaths (Nyashanu et al., 2022)	7
Affirmation of self‐worth (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Morley et al., 2022; Sarabia‐Cobo et al., 2021; Sun et al., 2020).	Professional pride and sense of responsibilities	Caregivers perceived themselves with their professional pride and responsibilities, on top of the social expectations during the COVID‐19 pandemic.	Sense of duty and commitment to care (Sarabia‐Cobo et al., 2021) Finding a positive meaning (Castaldo et al., 2022) Professional responsibility and identity (Sun et al., 2020) Confidence of recognizing their own expertise and skill set (Morley et al., 2022) Interest in the profession, affection for elderly (Bilal et al., 2020) Spiritual duty (Bilal et al., 2020) Passion for job (Bilal et al., 2020) Workaholic nature (Bilal et al., 2020) Professional commitment (Bilal et al., 2020) Self‐efficacy (Lingum et al., 2021)	10
	Trust in colleagues, managers and patients	Building better team spirit during the COVID‐19 pandemic.	Mutual support of the health care team (Castaldo et al., 2022) Taking the initiative to be altruistic and seeking team support by ‘huddling together for warmth’ (Sun et al., 2020) Increased affection and grateful sentiments (Sun et al., 2020) Engendered credibility and trust (Morley et al., 2022) Positive feelings regarding their health care system leadership, colleagues (Krok‐Schoen et al., 2021)	5

ConQual ratings were assigned to each synthesized discovery to assess confidence. The rating method assessed the reliability and believability of each study and finding (Munn et al., 2014). When the five criteria specified in JBI's critical assessment technique were not satisfied throughout the included studies, the dependability was downgraded. Credibility was also decreased when some findings contained in a synthesized finding were deemed ambiguous (Lim et al., 2022). The final synthesized findings might be used to formulate recommendations for health care practice or to inform policymaking (Table 5) (Munn et al., 2014).

TABLE 5.

ConQual ‘summary of findings’

Synthesized finding	Type of research	Dependability a	Credibility	ConQual grade
Caregivers protect older people against COVID‐19 infections (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Sizoo et al., 2020; Sweeney et al., 2022; Ter Brugge et al., 2022).	Qualitative and mixed methods	Moderate (downgrade 1 level, only 76.9% have at least 4 ‘yes’)	Moderate (downgrade 1 level b )	Low
Caregivers are concerned about older people's mental and physical health (Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sun et al., 2020; Ter Brugge et al., 2022).	Qualitative and mixed methods	Moderate (downgrade 1 level, only 61.5% have at least 4 ‘yes’)	High	Moderate
Caregivers show various emotions and mentality (Bilal et al., 2020; Castaldo et al., 2022; Jia et al., 2021; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sun et al., 2020; Sweeney et al., 2022).	Qualitative and mixed methods	High (100% have at least 4 ‘yes’)	High	High
Caregivers display preference in their learning needs (Bilal et al., 2020; Castaldo et al., 2022; Jia et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sun et al., 2020; Sweeney et al., 2022).	Qualitative and mixed methods	High (84.6% have at least 4 ‘yes’)	Moderate (downgrade 1 level b )	Moderate
Difficulties of management (Bilal et al., 2020; Jia et al., 2021; Krok‐Schoen et al., 2021; Marshall et al., 2021; Morley et al., 2022; Nyashanu et al., 2022; Sarabia‐Cobo et al., 2021; Sizoo et al., 2020; Sweeney et al., 2022).	Qualitative and mixed methods	Moderate (downgrade 1 level, only 69.2% have at least 4 ‘yes’)	High	Moderate
Affirmation of self‐worth (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Morley et al., 2022; Sarabia‐Cobo et al., 2021; Sun et al., 2020).	Qualitative and mixed methods	Moderate (downgrade 1 level, only 53.8% have at least 4 ‘yes’)	Moderate (downgrade 1 level b )	Low

^a Downgraded when ≤80% of the individual findings have ≥4 ‘yes’ responses to Questions 2, 3, 4, 6 and 7.

^b Downgraded due to mix of unequivocal and equivocal findings.

3. RESULTS

3.1. Search results

The results of the search are presented in a PRISMA flow diagram (Figure 1) (Moher et al., 2015). The search generated 904 studies, 684 of which remained after duplicates were removed. After a review of the titles and abstracts, 590 were excluded, and 94 full texts were intensively read. Subsequently, 81 texts were excluded. Thirteen full texts reviewed according to the JBI summary for eligibility against the inclusion criteria were included in this qualitative systematic review.

3.2. Study characteristics

The characteristics of the included studies are summarized in Table 2. The studies were conducted in the United States (n = 1), Canada (n = 1), China (n = 2), the Netherlands (n = 2), England (n = 3), Ireland (n = 1), Italy (n = 1), Pakistan (n = 1) and Spain (n = 1). Eleven studies were qualitative, and two used mixed methods. The qualitative studies used various methodological approaches, including interpretative qualitative study, phenomenological approach, qualitative exploratory study, empirical qualitative interview study, qualtrics survey, qualitative descriptive study, empirical phenomenological approach and constructivist grounded theory. The study settings comprised nursing homes and geriatric wards. Among the study participants, caregivers included nursing home nurses, hospital nurses, advanced clinical practitioners, senior nursing practitioners, physicians, health care providers, and owners/managers and staff of residential care settings for older people. Most studies defined the age range of older people. Data were collected through focus group discussions conducted through video communication, face‐to‐face or by telephone, as well as individual interviews, open‐ended questionnaires, focus group interviews, semi‐structured interviews, field notes or document reviews. Interestingly, researchers increasingly chose to perform qualitative interviews online or by telephone.

3.3. Methodological quality

The quality of the included articles is summarized in Table 3. Six studies met all criteria. Only half of the included articles located the researchers culturally or theoretically. Two articles (Krok‐Schoen et al., 2021; Ter Brugge et al., 2022) did not indicate whether ethical approval was obtained. Furthermore, three articles (Bilal et al., 2020; Lingum et al., 2021; Sizoo et al., 2020) reflected that researchers' influences on the research were unclear.

3.4. Review findings

Six synthesized findings were identified from 20 categories with 141 findings (synthesized findings in Table 4): (1) Caregivers protect older people against COVID‐19 pandemic; (2) caregivers are concerned about older people's mental and physical health; (3) caregivers show various emotions and mentalities; (4) caregivers display preferences in their learning needs; (5) difficulties of management; and (6) affirmation of self‐worth.

• Synthesized Finding 1: Caregivers protect older people against COVID‐19 pandemic.

This synthesized finding was underpinned by 18 extracted findings and subdivided into 3 categories: ‘strict visitor restriction’, ‘advance care planning for older people’ and ‘increasing use of virtual technology and telemedicine’. This synthesized finding demonstrated that caregivers have formulated detailed plans for prevention to protect older people from infection during the pandemic. The following findings contributed to this synthesized finding (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Marshall et al., 2021; Morley et al., 2022; Sizoo et al., 2020; Sweeney et al., 2022; Ter Brugge et al., 2022). Caregivers have needed to restrict visitors to hospitals and decrease visits between older people and their relatives. ‘It remains a “Devil's bargain”: protecting clients from infection (keeping the outside world out) and having contact with the people you love’ (Sizoo et al., 2020). They thus have become a bridge between older people and their relatives. ‘It happened, especially for older people, that grand‐children and children brought letters, photos, and wanted us to put them near their bed, and this was very touching, even if the person was not conscious, but for them, it was important […]. Or they sent us by phone the photo of the grandchildren, of the family, and they wanted us to show them to the patient’ (Castaldo et al., 2022). Furthermore, caregivers can detect loneliness in older people because of visitation restrictions and help them cope with lockdown (Marshall et al., 2021; Sizoo et al., 2020). ‘Her fear, sadness and loneliness, very tangible and strongly present, mimicking depression […]’ (Sizoo et al., 2020). Furthermore, to prevent caregivers from carrying the COVID‐19 virus, the freedom of caregivers has also been restricted (Sweeney et al., 2022).

Although caregivers have taught many older people to use technology to talk with their relatives, many older people have remained dissatisfied. ‘I prefer to see my relatives face to face and to be together with them physically—I never use these instruments’ (Nielsen et al., 2021). Simultaneously, the visiting regulations of nursing homes have been more free than those in general hospitals. During the pandemic, many older people at homes had difficulties in seeing physicians in the pandemic. They have been able to use virtual technology for telemedicine. Visiting restrictions have been implemented to minimize the traffic in nursing homes and thus prevent the introduction of COVID‐19. ‘It means they don't have to come out of the house; they don't have to, you know get to the surgery because they struggle with that … they absolutely love it’ (Morley et al., 2022). In conclusion, most nurses have made nursing plans for senior care in the same manner as before the pandemic. Many nurses indicated the importance of virtual technology in senior care in this pandemic. ‘We created a new service, so the frailty home treatment service, where we would be looking after almost like a virtual ward of poorly people in the community …’ (Morley et al., 2022).

• Synthesized Finding 2: Caregivers are concerned about older people's mental and physical health.

A close relationship exists between Synthesized Finding 1 and Synthesized Finding 2. Synthesized Finding 2 was underpinned by 17 extracted findings and subdivided into 3 categories: ‘concern for older people's mental state’, ‘concern for older people's physical state’ and ‘arrangement of hospice care for dying older people’.

Caregivers have protected older people against COVID‐19 pandemic. They have responded positively to the policy of restricting visitors. However, as a consequence, the quality of life of most older people has markedly decreased. Many caregivers worry about the mental and physical health of older people. ‘I worry about the impact of restricting visitors emotionally and clinically.’ ‘I think a lot about my older patients and their safety during this pandemic‐this keeps me up at night’ (Krok‐Schoen et al., 2021). This synthesized finding is an effect of the previous finding.

In addition, two studies have shown that geriatric practitioners providing hospice care for older people face difficulties that did not exist in non‐pandemic situations (Castaldo et al., 2022; Sizoo et al., 2020). Caregivers often stand in for the family in ensuring the best possible death during the last farewell, because of the visitation restrictions. ‘I saw physicians cry … or that there was nothing more to be done, both for the older …’ (Castaldo et al., 2022).

• Synthesized Finding 3: Caregivers show various emotions and mentalities.

This synthesized finding was underpinned by 35 extracted findings and subdivided into 4 categories: ‘fear of contagion’, ‘pressure increase’, ‘negative emotions’ and ‘emotional exhaustion’, in that order. The experiences described how COVID‐19 has emotionally affected caregivers caring for older people.

First, some studies have indicated that caregivers are afraid of being infected with COVID‐19 during care (Krok‐Schoen et al., 2021; Sarabia‐Cobo et al., 2021; Sun et al., 2020). ‘Of course I am afraid, I am terrified to think that I have it without knowing, and that I am infecting the residents … we have many positive cases and deaths, and it must be the workers who are bringing it to the nursing home … and that is very scary’ (Sarabia‐Cobo et al., 2021).

Simultaneously, owing to the shortage of caregivers during COVID‐19, caregivers are under great pressure and prone to burnout. Seven studies have reported that caregivers have had increased workloads (Jia et al., 2021; Lingum et al., 2021; Morley et al., 2022; Murphy et al., 2022; Sarabia‐Cobo et al., 2021; Sun et al., 2020; Sweeney et al., 2022). Because caregivers have been required to pay attention to the physical and mental health of older people and the prevention of infection, the increased workload was inevitable.

Furthermore, in this process, caregivers have had many negative emotions, such as depression or anxiety. ‘An elderly patient was suffering from wheezing, and it became increasingly severe. None of the treatments could ease her symptoms. She said “help” to me trembling, and I burst into tears’ (Jia et al., 2021). ‘Her fear, sadness and loneliness, very tangible and strongly present, mimicking depression’ (Sizoo et al., 2020).

Finally, some caregivers have had no spare time to address their emotions, thus leading to emotional exhaustion. ‘I take anxiolytics when I go to work, I need to be calm, I am not ashamed to say it … and to sleep too, I have insomnia, I haver never had it before, if I am not well, I will not be able to take good care of myself … and now we cannot fail, we cannot’ (Sarabia‐Cobo et al., 2021).

• Synthesized Finding 4: Caregivers display preferences in their learning needs.

This synthesized finding was underpinned by 22 extracted findings and subdivided into 4 categories: ‘optimization technique’, ‘different work and self‐care’, ‘communication skills’ and ‘emotional support’.

Caregivers have been required to add new skills and improve their technical proficiency during COVID‐19. Their roles have changed, because many caregivers caring for older people have had to work in emergency departments or accommodate nucleic acid testing for COVID‐19. ‘We created a new service, so the frailty home treatment service, where we would be looking after almost like a virtual ward of poorly people in the community ….’ ‘I hope the recommendation will not just be about creating roles. It's about all of those pillars in terms of research, leadership, clinical expertise, and education, to grow what we need for people, rather than the roles’ (Morley et al., 2022).

At the beginning of the pandemic, they felt caught off guard because they lacked relevant knowledge. They required more knowledge or self‐care (Sun et al., 2020). However, they now have more knowledge about COVID‐19 than they did at the beginning of the pandemic and, as such, prefer to acquire other more advanced knowledge (Morley et al., 2022).

Furthermore, caregivers have indicated learning needs for their communication with patients, medical staff and managers. ‘Timely, honest and consistent communication between managers, staff, residents and families throughout the pandemic experience is essential’ (Sweeney et al., 2022). ‘Some of the critical patients were not able to communicate, so we could not explain treatment plans to them. They could only accept what we offered’ (Jia et al., 2021). Studies have shown that during the pandemic, attention must be paid to the communication between physicians and nurses (Ter Brugge et al., 2022).

In addition, because the caregivers in Synthesized Finding 3 had negative emotions, they also wanted to learn or helped with emotional support (Jia et al., 2021). ‘There was a patient who refused to cooperate and ate little, because of the loss of his family. (N1) I saw the panic and fear in their eyes when I was keeping a distance from them’ (Jia et al., 2021). ‘It (COVID‐19) has depleted my energy more than my work typically does’ (Krok‐Schoen et al., 2021).

• Synthesized Finding 5: Difficulties in management.

This synthesized finding was underpinned by 33 extracted findings and subdivided into 4 categories: ‘difficulties brought by the government’, ‘financial strain’, ‘manager's competence’ and ‘the sense of danger inherent in the nature of the job’.

First, some have expressed anger regarding the slow governmental response in their sector: ‘ineffective/slow implementation of recognized infection control measures by government and residential service sectoral management’ (Sweeney et al., 2022). ‘The US federal government response has been a complete disaster in terms of rapid testing and securing adequate PPE’ (Krok‐Schoen et al., 2021). Caregivers have cited feelings of abandonment by the government and the wider health care sector. ‘Governments have failed … there has been no foresight, we are abandoned, exhausted … we fight alone’ (Sarabia‐Cobo et al., 2021). ‘Government says if nurses die due to coronavirus, their families will get Rs. 700,000. But … what do our families get? Nothing!’ (Bilal et al., 2020).

Some caregivers have expressed financial strain: ‘the issue with that was when the Government announced they would provide PPE equipment free of charge to all care homes and surgeries and whatever, which was fine but what they were doing was they were intercepting stock that we would have normally purchased from our suppliers. So then our supplier was saying we can't send it out because we've got to give it to the Government. And so our options for buying stuff then was quite limited’ (Marshall et al., 2021).

Furthermore, some caregivers have questioned their managers' competence. ‘A lack of support from operational managers and physicians, a lack of administration support’ (Morley et al., 2022). ‘But they rejected my leave request and told that if I don't show up, they will fire me’ (Bilal et al., 2020). ‘Respondents highlighted—poor management and leadership’ (Sweeney et al., 2022). ‘They facilitated us by providing the protective equipment. But that's all. They didn't do anything like increasing wages or reducing duty hours’ (Bilal et al., 2020).

Furthermore, a sense of danger is inherent in the nature of the job. During nursing of patients with COVID‐19, inequality has often been experienced by nurses, mainly unequal exposure to infectious environments and role ambiguity between physicians and nurses. Geriatric nurses have additional duties such as turning bed‐ridden patients and feeding patients who cannot take care of themselves (Krok‐Schoen et al., 2021). ‘We frequently needed to deal with patients, which increased the chance of infection, but doctors spent much less time in the ward’ (Jia et al., 2021).

• Synthesized Finding 6: Affirmation of self‐worth.

This synthesized finding was underpinned by 15 extracted findings and subdivided into 2 categories: ‘professional pride and sense of responsibilities’ and ‘trust in colleagues, managers and patients’. Seven studies have reported that caregivers express professional pride and a sense of duty (Bilal et al., 2020; Castaldo et al., 2022; Krok‐Schoen et al., 2021; Lingum et al., 2021; Morley et al., 2022; Sarabia‐Cobo et al., 2021; Sun et al., 2020). ‘The people we serve; and, those we feel a great sense of responsibility for …’ (Lingum et al., 2021). Many caregivers have managed to maintain joy despite the negative emotions of caring for older people during the COVID‐19 pandemic. However, several cases of a low sense of responsibility in nursing services were identified. ‘Some nurses were worried about being infected, so they secretly reduced the frequency of helping patients turn over and rubbing their backs’ (Jia et al., 2021).

Furthermore, caregivers trust in colleagues, managers and patients. ‘Everyone is very welcoming and friendly. Experienced colleagues will take the initiative to teach me. I also take the initiative to teach new colleagues’ (Sun et al., 2020).

3.5. ConQual summary of findings

ConQual ratings were awarded to each synthesized discovery to rate their confidence (Table 5) (Munn et al., 2014). One synthesized finding had a high grade, three had a moderate grade and two had a low grade.

4. DISCUSSION

The objective of this qualitative systematic review was to explore caregivers' experiences and perspectives in caring for older people during the COVID‐19 pandemic. At present, no prior articles have been completely consistent with the research methods and themes of this study. The 13 articles selected for meta‐synthesis resulted in 141 findings that were summarized into 20 categories and yielded 6 synthesized findings.

Evidence has suggested that caregivers protect older people against COVID‐19 pandemic through visitor restrictions, advance care planning, and virtual technology and telemedicine. Many quantitative studies on COVID‐19 have reported that testing and vaccines are the most important means to prevent COVID‐19 (Fiolet et al., 2022; Hyams et al., 2021; Soiza et al., 2021). Interestingly, qualitative research on caregivers' care of older people during the COVID‐19 pandemic has rarely described testing and vaccines directly.

Second, evidence suggested that caregivers are concerned about older people's mental and physical health. Because of the visitor restrictions in Synthesized Finding 1 and other reasons, older hospitalized patients have had difficulties in seeing their relatives and friends, and caregivers have been very worried about the psychological condition of these people. Many countries have enacted rigorous pandemic control procedures preventing visits to healthy older people. Older people may be prone to loneliness and sadness because of a lack of proficiency in using virtual communication (Nielsen et al., 2021). Caregivers of older people should focus more on their mental health while maintaining careful surveillance. Furthermore, COVID‐19 increases caregivers' workload. These results are similar to those of Gray et al. (2021). Furthermore, caregivers arrange hospice care for dying older people.

Most articles in this review showed that caregivers in different countries had various emotions and thoughts. This finding coincides with recent quantitative research (Dragioti et al., 2022) supporting that health care staff have shown negative emotions during the COVID‐19 pandemic, with symptoms of anxiety, depression and insomnia. Our research focused on refining the real‐world experience of caregivers. According to a study (Dragioti et al., 2022), nurses caring for patients with COVID‐19 have more chronic fatigue, poor quality of care, reduced work satisfaction and greater intention to leave their organization than without COVID‐19. Consequently, managers should provide wellness resources to caregivers during the pandemic as part of a long‐term retention strategy.

This systematic review regarding caregivers indicated preferences in their learning needs consistent with past reviews (Gray et al., 2021), which have described the limited knowledge of caregivers in senior care during the COVID‐19 pandemic. A related prior review (Gray et al., 2021) of COVID‐19 nursing home care has concluded that, at the onset of the pandemic, little was known about the novel coronavirus, including how to control it or how to properly protect against it. Staff reported feeling underprepared and lacking in skills and knowledge. However, this review found caregivers to have the need of optimization technique, self‐care and communication skills and emotional support in COVID‐19 care, although caregivers' knowledge has improved since the beginning of COVID‐19 pandemic, particularly in prevention and detection of COVID‐19. This study found that caregivers have significantly changed in that, after more than a year, they have gained more comprehensive knowledge of the new coronavirus, whereas they were caught off guard at the beginning of the COVID‐19 pandemic. Moreover, many managers and researchers have formulated more detailed guidance to help caregivers better serve older people. In contrast, caregivers are increasingly realizing the value of virtual technologies and the need for more personalized learning. This finding coincides with the research of Rose et al. (2021). However, virtual learning can also be a challenge for older adults (Birkhoff et al., 2021). Furthermore, according to a related study (Song et al., 2021), emotional labour can lead to caregiver exhaustion and decreased attendance. Therefore, caregivers need more emotional support, and managers should pay attention to this phenomenon. Additionally, caregivers should be trained in hospice‐associated expertise.

The management difficulties summarized in this study had not been discovered in previous similar investigations. Evidence suggests that the government brought a sense of crisis to caregivers. This view coincides with the research of Gray et al. (2021). Caregivers had a sense of abandonment by organizations and/or their governments. Similarly, we found that most caregivers complained that the government did not provide materials and formulate policies in a timely manner, thus placing them in a very dangerous situation. In contrast, several governments have implemented liberal policies in response to the pandemic's progress, taking into account the effects of economic and social difficulties. The present lockdown approach is more relaxed than those at the start of the pandemic. Although this policy may lead to many older people feeling less lonely, it places older people, the most vulnerable population group, at a much higher risk of infection and death. Therefore, the government's actions have increased the pressure on, and danger to, caregivers. Caregivers have complained of managerial incompetence (Krok‐Schoen et al., 2021; Marshall et al., 2021; Morley et al., 2022; Sarabia‐Cobo et al., 2021). Therefore, managers should pay attention to caregivers and develop guidance. Finally, caregivers sense danger due to the nature of the job. According to the hierarchy of needs theory (Liu et al., 2022), caregivers' safety needs are not being met. The nature of their work places caregivers in danger of infection. Therefore, during the pandemic, they have been prone to doubting their career choices or even leaving their jobs for external reasons, such as the government, managers and the nature of their work (Bilal et al., 2020; Jones et al., 2021).

Although caregivers have had a sceptical mentality about career choice during COVID‐19, many caregivers have realized their value. According to the hierarchy of needs theory (Liu et al., 2022), managers should consider the level of self‐actualization in the hierarchy of needs of employees. The results reported by Curtin et al. (2022) are also similar to those of this review.

5. STRENGTHS AND LIMITATIONS

This is the first qualitative systematic review of caregivers' experiences and perspectives in caring for older people during the COVID‐19 pandemic. Our article integrates the relevant experiences and perceptions of caregivers caring for older adults during the pandemic and provides insights into the underlying reasons for these experiences and perceptions. In this study, compared with prior studies, the quality and reliability of the included literature are better, and the publication years are more recent. To ensure the trustworthiness of this review, the research process involved multiple independent reviewers and ConQual scores. Throughout, the authors' potential influences on the research were duly considered. Interestingly, the first three authors are all master's degree students in relevant fields who have yet to begin working. Therefore, they were able to undertake the review with as little personal work experience as possible, while having a solid understanding of senior care. A major limitation was the exclusion of non‐English articles. Although most studies included in this article were qualitative studies, two mixed studies were included. Extracting fragments of qualitative research from mixed‐type research might have skewed the results of the article. To discover the experience of caregivers providing senior care, this study included some older patients' experiences of being cared for, thus potentially skewing the results.

6. CONCLUSION

This review synthesized existing evidence and explored caregivers' experiences and perspectives on caring for older people during the COVID‐19 pandemic. The results of a qualitative systematic review showed that caregivers' emotions, cognitions and knowledge influence all affected the quality of caregivers' senior care services during the pandemic. As COVID‐19 evolves, the feelings and thoughts of caregivers are changing, thus prompting managers to pay more attention to the stress and emotional experience of caregivers providing senior care. As a result of this study, organizational leaders and policymakers may become more aware of the need to support better management and geriatric care guidelines.

7. IMPLICATIONS FOR NURSING MANAGEMENT

This review emphasized the importance of management and providing support to caregivers during COVID‐19. First, for caregivers caring for older people, the implementation and formulation of prevention and management plans require the action of managers. Second, during the COVID‐19 pandemic, the workload of caregivers has increased, thus requiring better scheduling by managers. Third, managers should consider the negative emotions of caregivers and prevent negative emotions from affecting their work. Fourth, caregivers have learning needs, and managers can provide learning resources in their learning sessions. Fifth, some caregivers will doubt their career choice during the COVID‐19 pandemic, for reasons such as difficulties brought by the government and financial strain. It is necessary to improve the management competence of manager. Managers should formulate timely and effective management strategies and be considerate of caregivers. Finally, according to Maslow's hierarchy of needs theory, managers should ensure the personal safety of caregivers, respect them and find their personal value fulfilled.

This report offers an overview of experiences among caregivers caring for older people during the COVID‐19 pandemic. We discovered through a literature analysis that the experience of caregivers has changed as the pandemic has progressed. The findings serve as a reminder to relevant managers and policymakers to take measures in accordance with the passage of time and local conditions. Furthermore, during the pandemic, geriatric caregivers have appreciated advance care planning. The next stage in our research will examine directions in advance care planning and hospice care for older people during the COVID‐19 pandemic. In addition, virtual technology has gained attention during the pandemic, and many practitioners believe in its future potential. Our team also expects to determine the needs and challenges of older people in this regard. Because older people may have issues with technical learning, technology must be more innovative to be applicable to a larger number of older people. Finally, medical staff caring for older people perform extensive emotional labour, and we hope to broaden the current research by examining their deeper emotional labour experiences.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS APPROVAL

Not applicable. This is a qualitative systematic review work from published literature and formal consent is not required. (https://www.crd.york.ac.uk/prospero/#recordDetails).

Zhang, H. , Wu, Y. , Wang, N. , Sun, X. , Wang, Y. , & Zhang, Y. (2022). Caregivers' experiences and perspectives on caring for the elderly during the COVID‐19 pandemic: A qualitative systematic review. Journal of Nursing Management, 30(8), 3972–3995. 10.1111/jonm.13859