3.4.1. Mental health outcomes.

Worry. Eight studies explored the potential worry experienced by families of HCWs. Only two studies explored this prior to COVID and reported that spouses of paramedics [36] and families of EMS [37] experienced high levels of stress due to concerns about physical safety, working conditions (unhealthy foods in the canteen, long working hours) and safety risks to their HCW family member at work.

Six studies explored worry in families of healthcare workers in the context of COVID-19 specifically [25–27,38–40]. During the COVID-19 pandemic, family members were also worried about the physical safety of their HCW loved ones. For example, in a qualitative study conducted with 25 family members of HCWs in Iran during the pandemic, family members whose HCW wife or daughter was pregnant, specifically worried about both their wife’s/daughter’s lives as well as the life of the unborn child [38]. One of the spouses of a HCW shared his feelings with Mohammadi et al., [38]: “My wife is 24-week pregnant. She loves her job and says she became a doctor for times like this. I understand her, but I can’t help worrying. I’m afraid of the future. What if something happens to her and puts her life in danger. I’m afraid of premature birth, having a premature baby, and many complications that may follow. We don’t know how this unknown disease affects mothers and their babies. Thinking about the future and uncertainty about what it holds is always with me.” Families of HCWs were particularly worried that HCW would bring the disease home and that their children and other families would also contract it [39,40]. In a prospective observational study, which was conducted with 38 HCWs and their 81 family members in Italy, infection rates were lower for HCWs compared to their families, and researchers pointed out that HCWs were not a main source for the transmission of the COVID-19 for their families [25]. However, even though HCWs may not be the main source of transmission, there was still concern amongst family members about transmission risks [40].

Anxiety and depression. Seven papers focused on anxiety and depression experienced by families and friends of HCWs [27–31,38,41,42].

Only one study focused on the experiences of families before the COVID-19 pandemic. This qualitative interview study was conducted with five family members and close friends of HCWs with burnout in Sweden [42]. Family members reported that they were worried because they were struggling to understand HCW’s burnout experiences. Additionally, due to the burnout and job stress, family members were required to undertake more responsibilities in the home and family members described feeling anxious about how their daily lives were disrupted while they were taking more responsibilities at the home. However, it is important to highlight that this study failed to provide any detail about the demographics of participants, so it is difficult to know how transferable the findings of this study might be.

Six papers identified anxiety and depression in the families of HCWs in the context of the COVID pandemic. Families of frontline workers who had been working during the COVID-19 pandemic [29], stated that they experienced high anxiety. Similarly, families of HCWs in Iran [28,38], France [41], China [29,31], India [27], and Turkey [30], experienced intense anxiety and depression during the pandemic. Families mostly tended to be concerned about HCW’s health and working conditions [29,40], for example, having enough grocery supplies and when family members would be able to see their HCW loved one [29]. However, since these studies were conducted at a single point in time during the COVID-19 pandemic and there is no data on the mental health of the participants before COVID-19, these results should be considered carefully.

Secondary traumatic stress and PTSD. Four studies reported experiences of secondary traumatic stress and PTSD in families of HCWs, and all of these were conducted during or after the COVID-19 pandemic [29,32,38,40]. Families of HCWs who were working during the COVID-19 pandemic reported that they had vivid dreams about the traumatic situations that happened at the HCW’s work [40]. Likewise, it was reported that HCWs were sharing traumatic work experiences with families to seek support, but this may increase the risk of experiencing secondary traumatic stress amongst family members [38,40]. However, these studies’ sample sizes are very small making it hard to draw robust conclusions. Additionally, all four studies were either conducted during or after the COVID-19 pandemic, with no comparisons about the mental health and wellbeing of those families and HCWs before the pandemic.

Emotional burden. There were four studies that reported on the emotional burden that families experienced. Families of HCWs tended to see themselves as a source of support for the HCW and made emotional sacrifices, both before and during the pandemic.

Two studies were conducted before the pandemic and researchers reported that families tended to carry the emotional burden, protecting the rest of the family from the details of traumatic events that their HCW loved one experienced, “walking on tiptoe” [42], and trying to read the emotions of the worker and the level of the worker’s exhaustion, the expression on the worker’s face, or the lack of communication and try to comfort them [36].

Two studies were conducted during the pandemic and in these studies family members reported that they just tried to listen their HCW family member [40] and hide their own anxiety and fear to support them [38]. These findings show that family members experience emotional burden while supporting their HCW family member, however, the COVID-19 pandemic may have aggravated this.

3.4.2. Family relationships.

Family relationships and functioning. Seven studies investigated the relationship between work stress and its impact on family relationships. Results across these studies were consistent, showing that HCWs’ stress had a negative impact on family relationships before and during the COVID-19 pandemic. Families of HCWs in Hong Kong [33], and spouses of paramedics in Canada [36] demonstrated that higher stress experienced by the HCWs was correlated with more negative family relationships. In a qualitative study which included 14 spouses of paramedics, spouses stated that there was an extreme negative impact of the paramedic’s stress and trauma on family relationships. A husband shared his experiences: “She crowds in on herself. She becomes very quiet, won’t talk. And of course, the flip side of that is if you press the wrong button, then BOOM!” [36]. Some studies conducted during the COVID-19 pandemic have shown that conflicts experienced by families of HCWs in their family relationships have increased. For instance, in a study of 39 frontline HCWs, participants reported that they started to spend more time with their families, but this was emotionally draining because both families and managers required more time from HCWs and this caused conflicts at home [39]. Similarly, in a qualitative study, 28 HCWs pointed out that there was an enhanced tension in family relationships due to the financial concerns caused by COVID-19, one-sided parental decisions, or decreased couple’s time. For example, a nurse stated conflicts in family relationships due to parenting decisions: “I guess I am more restrictive with the kids and what they can do. I would rather have them not do some things and go some places. My husband is less weary than I am about it so that can create some tension” [43].

There were, however, studies which focused on the improvements in family relationships during the pandemic in HCW families. For example, according to the findings of a qualitative study which was conducted with 49 nurses and 48 family members in France, nurses and their family’s perceived lockdown as an opportunity to build stronger relationships with family members and to spend more time together cooking, baking, and playing games [41]. Similarly, Schaffer et al., [43] highlighted that there was a stronger bond between family members, and they were willing to help each other compared to before pandemic. However, these study participants were mostly female. More research is required with male family members.

Four studies reported a sense of pride amongst families of HCWs. For example, family members of HCWs who had been working during the COVID-19 pandemic in the UK [40], France [41], and Iran [38], reported that despite the lack of adequate equipment at the beginning of the epidemic, the high risk of contracting the disease, and poor working conditions, HCWs continued to save lives, and this led to a great sense of pride for families. Even before the COVID-19 pandemic, spouses of paramedics in Canada reported being proud of their HCW family members [36].

Couple relationships. Six studies focused on the relationship between occupational stress and couple relationships and intimacy, reporting that job stress may have a negative impact on couple relationships and intimacy both before and during the pandemic [34,36,38,40,44]. For example, before the pandemic, spouses of paediatricians reported that because of job stress and long working hours, they experienced intimacy and communication challenges [44]. Similarly, a longitudinal study’s findings highlighted that there was a relationship between paramedics’ perceived stress and burnout experiences at work and spouses’ interpersonal withdrawal [36]. Studies which were conducted during the pandemic also support these findings. For example, spouses of HCWs in the UK stated that their sacrifices were not recognised by their HCW partners and society [40]. Additionally, lack of privacy during the pandemic also caused some tension in couple relationships: “I think there is some tension in the marriage because the kids are around more. My husband and I are not getting as much alone time together and individually because the kids are around.” [43]. However, this study’s sample size is small.

Absence and Separation. Four studies reported the negative impact of HCWs being absent and separated from their families and they were all conducted during the pandemic.

HCWs who worried that they might spread the virus to their families often isolated themselves from their loved ones. For example, in a qualitative study in the UK, it was reported that because of the long working hours and shifts, HCWs tended to be away from their families: “Our kids didn’t get to see as much of their dad, and they missed him as well.” [40]. Similarly, a study conducted with 25 family members in Iran reported that HCWs could not come back to their home regularly because of long working hours and shifts which significantly impacted family members, especially children [38].

Even when HCWs were at home with their families, there was still often separation. For instance, Chandler-Jeanville et al., [41] reported that, due to transmission risk, some nurses limited their physical contact with their families. This was especially challenging for children who wanted to hug and kiss the HCW family member, but spouses and partners also stated that this limited physical contact impacted their relationship negatively as well. Schaffer et al., [43] supported these findings in their research which was conducted with 28 HCWs in the US. They reported that because of limited physical contact, families started to be creative in terms of communicating with the HCW. A nurse shared her experiences: “The girls text and facetime me more from their rooms in the house, which I used to never let them do.” This helped them to build new routines and rituals to retain their relationships.

3.4.3. Coping skills and resilience.

Coping skills. Seven studies focused on the impact of coping skills on psychological health and quality of life. The results of the studies were consistent, providing important knowledge about coping skills both before and during the COVID-19 pandemic. Studies conducted before the pandemic pointed out that family members and friends of HCWs in Sweden stated that searching for recuperation and learning something new about themselves helped them to re-energise and find strength to cope with the healthcare work stress [42]. Similarly, twelve family members of EMS workers in the US pointed out that developing their own interests helped them to cope with the impact of EMS work [37]. Additionally, emotional support, positive thinking, and sharing domestic responsibilities were helpful for families to cope with the HCW’s job [37]. Similarly, studies conducted during the pandemic reported that coping skills had an important direct impact on psychological health and quality of life amongst families of HCWs [27,28,35].

One study focused on humour as a coping strategy against occupational stress. In this study which was conducted with 14 spouses of paramedics in Canada, spouses reported that they used humour with their HCW spouses to reduce the impact of tragic events. “We’ve developed a very left field sense of humour. It’s questionable, but it’s good” [36]. However, this study focused on the experiences of families of HCWs before the COVID-19 pandemic. The perspective on humour and its use may have changed during the pandemic, when life was in serious danger not only for healthcare professionals but also for their families.

One study focused on religion as a coping strategy against occupational stress. During the pandemic, 22 out of 25 family members of HCWs in Iran reported that they spiritually grew during the pandemic and prayed for comfort and safety for everyone. One participant said that “Since COVID-19 began to spread; I have done more talking with God, vows, good deeds, and altruism. I feel more spiritual than before” [38]. However, since there is no other research which focused on the spirituality of families of HCWs, it is difficult to generalise these findings.

Social support. Six studies explored the impact of social support on coping with occupational stress amongst family members, with consistent findings pointing out the importance of social support to cope with occupational stress.

Two studies focused on social support before the pandemic and researchers reported that, thanks to social support, families of EMS workers in the US coped with the HCW’s job stress [37]. Spouses of paramedics pointed out another important topic: paramedics mostly had peer support during their shift, but that was not enough [36].

Four studies focused on the families’ experiences of social support during the pandemic. In their qualitative study which was conducted with nurses and their families in France, Chandler-Jeanville et al., [41], reported that families were sincerely grateful to their friends and extended family members for their support during the pandemic. Additionally, they were happy to hear handclaps and to receive presents from the local community because they tended to interpret them as evidence of social support [41]. Similarly, in a qualitative study which included 25 family members in Iran, 23 of them pointed out that they felt social support by the rest of society showed their gratitude to families of HCWs [38]. On the other hand, families of HCWs were worried that this appreciation would fade away too quickly and HCWs’ working conditions would not be improved [40,41]. In another qualitative study conducted with 28 HCWs in the US, HCWs reported that their families were stigmatised because of their healthcare work. For instance, one nurse manager shared her experience: “I stopped telling people that I was a nurse in public. I told my kids to stop telling people that I was a nurse because people were afraid of me because of potential exposure to COVID-19” [43].

3.4.4. Quality of life and social life.

Life satisfaction. Two studies explored life satisfaction amongst family members of HCWs. Families of HCWs who had been working on COVID-19 during the pandemic in the UK stated that they had to sacrifice many elements of their own work because of increased shifts of the HCW family member, and this impacted their job satisfaction [40]. Additionally, in a cross-sectional study conducted with 220 family members of nurses in Iran, researchers found that 30.77% of family members reported poor quality of life [35]. However, these studies were conducted during the COVID-19 pandemic. We do not have information about quality-of-life experiences of families of HCWs before the pandemic.

Social life.

Four studies examined the impact of shift work and long working hours on the social life of families. We found that shift work had a significant negative impact on the social life of families of HCWs and their experiences were similar before and during the pandemic.

Two studies were conducted before the COVID-19 pandemic. Findings of a qualitative study in the US with families of emergency medical workers demonstrated that shift work has a negative impact on family social life [37]. Likewise, for some HCWs there were difficulties in keeping their work/life balance due to shifts and long working hours. They reported that even if families can spend more time together despite shift work and long working hours, there will be some costs. Spouses of paediatricians [44] in New Zealand stated that while they spend time with their families, they do not have time for activities as a couple.

Two studies focused on the social life of families during the pandemic. In a qualitative study which was conducted with 39 frontline workers in Australia, HCWs tried to spend time with their families, but they were already working long hours. For this reason, spending time with their families came at the cost of losing personal space and “Me Time” [39]. Also, the social lives of families of HCWs were disrupted not only because of the HCW’s long working hours and shifts, but also social isolation and stigma. Twenty-eight HCWs in the US reported that because of the infection risk, their family members were stigmatised and had to withdraw from social activities. They specifically reported that they were worried about the impact of stigma and social isolation on their children’s mental health and wellbeing [43].

3.4.5. Practical Outcomes.

Domestic responsibilities. According to six studies with consistent results, family members of HCWs tended to take on more responsibilities at home, regardless of the pandemic. Families of HCWs stated that they have to be responsible for a lot of the domestic responsibilities that couples normally share because of the HCW’s job demands. These responsibilities included cleaning, paying the bills, shopping, childcare, and supporting vulnerable family members [29,37,39,40,42]. According to findings of two studies focused on the experiences of families before the pandemic, family members tended to have more responsibilities for cleaning and childcare [37,42] with family members perceiving that if they take over domestic responsibilities from the HCW family member, they may recover from their job stress quicker [37]. Similarly, during the COVID-19 pandemic, family members were willing to take on more responsibilities at home to help the HCW, [39,40].

During the pandemic, however, family members’ domestic responsibilities were increased not only because of the increased working hours and shifts, but also, because of the high-risk of carrying the disease home, family members tended to clean the house more than usual. A male partner of a physiotherapist who worked closely with COVID-19 patients during the pandemic in the UK reported that: "I’ve helped out making a packed lunch and when she came home from work every day, we got into a sort of routine where I would close all the curtains so she could strip off in front of the washing machine, put [her clothes] in the washing machine, and shower upstairs. So, I was helping out in that way” [40]. Similarly, a HCW who worked with COVID-19 patients during the pandemic in the US said that: “[My] husband goes around when I get home and wipes down and bleaches everything that I touch” [43].

Impact on living location. Two studies focused on how the families of HCWs are also impacted by a lack of choice of living location. For example, ten spouses of paediatricians in New Zealand before the pandemic [44] and 14 family members of HCWs in the UK during the pandemic [40] pointed out that they have to choose their home’s location based on the HCW, because of long working hours and shifts. Because of that choice, families of the HCWs sometimes needed to travel for several hours every day to go to their own job, which caused tension between family members. Results show that moving constantly due to HCW’s work location has a negative impact on families regardless of the COVID-19 pandemic [40,44].

4.1.1. Strengths and limitations of the included papers.

Most of the studies included in this review met the criteria for high-quality research. Yet, there are a number of limitations in the articles included in this review. Firstly, we aimed to include studies that focused on the experiences, views, needs and mental health issues of a variety of family members of HCWs. However, most studies focused on spouses, partners, and wives in heterosexual relationships, and children and teenagers of HCWs. This review found a gap in the literature, with a lack of research that focuses on the partners and spouses in same-sex relationships, parents, and siblings of HCWs. Secondly, most of participants in the included studies were female and there was a lack of research on male family members. Thirdly, most of the included studies reported on the mental health and wellbeing of family members during the COVID pandemic. There was no information in most studies about the previous mental health status of family members. Finally, in some of the qualitative studies included in this review, reflexivity was not included in the paper. For this reason, it is difficult to determine how the characteristics of the researchers who conducted this study may have impacted the data collection and analysis.

4.1.2. Strengths and limitations of the systematic review.

In this review we have synthesized the results of qualitative and quantitative studies, according to the highest quality standards. We included studies from thirteen different countries from four continents. For this reason, our results are potentially transferrable to different countries and cultures. Our research team was diverse, including researchers from different career stages, clinical experiences, and different cultural groups. This allowed us to consider our findings from a variety of perspectives and build a rich and in-depth analysis. Yet, there are some limitations. The search was restricted to the English and Turkish languages due to the spoken languages of the researchers. Therefore, there may have been studies that were written in other languages that were missed.