Look, you are (not) alone: circulating gift and the mental health of healthcare professionals during the COVID-19 pandemic

Abstract

The mental health of health professionals who worked directly in services during the COVID-19 pandemic to care for patients affected by the disease became a fundamental issue to be considered, given the several consequences of this activity for these professionals. This article aimed to understand the challenges and demands of health professionals concerning support to address the emotional and physical exhaustion of working on the so-called frontline during the COVID-19 pandemic. The qualitative methodological approach was based on semi-structured interviews conducted online with these professionals after the first months of the pandemic. The hero’s place in which they were set, even if only in media discourses, soon gave way to their weaknesses and fragile work relationships to emerge: stress, fear, and the listening and reception desire. Marcel Mauss’ gift theory was brought up considering that new ways of reading and interpreting health work relationships contribute to necessary and urgent reformulations of their current context, targeting mental health and, more broadly, the comprehensive health of healthcare professionals.

Key words:
COVID-19; Mental health; Health professionals

Resumo

Durante a pandemia de COVID-19, a saúde mental dos profissionais de saúde, que trabalharam diretamente nos serviços voltados para o cuidado dos pacientes afetados pela doença, tornou-se questão fundamental a ser considerada, dado os diversos desdobramentos que essa atuação gerou para esses profissionais. O objetivo deste artigo foi compreender desafios e demandas dos profissionais de saúde em termos de suporte para lidar com o desgaste emocional e físico com a atuação na chamada linha de frente durante a pandemia de COVID-19. A abordagem metodológica qualitativa se deu a partir de entrevistas semiestruturadas realizadas em ambiente online com esses profissionais, passados os primeiros meses de pandemia. O lugar de herói em que eles foram colocados, ainda que apenas nos discursos midiáticos, logo deu espaço para que as fragilidades destes e das relações de trabalho aparecessem: estresse, medo e o desejo de escuta e acolhimento. A teoria da dádiva de Marcel Mauss foi trazida considerando que novas formas de leitura e interpretação das relações de trabalho em saúde contribuem para reformulações necessárias e urgentes do contexto em que se encontram hoje, visando a saúde mental e, mais amplamente, a saúde integral dos profissionais da área de saúde.

Palavras-chave:
COVID-19; Saúde mental; Profissionais de saúde

Introduction

This article contextualizes the healthcare professional’s role in caring for patients affected by COVID-19 in the first year of the pandemic. More than two years into the onset of the health emergency¹, this work presents statements from health professionals who worked in person during the first months of the pandemic in Rio de Janeiro state public and private institutions.

The global flexible work paradigm, which defines the free worker as starting from their ability to be open and prepared for changes, produces new power and control² structures instead of creating better conditions. The pandemic emerges in this setting of devaluation, demanding more from workers without ensuring the necessary rights and support. Besides the harsh epidemiological context, the pandemic revealed what years of substandard work resulted in the lack of public policies, fragile labor rights, and health sector underfunding³.

The first Brazilian case of the disease was recorded on February 25, 2020⁴. In the subsequent months, registered cases and deaths increased dramatically, and the demand grew exponentially for these professionals. Besides exposure to physical conditions, which generated a large number of infections and even deaths of healthcare workers⁵, according to the World Health Organization (WHO), professionals were at an even greater risk of developing mental health issues⁶ during this period. Even so, actions aimed at caring for professionals were not always put into practice or seen as a priority by public or private services.

We are in 2022, and the health emergency persists, resulting in several meaningful and lasting developments⁷. Thus, addressing how workers’ mental health has been affected in recent months is vital, considering their precarious context in the pre-pandemic period.

The present study seeks to understand the needs and demands highlighted by health professionals regarding support to address emotional and physical exhaustion and the challenges faced by those who worked on the so-called frontline during the COVID-19 pandemic. Given the multiplicity and characteristics of health work, the present study opted to listen to health professionals providing direct and continuous care to patients infected by COVID-19.

Methodological path

Based on the interest and need to know more about health professionals and their work in the COVID-19 pandemic, a group of researchers from the Fernandes Figueira National Institute of Women, Child, and Adolescent Health - Fiocruz (IFF/Fiocruz) developed the research project “Clinical-epidemiological and psychosocial profile of health professionals in the face of the COVID-19 epidemic in the state of Rio de Janeiro (COVIDPRO)”. This project is registered on Plataforma Brasil under CAEE 31997320.5.0000.5269 and was approved by the IFF/Fiocruz Research Ethics Committee under Opinion N° 4.102.925.

A questionnaire was prepared with 30 closed-ended questions and one open-ended question⁸ searching for data on demographic and work characteristics and their interface with mental health. This document was shared with participants in an electronic form developed on the Google Forms platform and sent with a link for access through social networks.

This form was answered by 1,190 participants, who accepted the Informed Consent Form before starting the questionnaire. Five hundred fifty-four responded to the open-ended question: “We would like to leave this space open for you to write how you feel during this pandemic or contribute with suggestions for issues not covered in this study”.

After completing the questionnaire, it was possible to signal interest in participating in the interview that integrates the qualitative part of the study, which this article presents. One hundred twenty-six of these 554 people who responded to the open-ended question volunteered to participate in the interview. An email was sent to those providing direct and continuous care to COVID-19 patients, inviting them to the next step. In the end, ten interviews were held virtually via the Zoom platform.

Methods: the qualitative stage

Semi-structured interviews⁹ were performed from a previously prepared roadmap. Each interview lasted an average of 40 minutes, totaling more than seven hours of recording. The roadmap aimed to grasp what health professionals’ most significant challenges were and how they addressed these issues in the first months of the pandemic: their work routine, how they felt in this environment, and how this was reflected in their personal lives. We also aimed to understand what support each professional received or would like to have received as a healthcare worker in such a challenging time. The ten respondents were from different professional categories, age groups, and work profiles, and all were Rio de Janeiro state residents (Chart 1).

Chart 1
Characteristics of respondents.

Interview	Gender	Age	Profession	Work sector
Interview 1	Female	58	Nurse	Human milk bank
Interview 2	Female	51	Nurse	Nephrology/dialysis
Interview 3	Male	41	Physical education professional	Psychiatric hospital
Interview 4	Female	52	Physiotherapist	ICU
Interview 5	Female	56	Doctor	Outpatient clinic, private office
Interview 6	Male	27	Doctor	Emergency care, outpatient clinic, home care/home visit
Interview 7	Female	35	Nurse	ICU, Emergency care
Interview 8	Female	34	Doctor	Surgical/obstetric center (including delivery room), pathology laboratory
Interview 9	Female	32	Nurse	ICU, Emergency care
Interview 10	Female	30	Speech therapist	Outpatient clinic

• Source: Authors.

The interviews were subjected to meaning interpretation method principles. Under this method, the context, reasons, and logic undertaken that evoke actions and interactions between groups and institutions¹⁰ matter. The gift theory, whose main systematizer is Marcel Mauss¹¹, supported the analysis structure of the interviews. The extracted participants’ statements revealed the central ideas and their underlying meanings, ultimately providing the organization of interpretative cores. The discussion on mental health and work relationships was articulated considering the interpersonal exchange system’s effect.

Lacerda and Martins¹² discuss the importance of collective health studies, adding the gift theory to their health services analyses. This allows an expanded understanding of how social relationships and social networks are established in the daily routine of health services. The authors point out that the gift circulation in health is still little explored in Brazil. However, ongoing discussions elucidate that relationships in health services are also established from this paradigm at the most diverse care levels and intertwine with the state and commercial rationales.

Results and discussion

Social relationships can be analyzed from different categories, but we cannot downsize them to just one. The power relationships that arise and the importance of the economic interest that guides many interactions are fundamental. However, they cannot expose exchanges that cannot be described or explained within utilitarian thinking. The option to discuss the results of this study based on the concept of gift aligns with the perspective that social relationships in health and work must be interpreted by subverting market logic¹³.

Understanding the gift as a bare exchange system of social life allows us to break with this utilitarian and dichotomous thinking in which society would only be the result of the actions of the State and the market¹⁴. Unlike the two-party system of the market, which works through the give-pay equivalence, in the gift (give-receive-return), the returned goods never have the same value as that initially received; the value that matters is qualitative: what grounds the return is not the equivalence, but rather asymmetry.

To mark the distinction of the gift against the economy, Caillé¹⁰ proposes a definition in which the gift can be qualified as any service or good provided without the guarantee of return to create, feed, or recreate the social bond between people. This definition brings to the fore a dimension ignored or even denied by economists and shows that goods and services can also be valuable based on their capacity to create and reproduce social relationships, thus having a value not only for exchange or use but as a bond, which is worth more than the goods.

As a result, we can understand that a gift is not an economic model but a person-to-person social system that continues to this day and is, therefore, dear to analyzing current situations and contexts¹⁵. Very little was known about COVID-19 during the first months of the pandemic, its transmissibility and severity, and health professionals were allocated on the frontline in this setting full of uncertainty. Those who, even without knowing what awaited them, often without resources, needed to be the “heroes” or “warriors”. The narrative created about this experience was closely linked to these signs, even before topics such as scarcity of resources, increased workload, and rights that were not being fulfilled were questioned.

What were the limits of the infection issue? We were living in a surreal movie. It’s one of those science fiction movies. So, we had yet to determine when it would end. Whether you had control over it or not, and how this infection occurred. So, much stuff. It was much stress due to that (E1).

I need to find out why it wasn’t even worth the money. The money wasn’t even worth telling you it was about it, but I was there (E9).

The asymmetry, a fundamental point for discussing the gift, was soon exposed. It was not for the salary that people stood up and supported themselves or thought they would sustain their position before the advancing pandemic. This hero status has always been very fragile. So, what else was at stake? What else can we say about these exchanges in which what is offered is much more than what is received in return if we could put it objectively?

A vital characteristic to consider is that symmetry in the gift circulation is not always possible nor desirable, such as when differences are exacerbated, such as adults and children, or care for people in health or socially vulnerable situations. A new term, benevolence, should be added to discuss this asymmetry. Someone needs to be benevolent.

More than half of the people who went to the frontlines could choose whether to be in the frontlines or not. Yes. Sometimes, not in that sense... Some did so very unselfishly (E5).

The highlighted excerpts make us wonder what this desire would be, what would be at stake for health professionals to make themselves available to work in a very uncertain and, as we will see, often precarious setting. It is not the money, in the respondent’s words. However, something that she cannot name but still made her “go” makes us bring the gift theory to discuss work relationships and the symbolic exchanges of these professionals during the most challenging moments of the pandemic, which cannot be merely narrowed down to an economic relationship.

Considering the gift’s symbolic cycle, what moves us is the desire to be recognized as generous donors. However, this recognition is intertwined with several social aspects. Therefore, recognizing that not all gifts bring honor and prestige is an essential improvement in the gift theory¹⁶.

Workers are heroes. And then many donations. We received bottles of vitamins, alcohol gel, and moisturizers, right? Moreover, this was distributed among the people on the team. That’s a treat, let’s say. We are grateful for all the good things we receive. On the other hand, these things don’t persist. They are timely. Today, we are habitual. A trivialization [...] Yesterday, we were heroes. Today, we are unemployed and without a salary (E2).

Once again, the asymmetry, typical of gift exchanges, surfaces. Although most professionals genuinely desired to be on this frontline, occupying this position took work. The complex setting that the pandemic created brought several consequences for those who worked directly in patient care. The new care demands generated physical and mental exhaustion among professionals, influenced by decision-making in extremely delicate situations and suffering from losing patients and co-workers. All of this contributed to the emotional overload of these professionals, affecting their mental health¹⁷.

We were doing cardiac massage on one. Another shouted: “The other one stopped.” So, I’m running towards the fan. Another doctor is shouting at me, and that right there is... That was my most significant impotence at the beginning. There was a day when I sat in the car. I cried for about five minutes without stopping. Compulsively (E4).

Even though the care demands, which these professionals are accustomed to address, are linked to the physical health of their patients, during the pandemic, the issue of mental health care, of embracing pain and suffering, became even more evident as something that cannot be dissociated from biological aspects and disease care, reinforcing the meaning of comprehensive health¹⁸. However, dealing with suffering so openly and amid so much uncertainty created even more overload on professionals, who also needed a receptive place for their suffering.

We worked without pay, and no one was absent. Very few people were missing. Everyone went, you know? That was scary. What also scared me was that patients didn’t ask. Rarely a patient doesn’t ask you for anything. Nothing. Not even water. [...] Patients were silent all the time. I was like: “Guys, what a strange thing. Nobody talks? Nobody asks for anything?” They didn’t ask, and I said... Then, I saw how the symptomatic patient was in the pandemic. Nobody spoke. They were afraid. (E7).

The respondent’s statement is blunt. At some point, she realizes that the silence has a meaning. It was fear, the fear of dying, that patients faced seeing so many others dying every day. This fear was also put on the professionals, affecting their mental health.

I was scared. Just going to the hospital made me very scared. I was left with a mix of wanting to have the courage to help. I really wanted to help, you know, because it was when we needed it. Everyone needed to help. Moreover, I didn’t want to talk about my fear. I didn’t even want to talk, you know? You see, I get emotional to this day because it was hard for me, you know? That moment (E10).

The respondent’s statement points to the question about gift and mental health. The hero’s role implied an emotional availability that is often hard to sustain. Permanent fear certainly generated high stress and affected professionals’ daily lives. “Not talking” appeared as a fragile but possible psychic defense to address suffering and the desire to remain working on the frontline. There was a lack of strategies to make professionals feel safer to face the pandemic and all its consequences. The idea of the group as a team supporting each other and working together was certainly crucial to providing a psychological contour to professionals, but insufficient to avoid stress-related outcomes¹⁹.

Having a space to address these new feelings linked to work and emotional overload was necessary; listening to these professionals was fundamental to rethinking the place of mental health in a unique moment, which exacerbated and complicated pre-existing challenges in health work²⁰. Several demands were identified when people started listening to these professionals. Some measures were crucial^20-23: from actions to implement strategies to provide more safety to professionals, such as training in the correct use of PPEs and availability of this equipment, better flow and screening of these patients (so that professionals are not so exposed to undiagnosed patients), testing, workload reduction and, finally, psychological support for these professionals.

I thought about the lack of management, in the sense of presence, even in the units, to say: “Hi, how are you? How are things there?” That was missing, right? Someone must be present, showing up and saying: “Look, you’re not alone” (E1).

The role of someone who could serve as a reference for professionals within their services often needed to be completed. Typically, heads of sectors and managers could not be close to their teams because of uncertainty and almost daily changes in information and protocols. However, professionals who occupy these leadership positions must understand the sources of employee concerns and work together to reduce them. Concrete answers are expected in order to reduce these concerns, not even solutions to problems, but that questions raised are listened to and acted upon to have them addressed, showing that their perspectives were heard and considered relevant²⁰.

These measures start from listening and reclaiming the subject’s place by circulating the gift: giving, receiving, and reciprocating. Nothing works if professionals and managers do not permanently help each other with technical advice, emotional support, and information of all sorts, thus recreating the social bond. Even if asymmetrical, the gift implies a circulation in which everyone recognizes themselves as subjects participating in the same social and historical moment, committed to the fabric of the health work process.

Health practices are complex and diverse. So, in some services, social relationships are more centered on the gift paradigm, and the market paradigm is more prominent in others. Services whose care is based on the bond and appreciation of individuals tend to present more gift-based social actions¹². Again, strengthening social ties at work is a process in which the worker’s physical and mental health are pillars for better health care.

Final considerations

Health work is increasingly involved in market logic, and the gift theory brings us the interpretation of relationships built beyond this logic, reinforcing the importance of interpersonal exchanges in health services.

For these professionals, being seen, embraced, and recognizing their fears and challenges in their work environment is urgent. As much as the importance of support is recognized, such as support from family and friends, exercise, hobbies, and even the space for individual psychotherapy, being able to expose own weaknesses in one’s work environment and have them recognized as real challenges is crucial in the statements of these professionals.

It is impossible to generalize how each health professional addressed the issues over time. There are multiple experiences, professional categories, work environments, and how each person can deal with work-related issues daily. However, if, on the one hand, we cannot respond for everyone, we also cannot individualize the effects of these relationships at work to think about the support these people need. We should move forward and understand these effects on the spaces and relationships built at work.

Protocols aimed at health care for workers are welcome and hold their place of relevance. However, we should consider strengthening workers’ personal and internal motivation and their respective contexts. Although the gift circulation is asymmetrical, it encompasses personal and contextual aspects so that giving-receiving-returning cannot be separated from the health work process.

In this sense, the work context of professionals, which involves everything from salaries to interpersonal relationships and working conditions, assumes a critical role. These issues come to light in a health emergency such as COVID-19, revealing the need for support and care for healthcare workers’ physical and mental health. Health services should be organized to meet the workers’ demands, exercising daily what could become more delicate in a possible new health emergency.

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Chief editors:

Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  23 Oct 2023
• Date of issue
  Oct 2023

History

• Received
  30 June 2022
• Accepted
  01 June 2023
• Published
  06 Sept 2023