Covid-19: a new phenomenon of social representations for nursing teams in intensive care

Abstract

Objective

to reflect on COVID-19 as a phenomenon of social representations for the Intensive Care Unit nursing team, analyzing the implications of this theoretical understanding in the design of professionals’ social practices.

Method

this is a theoretical-reflective study, based on the framework of social representations. Scientific articles, books and official data on COVID-19 were collected; subsequently, reflective deepening was carried out based on the theory precepts.

Development

COVID-19 has had a strong impact on nursing care in intensive care. Meeting the criteria of social representations: relevance, practice, consensus and affiliation; the dimensions of affections, imagery and social practices mobilized in the social construction of this phenomenon; characteristics of daily life of social belonging of nursing teams working in intensive care before patients with COVID-19 were theoretical arguments that supported the defense that COVID-19 is a phenomenon of social representation for this social group.

Conclusion and implications for practice

studies of professionals’ social representations about COVID-19 can support the proposition of care-education technologies that qualify their performance in caring for critical patients with COVID-19.

Keywords:
Coronavirus infections; Psychology; social; Intensive Care Units; Nursing; Critical care

Resumo

Objetivo

refletir sobre a COVID-19 como um fenômeno de representações sociais para a equipe de enfermagem da Unidade de Terapia Intensiva, analisando as implicações dessa compreensão teórica no delineamento das práticas sociais de tais profissionais.

Método

estudo teórico-reflexivo, pautado no referencial das representações sociais. Captaram-se artigos científicos, livros e dados oficiais sobre a COVID-19; posteriormente, procedeu-se o aprofundamento reflexivo com base nos preceitos da teoria.

Desenvolvimento

a COVID-19 vem apresentando um forte impacto no cuidado de enfermagem na terapia intensiva. O atendimento dos critérios das representações sociais: da relevância, da prática, do consenso e da afiliação; as dimensões dos afetos, imagética e das práticas sociais mobilizadas na construção social desse fenômeno; e as características do cotidiano da pertença social da equipe de enfermagem atuante na terapia intensiva diante dos pacientes com a COVID-19 foram os argumentos teóricos que sustentaram a defesa de que a COVID-19 é um fenômeno de representação social para esse grupo social.

Conclusão e implicações para a prática

estudos das representações sociais desses profissionais sobre a COVID-19 podem subsidiar a proposição de tecnologias de cuidado-educação que qualifiquem a sua atuação no atendimento aos pacientes críticos com a COVID-19.

Palavras-chave:
Infecções por coronavírus; Psicologia Social; Unidades de Terapia Intensiva; Enfermagem; Cuidados críticos

Resumen

Objetivo

Reflexionar sobre la COVID-19 como fenómeno de representaciones sociales para el equipo de enfermería de la Unidad de Cuidados Intensivos, con el análisis de las implicaciones de esta comprensión teórica en las prácticas sociales de dichos profesionales.

Método

Estudio teórico-reflexivo, basado en el marco de las representaciones sociales. Se capturaron artículos científicos, libros y datos oficiales sobre la COVID-19; posteriormente, se procedió a una profundización reflexiva basada en los preceptos de la teoría.

Desarrollo

la COVID-19 ha tenido un fuerte impacto en la atención de enfermería en cuidados intensivos. Cumplir con los criterios de las representaciones sociales: relevancia, práctica, consenso y afiliación; las dimensiones de los afectos, de las imágenes y de las prácticas sociales movilizadas en la construcción social de este fenómeno; y las características cotidianas de la pertenencia social del equipo de enfermería que trabaja en cuidados intensivos ante pacientes con COVID-19 fueron los argumentos teóricos que sustentaron la defensa de que la COVID-19 es un fenómeno de representación social para este grupo social.

Conclusión e implicaciones para la práctica

Los estudios de las representaciones sociales de estos profesionales sobre la COVID-19 pueden apoyar la propuesta de tecnologías de cuidado-educación que califiquen su desempeño en el cuidado de pacientes críticos con COVID-19.

Palabras clave:
Infecciones por Coronavirus; Psicología social; Unidades de Cuidados Intensivos; Enfermería; Cuidados críticos

INTRODUCTION

The pandemic by the new coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 - SARS-CoV-2, has brought about a disease of high importance for global public health, COVID-19, which modified social, political, economic, geographical and scientific settings. The magnitude of this pandemic, one of the largest in history, is seen in data on the spread of the disease, showed that, five months after the emergence of the first cases in China in December 2019, that the number of infected people in the world exceeded the mark of 25 million. In Brazil, the first case was recorded on February 26, 2020, and six months later, the infected were over three million, of which more than 120,000 had lost their lives. One year after the beginning of the pandemic, the world registered more than 105 million cases of COVID-19 and two million and 300,000 deaths, while in Brazil cases totaled more than 9 million, in addition to 234,000 deaths^1,2.

Given the numerous impacts that the emergence of COVID-19 brought to society, this article was based on the understanding that this new disease is a phenomenon of psychosocial knowledge that arouses the elaboration of Social Representations (SR) by the population, within which people organize their social practices.

The Theory of Social Representations is in the field of psychosociology of knowledge and was proposed by Serge Moscovici. It is a knowledge elaborated in social interactions and shared by individuals of a social group - the knowledge of common sense. SR are conceptualized as: “almost tangible entities; they circulate, intersect and crystallize incessantly through a speech, a gesture, an encounter, in our daily universe”^3:39.

The understanding of COVID-19 as a phenomenon of representation is based on the criteria for identifying SR, proposed to guarantee the validity of SR studies. They are: functional consensus, relevance, practice, holomorphosis and affiliation⁴.

In view of these criteria, it is considered that COVID-19 meets the criterion of the relevance of SR, i.e., it arouses affections that mobilize individuals and social groups to the circulation of information about this phenomenon in the context of social relations and the taking of position. This is evidenced by the intense movement of scientific dissemination, strong engagement of people in social networks, incessant approach to the theme in the mass media; there is an imagery and symbolic dimension disseminated by certain social groups (affiliation) that contributes to the process of elaboration of SR. In this sense, there are images and meanings that refer to a plague, an invisible enemy, “comunavirus”, Chinese virus; there is a projection of the disease in the other that permeates the groups of belonging in the light of social identity (functional consensus); with this, the highest risk of the disease is projected in the groups of elderly and people with clinical comorbidities; the different observable behaviors in everyday life are indicative of an existence of a socio-symbolic logic about the phenomenon that guides people’s social practices, of adherence versus non-adherence to the proposed disease control measures, of compassion or prejudice against those infected with the virus (practice).

Other SR scholars also corroborate this statement of COVID-19 as a phenomenon of SR^5,6. One of them states that it is a new object, with a strange name, which resulted in daily mass communication, new social rules, deaths and devastating effects. Thus, it is not only a medical and scientific object, but social. In this understanding, he considers that the reactions to this threat show not only about the virus and the risks it poses, but on people, their systems of thought, relationships with others, the values and principles that govern social functioning. Therefore, it is a revealing phenomenon of society, and SR allow us to understand how this social dynamic is appropriated by the subject and manifests itself in systems of thought and social practices⁵.

In particular, the social group of nursing professionals, especially those working in Intensive Care Units (ICUs), the exercise of their role in caring for patients with COVID-19 has raised reflections about the psychosocial impacts that this disease has brought in this group^7-9. These reflections are based on studies already developed on COVID-19, and in research based on previous experiences of epidemics and outbreaks, such as Severe Acute Respiratory Syndrome (SARS – 2003) or Middle East Respiratory Syndrome (MERS -2015)^9,10-12.

In the case of these previous epidemics, psychosocial effects have become more widespread than the epidemic itself, extending for a long time. In the SARS outbreak, 18 to 57% of professionals experienced emotional problems and psychiatric symptoms during and after the epidemic; and in MERS, stress and dysphoria were also observed. These psychosocial effects resulted in practices characterized by misconduct, delays in treatment due to communication failures, absenteeism and omissions^9,10.

Specifically on COVID-19, studies already developed on nursing care for patients with COVID-19 showed that this action brings psychosocial repercussions to professionals, who permeate the experience of feelings of loneliness, helplessness, stress, irritability, physical and mental fatigue. Such impacts may reflect on psychological health, human relations and the social practices of subjects, especially care. Therefore, they can compromise the ability to make decisions, by fear, inability to face suffering, lack of knowledge^11,12.

Considering this context of nursing professionals’ actions in the care of critically ill patients infected with COVID-19, the theoretical assumption that this disease is configured as a phenomenon of SR for this social group was raised.

Regarding the identification of SR phenomena, it should be punctuated that the selected group does not always have representation of a given object, sometimes only a set of disjointed opinions and images. From this perspective, the object must have a social thickness, sociocultural relevance to the group, i.e., SR as a practical thinking modality should emerge from the group’s practices, expressed in behaviors and communications¹³.

In view of this, it is based on the understanding that COVID-19 has social relevance for ICU nursing professionals. When considering this theoretical understanding, possibilities are opened to unseethe norms, values, affections and attitudes that support the sociosymbolic meanings that guide the behaviors of such professionals towards COVID-19, as well as for elucidation of existence of stereotypes, rumors and stigmas.

Therefore, knowledge of SR can support the formulation and implementation of educational technologies aimed at professionals, with a view to reframing potential meanings that foster fear, anxiety, stigmas and stereotypes in face of COVID-19, which can impact on success of coping actions, in quality of care and in nursing professionals’ health.

The aim of this article was to reflect on COVID-19 as an SR phenomenon for the ICU nursing team, analyzing the implications of this theoretical understanding in the design of professionals’ social practices.

METHOD

This is a theoretical-reflexive study, which was based on the SR framework. For its construction, the first step was to capture scientific articles and books that addressed the theoretical precepts of SR, the characteristics of SR phenomena, as well as about intensive care in the context of the COVID-19 pandemic. The search for books occurred in a sectoral graduate library, and articles occurred in an exploratory way in virtual databases with the descriptors social psychology, critical care and COVID-19. Moreover, there was access to the official databases of the Brazilian Ministry of Health and the World Health Organization to collect up-to-date data on the COVID-19 pandemic and the prevention and control actions adopted/recommended by these agencies.

The second stage was the theoretical-reflective deepening based on the preliminary bibliographic survey carried out and its interpretation in the light of theoretical precepts: criteria for identifying SR and the dimensions that contribute to its elaboration: affections, images, attitude / practice; characterization of social belonging and concept of social identity.

DEVELOPMENT

The performance of nursing professionals in ICU settings in coping with COVID-19: characterizing social belonging

The Theory of Social Representation is about two-way social construction. First, SR are socially constructed through public discourses in the groups. The way people think about the “real and imaginary” things of their world is the result of discursive and therefore socially constructed processes. In a second sense, this knowledge is created by the group. Since this knowledge is created in and by the group, consequently, it provides a notion of what behavior to expect from the members of that group to face an object, since the representation is socially shared. Thus, SR allow to define the identity of the group as well as its social belonging¹⁴.

Thus, one of the axes of the theory starts from the understanding that such SR emerge as elaborations of social subjects about an object; therefore, we seek to explain the meaning attributed to the represented object not from an isolated individual, but from its belonging to a group¹⁴.

In the light of this understanding, when thinking about COVID-19 as a phenomenon of SR for ICU nursing professionals, interest of this article, it should be highlighted that in ICUs there is a sense of belonging that unites nursing professionals, from which they give meaning to the world, deal practically with daily life and establish communicative relationships. There is a social identity in this setting, which encompasses the guiding elements of the ways of using technologies, typical ICU patient figure, as well as attributes of an ideal nurse, sense of work, intra- and inter-team relationship¹⁵.

With the emergence of COVID-19, this phenomenon began to integrate the daily life of nursing professionals in ICUs, immersed in affections, images, symbols, norms and values. Different aspects show its relevance to this group of belonging.

First, it is necessary to point out that COVID-19 is a disease that, in most of the population, is present with mild symptoms of a flu-like syndrome, requiring only symptomatic treatment of the clinical picture, without the need for hospitalization. However, a portion of those infected clinically evolve with severe respiratory syndrome and need for oxygen therapy support. Thus, 10 to 15% of infected patients are at risk of developing respiratory failure, requiring ICU admission¹⁶. Data from China’s National Health Commission showed that in February 2020, in Wuhan, about 15% of patients developed severe pneumonia and 6% required ventilatory support¹⁷.

In the case of these patients who require hospitalization in intensive care sectors using ventilatory support, nursing teams have a primary role in providing care, which requires technical-scientific knowledge, skill and experience of professionals for the implementation of a nursing care model to critically ill patients with COVID-19. This model includes different care routines, which include: on admission, the collection of history and physical examination; the assessment of care risks and application of preventive measures, such as pressure injury, fall, ventilatory-associated pneumonia; identification of nursing diagnoses related to COVID-19; care plan implementation, which involves family support, mechanical ventilation control, respiratory monitoring, among others, performing procedures and records¹⁸.

In the context of providing direct care to this clientele, it is noteworthy that nursing professionals become susceptible to infection. In Brazil and in several countries, thousands of healthcare professionals who worked on the frontline were removed from service and many died by COVID-19, such as Italy, the USA and China¹⁹. As for Brazil, the Federal Nursing Council Observatory, which monitors the number of professionals infected with COVID-19, recorded in February 2021 48,234 cases and 556 deaths, equivalent to 2.01% of the mortality rate of professionals, one of the highest in the world²⁰.

This aspect, in particular, articulates the anxiety and fear of contamination in relation to themselves, team and family members, feelings that are accentuated when considering the availability of personal protective equipment in many health institutions, since in hospitals in Brazil and the world there was a scarcity of such equipment. In this direction, several authors have discussed the impact of COVID-19 on nursing, pointing out the challenges and vulnerabilities that the pandemic has accentuated in this professional category^7,8,21.

Regarding this, in reflection on nursing workers’ health before the COVID-19 pandemic, it was considered that physical and psychological protective measures are necessary for professionals, because despite the recognition of its importance in the frontline, working conditions did not follow the measures to cope with the pandemic, with precarious situations of lack of personal protective equipment, low wages, high workload and reduced number of professionals²¹.

Another analysis of this theme signaled professionals’ inadequate occupational protection, due to the lack of inums and protective equipment. This signaling was corroborated by the number of complaints received by the Federal Nursing Council from the beginning of the pandemic, higher than the 3,000 cases, mainly motivated by the lack, scarcity or poor quality of personal protective equipment⁷.

The authors also highlighted distancing of professionals from their families, in order to reduce the risk of contagion of parents, children and spouses. In this regard, they highlighted the need to recognize the value of nursing professionals in view of their role in the performance in the face of COVID-19, which should be materialized in better working conditions and in financial and social valorization⁷.

These listed vulnerabilities have repercussions on the subjectivity of nursing professionals and compromise their mental health. A study that sought to identify the prevalence and factors associated with anxiety and depression in 88 nursing professionals working to cope with COVID-19 found a prevalence of 48.9% of anxiety and 25% of depression, primarily in nursing technicians in critical care sectors²².

A study conducted with 85 ICU-COVID-19 nurses in China on its main manifestations related to psychological stress found decreased appetite or indigestion (59%), fatigue (55%), difficulty sleeping (45%), nervousness (28%), frequent crying (26%) and even suicidal thoughts (2%). This picture was higher in inexperienced nurses, with no experiences of care for critically ill patients²³.

These results indicate the high psychological pressure faced by nursing professionals who care for critically ill patients and demonstrate that the work setting within ICU-COVID-19 is challenging. Moreover, having to deal with the increasing number of deaths of patients with COVID-19, a death without farewells, only with healthcare professionals brings a great impact. This is because, when people with COVID-19 enter the hospital they totally move away from the life of their families, without visits, and it is up to professionals to soften the feeling of isolation and provide humanistic and spiritual care to patients and families^24,25.

This set of elements portrays the social context of nursing professionals’ actions in the face of critically ill patients with COVID-19. A unique experience, permeated with feelings, challenges, difficulties, images and behaviors. Therefore, this experience in coping with COVID-19 strengthens the social belonging of this group and is articulated to the social identity of intensive nursing, which is projected in the object’s SR. The social identity understood as a subjective and dynamic phenomenon that allows the realization of similarity between one another, and that mediates the meanings attributed to one another and the others²⁶.

COVID-19 as a phenomenon of SR for the ICU nursing team and its implications for social practices

When thinking about SR, it is necessary to highlight its affective dimension, as well as the great mobilization of affections that everyday life generates. Affections are “the emotional coloring that permeates human existence and, in particular, the relationship with the world”^27:89. They embrace feelings and emotions. The former includes moods (anxiety, depression) and assessments (positive/negative), while emotions are a complex phenomenon, which can disrupt the normal flow of cognition and action (fear/anger)²⁷.

Regarding the interface between affections and everyday thinking, it is emphasized that the latter is built from the tension of everyday situations, the people who will be present in these situations, the task to be performed, i.e., in the pragmatic demands of social existence. On these occasions, the expression of thought in prescriptions, judgments, concepts is not indifferent to the other, on the contrary, it starts with the understanding that our actions will affect us because they will affect others. In this sense, daily life promotes affections, “which shakes us and puts us in another state of being, which pushes us into action. Or reveals us an unexpected world to elaborate”^27:88.

Therefore, affections are not experienced by a lonely individual due to their moods or mental dispositions, but are in everyday life in the relationship with the world and with the other.²⁷ An example of this was seen in the research on HIV/AIDS SR. In this research, affection, including feelings of fear, anxiety and impotence, played an important role in the formation of SR. Constructing the representation occurred before impotence in the face of an unknown social object, which resulted in defensive representations of a type “I do not, my group does not”. The figure of the plague and the fear of contagion triggered the attribution of guilt to the other, which was preceded by the affection that settled before the fear of death²⁸.

In the case of COVID-19 for ICU nursing professionals, the lack of in-depth knowledge about the disease, its forms of treatment and means of dissemination; the news circulating in the mass media, which portrays the high number of deaths of infected people, including nursing professionals; the high potential for transmissibility attested by scientific research; the severe situation that is established in a portion of patients and the need to provide care to them by nursing professionals are triggering elements of emotional responses in professionals, in which the disease’s SR is articulated.

In the light of this understanding, daily social belonging of ICU nursing teams in the face of patient care with COVID-19 is indicative that this phenomenon is configured as SR for this group. Thus, it can be insgiven that, due to its relevance, the affections that are impregnated in daily life of this belonging are triggers of information that express the need to appropriate this daily, to dominate the environment, to identify and solve problems, to know how to behave from its group belonging. Soon, the fear of impotence in the face of this social object “provokes” this group, mobilizes conversations²⁷ among nursing professionals, fostering representations and social practices.

Another aspect to be scored in the SR elaboration is that the performance of healthcare professionals in relation to COVID-19 has been portrayed through images published on social media, which illustrate population’s attitudes towards this group. In one of them, health units are portrayed as battlefields, with war frontline formed by healthcare professionals, soldiers who defend the population; another image points to professionals as superheroes responsible for saving the population from the impact of COVID-19; also circulate images that refer to the solidarity/empathy of the population to professionals, the death of many patients, illness of other team members, lack of infrastructure for care.

These images have a strong affective load and are loaded with senses. By giving, for example, a status of superheroes to healthcare professionals, if on the one hand it adds value, on the other hand, it causes additional pressure, because superheroes do not fail, do not give up or fall ill⁹. Professionals directly involved in caring for a disease with high contagion potential may also suffer stigma⁹, as reported by the news that in Italy professionals were pressured to move from the place where they live by other residents. In Brazil, messages/banners such as: “Do not discriminate/judge those who tested positive for COVID-19, be fraternal, be supportive, do not spread negative comments, prejudice or hurt”, which were disseminated in some media by legal entities.

Such images are important to be identified, because every representation has an imagery dimension of the social object that simplifies it and that is naturalized as the real object itself, and becomes the reference theory for understanding reality³. There is, therefore, a social image about these professionals and their role in combating COVID-19, which also results in pressure to inference for this group to explain this object, stand before it and, from this, conduct its actions³.

Pressure to inference is one of the three essential aspects that focus on SR elaboration, which also includes the dispersion of information and focus. In pressure to inference, explaining the object is the focus, requiring individuals or groups to assert themselves³. An illustration of the position taken by this group was the calls to the population made by nursing professionals on social media during the pandemic. A study that analyzed these appeals identified the hashtags: where is my PPE; stay at home; now we are heroes; nothing new on the frontline²⁹.

The positions guide social practices and understand how practices are outlined is essential to think about interventions and proposals for improvements. The term, social practice, can be understood as the behavior (observable action) expressed by individuals who are part of social groups³⁰. In the understanding that there is an interdependence between representations and social practices, it is understood that the social actor elaborates a cognitive system that gives coherence and meaning to the represented phenomenon and, at the same time, to the behaviors undertaken. In this sense, behaviors cannot be studied apart from an “action-representation system”. Moreover, practices are constructions of the groups of belonging, so they express themselves considering the norms and social roles³⁰.

Observations developed by the authors from their experiences as teachers and nurses in ICU-COVID-19 settings allow us to bring illustrative elements to think about the implications of SR of this phenomenon in the social practices of nursing professionals.

An example of this is related to the first months of spread of the pandemic in the country, marked by the overload of healthcare services by COVID-19 cases, which generated high demand for care for critically injured patients. When approached in this period, the reports of professionals when referring to assistance in the sector made analogy to a war situation, aggravated by the lack of professionals to meet the care demands and the fear of contamination. This situation resulted in emotional responses from some nursing professionals, expressed in moments of crying in the corridors as well as in care behaviors marked by the incessant struggle in defense of human life.

This defense was “anchored” in a classification of patient care, which placed those who were serious with COVID-19 in the priority place, as a consequence, materialized in care actions aimed at their immediate care. This, in some care situations, led professionals to neglect their individual protection.

However, given the high number of professionals infected and away from patient care, and even the cases of death, it was observed in a second moment that professionals began to put their safety and protection classified first, categorization reflected in practices that valued adequate attire, team training for some clinical procedures, emotional balance, attention to care protocols.

Another aspect referred to the hiring of new professionals, since in the health system crisis caused by the pandemic, many hospitals had to hire a large number of professionals⁸. It was noticed that for many of these professionals it was their first job, others with experience in areas other than intensive care and, still, in the face of care demands, many institutions did not have enough time for prolonged training.

As a result, some teams were composed, almost in their entirety, by professionals inexperienced in intensive care, an aspect that also affects care practices, with potential influences on the quality of care. This is because experience is an element that focuses on the symbolic construction of phenomena³, which in the case of the context under analysis brings articulated the construction of the novelty of intensive care, which involves complexity, challenge, admiration or fear, and is expressed in the ways of professional acting.

More recently, after the reduction in the number of severe cases in critical sectors, it was noticed behaviors of professionals characterized by the absence of use of personal protective equipment, such as masks during traffic through hospital areas, as well as situations of agglomerations of professionals, behaviors that contradict health authorities’ recommendations. Some institutions have even issued documents warning professionals about the risk of such actions in relation to the disease proliferation.

By illustrating these aspects of nursing professionals’ practices in daily life captured from empirical observations, and establishing relationships with SR, it is possible to think about the impacts of COVID-19 on nursing care in intensive care. Thus, the emergence of COVID-19, a disease that is configured as a new psychosocial phenomenon that was introduced into society, in general and, in particular, in the work context of healthcare professionals, has had an impact on the expression of science and art of nursing care, the safety of care provided to critical patients and the quality of life of professionals.

Therefore, by defending the construction of this phenomenon in the light of SR theoretical framework and the possibility of analyzing the SR of ICU nursing teams against COVID-19 and its implications for social practices, the results will allow the proposition of technologies care-education that qualifies the performance of these professionals in nursing care.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The SR criteria articulated to the characteristics of social belonging of a nursing team working in the ICU before the COVID-19 supported the defense that such object is a phenomenon of SR. Thus, the above in this article highlighted theoretical arguments related to the criteria of relevance, practice, consensus and affiliation, as well as related to the dimension of affections, imagery and social practices, which compete in the process of elaboration of SR on COVID-19 by nursing professionals working in the ICU.

In view of this, it is considered that the nursing practice as the largest workforce of the Brazilian Unified Health System (Sistema Único de Saúde) in providing nursing care in the context of this pandemic implies the need to explain the SR that they attribute to COVID-19, here highlighted by icu professionals, taking into account the context in which they are produced and, consequently, how these SR guide the group’s positioning towards this object and feed the practices. Therefore, this understanding makes it possible to understand the logic of these professionals in the conduct of a care plan, their affections and decision-making processes.

Thus, studies are recommended that the SR’s structure of this phenomenon and its elaboration processes by nursing professionals in the ICU are recommended. With this, the information may support, within the scope of SUS, the implementation of strategies by nursing management teams that consider such sociosymbolic meanings about COVID-19, which has the potential to: improve communication with nursing professionals in the light of their subjectivity; promote their physical and mental health; minimize fear, anxiety and potential stigmas related to COVID-19; expand the adoption of behaviors towards the disease with patient safety and quality of care.

• FINANCIAL SUPPORT

  This study was financed by National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) - Research Productivity Grant Process 315642/2020-3.

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Edited by

ASSOCIATE EDITOR

Antonio Jose Almeida Filho https://orcid.org/0000-0002-2547-9906

SCIENTIFIC EDITOR

Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Publication Dates

• Publication in this collection
  05 July 2021
• Date of issue
  2021

History

• Received
  17 Mar 2020
• Accepted
  28 Apr 2021