Implications of nursing performance in coping with COVID-19: emotional exhaustion and strategies used^a

Abstract

Objective

to analyze the self-perceived implications and strategies used by Nursing workers from COVID-19 and non-COVID-19 units regarding professional performance in coping with the pandemic.

Method

a multicenter and descriptive-exploratory study with a qualitative approach, developed at four hospitals in southern Brazil between January and May 2021. 19 workers from the Nursing team were interviewed, 10 of which were assigned to COVID-19 units and 9 to non-COVID-19 units. Thematic content analysis was performed.

Results

two categories emerged: (1) Emotional exhaustion and its impact on work, due to severity of the patients and high number of deaths in COVID-19 units and organizational changes and work overload in non-COVID units; and (2) Coping strategies used, similar in the units in terms of self-care, leisure, physical activity and spirituality, but different in terms of professional fulfillment, present in the COVID-19 units.

Conclusion and implications for the practice

The pandemic increased exhaustion in the Nursing workers who used mitigating strategies, highlighting the difference in understanding the cause of exhaustion and in carrying out the work felt by workers in COVID-19 units. The need to monitor the health of Nursing workers that were active during the pandemic is highlighted.

Keywords:
COVID-19; Nursing; Multicenter Study; Occupational Health; Mental Health

Resumo

Objetivo

analisar as implicações autopercebidas e as estratégias utilizadas por trabalhadores de enfermagem de unidades dedicadas e não dedicadas à COVID-19 acerca da atuação profissional no enfrentamento da pandemia.

Método

estudo multicêntrico, descritivo-exploratório, com abordagem qualitativa, desenvolvido em quatro hospitais do sul do Brasil, entre janeiro e maio de 2021. Foram entrevistados 19 trabalhadores da equipe de enfermagem, sendo 10 lotados em unidades dedicadas à COVID-19 e 9 em unidades não dedicadas. Fez-se análise de conteúdo do tipo temática.

Resultados

emergiram duas categorias: (1) Exaustão emocional e seu impacto no trabalho, devido à gravidade dos pacientes e ao elevado número de óbitos nas unidades dedicadas e às mudanças organizacionais e à sobrecarga de trabalho nas não dedicadas; e (2) Estratégias de enfrentamento utilizadas, semelhantes nas unidades quanto ao autocuidado, lazer, atividade física e espiritualidade, mas diferente quanto a realização profissional, presente nas unidades dedicadas à COVID-19.

Conclusão e Implicações para a Prática

a pandemia incrementou a exaustão dos trabalhadores da enfermagem que utilizaram estratégias atenuantes, com destaque para a diferença na compreensão da origem da exaustão e na realização com o trabalho sentido pelos trabalhadores das unidades dedicadas. Evidencia a necessidade de acompanhamento à saúde dos trabalhadores de enfermagem atuantes na pandemia.

Palavras-chave:
COVID-19; Enfermagem; Estudo Multicêntrico; Saúde do Trabalhador; Saúde Mental

Resumen

Objetivo

analizar las implicancias autopercibidas y las estrategias que utilizan los trabajadores de Enfermería de unidades dedicadas y no dedicadas a COVID-19 en la actuación profesional para enfrentar la pandemia.

Método

estudio multicéntrico y descriptivo-exploratorio con enfoque cualitativo, desarrollado en cuatro hospitales del sur de Brasil entre enero y mayo de 2021. Se entrevistó a 19 trabajadores del equipo de Enfermería, 10 de los cuales fueron asignados a unidades dedicadas a COVID-19 y 9 a unidades no dedicadas. Se realizó análisis de contenido temático.

Resultados

surgieron dos categorías: (1) Agotamiento emocional y su impacto en el trabajo, debido a la gravedad de los pacientes y a la alta cantidad de muertes en unidades dedicadas y a los cambios organizacionales y a la sobrecarga de trabajo en unidades no dedicadas; y (2) Estrategias de afrontamiento utilizadas, similares en las unidades en cuanto a autocuidado, ocio, actividad física y espiritualidad, pero diferentes en cuanto a la realización profesional, presentes en las unidades dedicadas a COVID-19.

Conclusión e implicancias para la práctica

la pandemia aumentó el agotamiento de los trabajadores de Enfermería que utilizaron estrategias para atenuarlo; se destaca la diferencia que hay en la comprensión del origen del agotamiento y en la realización que sienten los trabajadores de las unidades dedicadas con su trabajo. Cabe destacar que es necesario monitorear la salud de los trabajadores de Enfermería que actúan en la pandemia.

Palabras clave:
COVID-19; Enfermería; Estudio Multicéntrico; Salud Laboral; Salud Mental

INTRODUCTION

The COVID-19 pandemic caused health professionals to have greater exposure to biological risks because it is a highly transmissible virus through aerosols and droplets generated in procedures such as orotracheal intubation, nebulization and upper airway aspiration, among others.¹ Once again exposed to risks of an unknown disease, with rapid and important changes, the professional Nursing practice has become a situation that generates fear, concern and anguish.²

Health professionals are at a higher risk of developing psychological problems after catastrophes/tragedies than the general population and, when comparing health professionals, nurses are the most prone to mental illness, evidenced in the form of exhaustion, depression, anxiety and post-traumatic stress.^3-4 It was no different in this pandemic, as Nursing was highlighted in studies carried out during this period due to the high prevalence of mental health harms and higher risk of developing emotional exhaustion at work.^5-7

Coping with the pandemic was marked by the formulation of strategies to contain viral dissemination⁸ and nurses occupied the important function of planning, organizing and, together with nursing technicians/assistants, operationalizing such changes, also being impacted by the changes. Among the organizational changes, there was separation of patients infected and not infected with the Coronavirus, modifying the physical space and the flow of care performed by the professionals,^9-10 with hospitals having COVID-19 and non-COVID-19 units.

In addition to that, agile and intense learning was necessary to care for patients diagnosed with COVID-19, among them, those related to putting on and taking off Personal Protective Equipment (PPE), management of respiratory devices, care for critical situations and those related to systemic complications due to the Coronavirus infection.⁹

These new situations increased the workload of professionals, who were already under adverse working conditions and were also subjected to a change of area, team, leadership and even a reduction in the number of experienced employees in the sector, increasing stressors and overload factors.⁹ National and international studies show an increase in workload and exhaustion during the pandemic period, revealing that the professionals were more vulnerable in the last two years.^2-3,11

The contributing factors to this greater exposure to illness in the pandemic were the increase in the number of patients and working hours, as well as the lack of PPE, and the worsening of physical and mental fatigue was mainly caused by the increase in workload.¹² These factors can cause exhaustion and depression, evidenced in health professionals during this period, especially in nursing technicians.¹¹

Given the above, this study aimed at analyzing the self-perceived implications and strategies used by Nursing workers in COVID-19 and non-COVID-19 units about professional performance in coping with the pandemic.

METHOD

A multicenter study with a descriptive-exploratory design and qualitative approach, following the recommendations set forth in the Consolidated Criteria for Reporting Qualitative Research (COREQ). This study was conducted in four tertiary-level public hospitals from southern Brazil, selected for being a reference in the care of patients infected by the Coronavirus. In order to preserve anonymity of such hospitals, the following coding was used: HA (784 beds), HB (237 beds), HC (919 beds) and HD (403 beds).

The population consisted of Nursing teams workers (nurses and nursing technicians and assistants) who were active in the assistance provided during the pandemic in all four hospitals. All were invited to participate in the study via institutional email messages, answering an electronic form and excluding those were away from the functions during the data collection period. The sample of this study was selected from those who filled out the form, from the umbrella study entitled “Performance in the COVID-19 pandemic: Impacts on Nursing workers psychological health” (n=845). In other words, among the respondents to an electronic form, 353 workers showed greater interest in discussing the experiences of the pandemic, leaving records in an open and optional question found at the end of the form. From the analysis of such records, 35 workers were intentionally selected, who were invited to participate in the interview with the purpose of deepening on experiential and subjective aspects, using the qualitative approach.

The selection criteria adopted were the records' content, showing interest in discussing the subject matter on the part of the worker, and filling out the contact data. Among the 35 individuals invited to take part in the study, 15 did not answer the invitation and one did not accept it, under the reason of lack of time and interest at that moment. Therefore, the sample was defined by data saturation, consisting of 19 participants distributed in the four hospitals, as follows: five HA participants, three HB participants, five HC participants and six HD participants. This sample did not intend to be numerically representative, but rather the possibility of deepening on the workers' singular experiences and their performance context in COVID-19 and non-COVID-19 units. Thus, the sample comprised by 19 participants proved to be suitable for the qualitative approach of the research object.

A semi-structured interview script with the following questions was used for data collection: Tell me about your work routine and performance during the COVID-19 pandemic. Which changes did the pandemic impose on your job? How did such changes impact you? Did working in the COVID-19 pandemic exert any impact on your health? Which strategies have you used to take care of your health given the context of your work during the pandemic? In addition to the questions, the participants were characterized according to the following variables: gender, professional category and work unit.

Data collection was carried out between January and May 2021 via video calls in the Google Meet platform and guided by the lead author of this manuscript, who is an MSc student. The interviews were scheduled according to the participants' availability after clarifying the study objective and accepting participation, and they were recorded and lasted approximately 20 minutes each. Five participants answered during their work shift and in a private place, and the others preferred scheduling outside their working hours.

The data were transcribed and analyzed based content thematic analysis,¹³ following the following three phases: pre-analysis, which consists of a floating reading of the material until its incorporation, where the first impressions on the reports appeared; exploration of the content, phase in which categorization of the material was initiated, summarizing it in expressions; and interpretation of the results, where the findings were compared to the literature. The content of the transcriptions was not submitted to validation so as not to overload the workers with more requirements.

This study respected the ethical precepts of research studies with human beings and was registered and approved by the National Research Ethics Commission, under CAAE code 33105820.2.0000.0008. The Free and Informed Consent Form was sent together with the online form, informing that the participants could be invited to a second stage and, also, ethical commitment was reestablished before starting to apply the script of questions. In the transcript of the interviews, the names of the workers were replaced by the acronyms NT for nursing technician and NUR for nurse, accompanied by the number referring to the order of the interviews and ‘COVID’ for workers of the COVID-19 units and ‘Non-COVID’ for the non-COVID-19 units, in order to preserve the participants' anonymity.

RESULTS

The study participants were 19 Nursing team workers, of which 10 (52.6%) were nurses, 16 (84.2%) were female and 10 (52.6%) were from units devoted to the care of COVID-19 patients. The categories and their subcategories are described below.

Emotional exhaustion and its impact on work

This category describes the topics grouped into five subcategories: Self-perceived exhaustion; Identifying wear out in the colleagues; The cause of exhaustion; Impacts of exhaustion on the assistance provided and on the relationships; and Questioning permanence in the profession.

‘Self-perceived exhaustion’

The workers reported experimenting symptoms of physical and mental wear out, irritability, sadness and anguish. This exhaustion was perceived in the speeches of the workers who worked in both areas, revealing that coping with the pandemic generated changes in flows and processes in all care areas and an impact on all Nursing workers in the hospital context.

[...] we had some very long workdays, we had to work four nights in a row due to the need for workers, so it may be that I'm not 100% on the third or fourth night, but if I'm not there, there will be no one. (NT 10 - COVID)

[...] I had a true feeling of psychological and emotional exhaustion. [...] now I'm certain that it's the first time that I've had this feeling in my life. (NUR 3 - COVID)

I only wanted to get home, take a bath and lie on the bed [...] I arrived really exhausted due to the stress. It was really tiring, really anguishing, physical and mental exhaustion. (NT 2 - Non-COVID)

[...] I'm more tired, more exhausted, I'm more short-tempered. I'm in my last stage of physical and mental exhaustion. (NT 8 - Non-COVID)

‘Identifying wear out in the colleagues’

Even if the interviews conducted dealt with the health situation of the worker interviewed, many of them described the situation they noticed in their Nursing team colleagues. These reports showed the empathy they felt towards their coworkers, given the weakness of the team.

Even tired and exhausted they came to work overtime, because they couldn't understand that they had reached their limit. [...] at some moment we'd have to recognize that the limit, both physical and emotional, was reached and that we needed to breathe. We had fatigue out of compassion for our co-workers, who we saw exhausted and that we were empathetic with that situation. (NURS 3 - COVID)

[...] depending on the month there were employees who were more exhausted, sometimes one group was more exhausted and another more balanced, alternating, we realized that the team is very tired because of this whole context. (NUR 2 - Non-COVID-19)

‘The cause of exhaustion’

Among the causes attributed to exhaustion, the workers from the COVID-19 units pointed out the instability and critical level of intensive care of patients affected by the disease, as well as the high number of deaths witnessed. In turn, in the non-COVID-19 units, the various organizational changes and work overload were experiences common to all the workers.

[...] this type of patient [critical/severe] started to require a lot of work from the personnel, to stretch the employees, then I noticed that the personnel started to be exhausted, I started to be exhausted [...] (NT 4 - COVID)

The unit where I worked was allocated for training, then people went there and, after they were trained, they went to the others. We had intense work overload. In addition to that, we kept thinking about this when we got home, it was impossible to totally disconnect from all that madness [...] (NURS 3 - COVID)

[...] the team was also very different, so there were some technicians very difficult to deal with, a team that I didn't know, that I wasn't a reference. So I didn't feel very much like a nurse in that sector, for conflict management, problems [...] (NUR 1 - Non-COVID-19)

[...] every day there was a new protocol, a care protocol with different referrals, one hour there was a specific unit to perform PCR [exam], soon defined that each unit would collect from its patients. (NUR 4 - Non-COVID-19)

‘Impact of exhaustion on the assistance provided and on the relationships’

The workers interviewed showed concern about the effects of exhaustion on care quality and safety due to work organization, the smaller size of the team, greater workload and difficulty managing conflicts. The interviewees also mentioned inattention, tiredness, irritation and impatience, with repercussions on the socioprofessional relationships at work.

[...] we got to have 8 patients with COVID-19. I manage to organize and assist my patients if I have six, more than that it's difficult. We're very overwhelmed, very tired, we can't offer that affectionate assistance, of course it's not always, it's days. (NT 1 - COVID)

[...] I ended up being rude to a doctor one day, because I told her “Doctor, I don't have anywhere else to put people” (NT 7 - COVID)

[...] I feel more distracted some days. [...] it will directly interfere with the safety of the patient under our responsibility. (NUR 2 - Non-COVID-19)

The work environment is very tense, an interprofessional quarrel, because many don't care, they don't care [...] so there was this tension in the team, some demanding and others calmer, asking for calm, to wait, that there'd be a solution, but it's tiring, really tiring. (NT 6 - Non-COVID)

‘Questioning permanence in the profession’

The workers reported the discomfort generated by seeing patients suffering every day, such as loneliness, fear, anguish and even their death, evidencing doubts about the desire to remain in the profession.

[...] impotence comes up, I felt frustrated and questioned my professional career choice at some moments [...] (NUR 3 - COVID)

[...] I thought about seeking another profession [...] seeing people suffer is really tiring. (NT 6 - Non-COVID)

In view of the experiences of negative feelings reported by the participants, attempts to overcome this adverse situation were described, adopted in view of the harms to workers' health, which made up the second category, dealing with the coping strategies used by the workers during their performance in the COVID-19 pandemic.

Coping strategies used

The topics that emerged in this category were grouped into seven subcategories: Maintaining healthy habits; Professional support specialized in mental health; Family support; Expressing spirituality and religiousness; Activities to promote well-being; Information referring to the pandemic; and Fulfillment with work and its results.

‘Maintaining healthy habits’

Investments in strengthening physical health through healthy eating and regular physical exercise practices (such as yoga, Pilates, stretching, etc.) was the strategy most used by the workers as a protective measure. Many workers attributed the efforts to the need to maintain the immunity that would protect them against the Coronavirus.

I've always tried to do some physical activity, even when the gym closed. [...] it's my moment when I need to forget the rest. (NT 1 - COVID)

[...] I've always tried to be with high immunity. [...] I took vitamin shots, exercised, worked out, rode my bicycle, surrounded myself with situations. (NT 5 - COVID)

I've always prioritized eating and sleeping well to feel well physically, to recover, so that my immunity was good. (NUR 1 - Non-COVID-19)

[...] I kept on doing physical exercises, which was an escape valve [...] taking care of what I ate, to maintain balance as a whole. (NUR 2 - Non-COVID-19)

‘Professional support specialized in mental health’

Some workers who underwent psychological and/or psychiatric monitoring before the pandemic highlighted the relevance of this support in the face of new difficulties, as well as many workers reported the need to intensify or initiate this support to face the current situation at work.

[...] I immediately sought psychiatric and psychological help, my psychiatrists didn't want to prescribe any medications, now after almost a year we're thinking about it. (NT 5 - COVID)

[...] I've been in treatment [with a mental health professional] for some two years now. It helped me a lot. (NT 2 - Non-COVID)

‘Family support’

Support from the family, friends and pets was also pointed out as a measure used as a support source by the workers to mitigate the tiredness and sadness they were facing. There has been strengthening of the workers' relationships with their children.

I tried to integrate more with my children, I made a habit of arriving, picking them up and leaving, taking the dog to urinate, just to take a walk, to clear my head. (NUR 8 - COVID)

Sometimes I would go to a friend's house, some work group, we would meet at the house of one or the other, circumventing the isolation rules, because we'd go crazy otherwise[...] (NT 7 - COVID)

[...] playing with him [son] on the street to try to forget a little [about the situation]. [...] to try to get a clear head, not to be in a routine only at home and work. (NT 8 - Non-COVID)

[...] we made some group calls [video-message] to complain, to cry, to laugh. I talk every night to another peer. (NUR 4 - Non-COVID-19)

‘Expressing spirituality and religiousness’

The expression of spirituality by reading texts and books on the topic, meditation and relaxation and breathing techniques, as well as religiousness through individual and group prayers, both inside and outside work, were alternatives that were strengthened or even initiated during the pandemic as a coping strategy among the workers.

[...] I tried to find alternatives such as meditations, like spiritual readings to disconnect a little. (NUR 3 - COVID)

[...] in the prayer group there are many people who talk to you, encourage you and tell you that they're praying for you, such things that lift my spirit [...] (NUR 8 - COVID)

[...] I learned meditation, breathing and relaxation techniques [...] (NT 6 - Non-COVID)

The technicians gather three to five minutes and pray, they pray for everybody. [...] I end up going in with them. (NUR 9 - Non-COVID-19)

‘Activities to promote well-being’

The participants mentioned performing daily activities that generate pleasure and satisfaction as a coping strategy, highlighting activities of an artistic nature, of a relationship with land and animals, and other small actions that make a difference in their lives.

I did another kind of reading, lighter, to see if it calmed me down a little, and it was effective. [...] I started knitting to calm down [...] I really like to touch plants, they saved me, and I have cats. (NUR 5 - COVID)

[...] things I like to do: watch a series, go there to the balcony of the house and have a “chimarrão”, read a book [...] (NUR 6 - COVID)

[...] I did manual work, art therapy to be able to contemplate such freer moments at home. (NUR 2 - Non-COVID-19)

[...] I started doing crafts at home to change the focus and think about other things, I learned macramé, I do some work like this to unwind. I didn't know how to grow anything and now I have a really nice garden at home. (NT 9 - Non-COVID)

‘Information referring to the pandemic’

Watching the news in order to follow the pandemic situation was a strategy used by some and avoided by others, without differentiating between the workers who worked in COVID-19 and non-COVID-19 areas, as shown in the following statements.

[...] I took such measures, of no longer watching those news, trying to protect myself a little, it was causing me a lot of anxiety, I chose not to watch any more TV, news, I only read material related to the service, because I had to. (NUR 5 - COVID)

[...] from the beginning I tried to be well informed, to be able to act in the best possible way [...] (NT 10 - COVID)

I don't watch TV or COVID news, because I think it's worse. (NT 8 - Non-COVID)

[...] we followed the data here in the hospital, we always rely a lot on the transparency of the information here [...] (NUR 2 - Non-COVID-19)

‘Fulfillment with the work and its results’

Given the most varied strategies described by the interviewees, this was directly linked to the work context and not to the private life habits. The workers from the COVID-19 units reported feeling fulfilled because they knew that their profession was crucial at this very important time, as well as grateful for having a job in the period when many people became unemployed, serving to face the adversities experienced; however, in the non-COVID-19 units there was no mention to this in the speeches.

So our percentage of cure here is good, the teams are wonderful, they get very good results and this is very satisfactory, when a patient is discharged and you followed the whole process [...] (NT 1 - COVID)

[...] I went to the unit with great pride, although being there was scary, I felt great pleasure, even more than in my unit of origin [...] (NT 4 - COVID)

[...] so work helped me a lot not to go crazy, because I like what I do. I think about people who have no job [...] (NT 7 - COVID)

We stop and think that we have to thank, that we're fulfilling the mission of what we choose, that we have a job, other people have nothing to eat [...] (NT 5 - COVID)

DISCUSSION

The workers of the Nursing teams who worked in the COVID-19 and non-COVID-19 units reported intense emotional exhaustion describing signs and symptoms resulting from the intensification of the assistance pace and demands in coping with the pandemic. These findings corroborate studies that showed the psychological illness of these professionals during this period.^14-20

Compassion in relation to the colleagues' distress and illness was a feeling that represented an addition to the workers' own wear out. During the pandemic, compassionate fatigue for colleagues was associated with the Nursing professionals' emotional exhaustion,²¹ revealing more negative effects for the workers who were active in this period, mainly because support among colleagues is a fundamental resource in coping with adversity.^10,22-23

In the COVID-19 units, the workers related exhaustion mainly to the patients' criticality, due to severity of the disease and to the instability they showed. These professionals, who directly treated infected patients, had greater emotional wear out and exhaustion.^{7,16,18-20,24} However, a study conducted in China showed greater emotional exhaustion in the professionals who did not work directly with contaminated patients, when compared to those who worked directly with them, linking this fact to PPE insufficiency and lower quality, as well as to less rigor in the work processes, which gave them the feeling of greater exposure and increased the fear felt.²⁵

Several can be the causes of the increase in emotional exhaustion among the Nursing professionals who worked during the pandemic, such as the increase in working hours and demands, constant PPE use, the countless and frequent institutional changes, the distancing of sick professionals or because they belong to the group at risk for the disease and also the constant concern not to get contaminated and not to contaminate those close to them, as well as to provide better care to the patients.^26-31 Faced with such experiences, the participants reported an impact on the interpersonal relationships because they were more stressed and irritated to deal with others, thus making coexistence among team members more distressing.

Both in this and other studies, the participants' exhaustion is shown through job (dis)satisfaction, the thought of giving up the profession, low professional fulfillment, interpersonal conflicts and even harms to the patients.^14,17,24,28 The thought of abandoning the job, revealed by the interviewees, was also described in another study,²⁸ associated with the high number of deaths and direct contact with the patients' suffering.^17,32

The workers recognized that emotional exhaustion generated impacts on care. Exhaustion was associated with the increase in the number of care-related errors, with and without harms to the patients, linked to insufficient time to provide care.¹⁴ The decrease in care quality, and consequently of patient safety, was associated with emotional exhaustion and work overload.³³ Workers in COVID-19 units had illness also linked to high mortality rates due to the disease and inability to help the patients due to ignorance, work overload and lack of material resources.^26,32,34

In view of the impact generated by the adversities brought about by the pandemic, the workers sought several personal strategies aimed at mitigating the exhaustion and distress felt. There were particularities in the strategies regarding the performance area being COVID-19 or non-COVID-19, as only in the COVID-19 areas did the workers show fulfillment with their job. This difference was evaluated, revealing that the workers from the COVID-19 units pointed out the support provided by the institution, through the offer of uniforms and food, free parking, increased breaks in work shifts and also a quiet place to rest, as strategies that would help them deal with the pandemic.²³

Physical and mental health care stood out among the strategies used by the workers. Physical exercise, rest and adequate nutrition were described as practices to prevent mental health problems and improve immunity.³⁵ A study showed that 90% of the Nursing professionals who resorted to these practices during the pandemic showed benefits in mitigating stressors.³⁶ The search for specialized professional support, such as psychologists and psychiatrists, was a reality among Nursing professionals; in addition, medication use to aid mental health increased among Brazilians during the pandemic period.^37-38

Self-care was also represented by spirituality and religiousness actions by the participants of this study, being found in the literature as strategies for mental health preservation and that should be stimulated by the institutions to Nursing professionals, mainly in stressful situations such as the COVID-19 pandemic.³⁶ These practices were related to better quality of life and to lower levels of mental exhaustion³⁹ and also served as a mechanism in coping with and mitigating the situation.^30,36

The search for support in coping with the difficult experiences often took place through coexistence with family and friends, although at many moments this approach has occurred through digital resources (video calls through cell phones, tablets and computers) to maintain compliance with social distancing restrictions, with the professionals highlighting the relevance of protection and appreciation by the their family members.^10,23,36

The participants also highlighted satisfaction at work as a subjective strengthening resource, linked to the feeling of duty accomplished and the pride of being a Nursing worker active during the pandemic. However, they related this pride to the fact that they were employed while other people from other areas were not able to work during this period. Given the above, the need is emphasized to transcend the recognition manifested by applause and symbols of heroism, in the form of appreciation by the work institution, including mental health support, adequate working conditions, increased wages and decreased workload, which has been acclaimed by Nursing worldwide.^{10,22-23,30,36}

In addition, many workers understood that updating information related to the pandemic helped them to cope, in order to feel more prepared to deal with the situation, although there were those who preserved themselves from this excessive amount of information, as they associated such excess to exhaustion. Many professionals seek references about the virus in order to protect themselves, but when they are outside work they seek to distance themselves from this information.³⁶ For being a new situation, the need for correct and frequent information is highlighted, aiming at greater professional protection,^10,23 as well as the importance of nurses seeking and disseminating this knowledge.⁴⁰

CONCLUSION

Nursing workers who were active both in COVID-19 and in non-COVID-19 units perceive themselves to be emotionally exhausted, as well as their teammates. However, the cause of emotional exhaustion in the COVID-19 areas was related to clinical instability and high number of deaths of COVID-19 patients, while in non-COVID-19 areas it was linked to the frequency of institutional changes. For both areas, exhaustion exerted negative impacts on patient care, interpersonal relationships and the desire to remain in the profession.

Faced with the exhaustion felt and the stressors imposed by the pandemic situation, the workers used strategies to mitigate distress, with emphasis on the increase of physical and mental health care, through adequate nutrition, physical exercise, rest, search for professionals specialized in mental health and the practice of activities that promote well-being, linked to spirituality, religiousness and art. Only the workers from COVID-19 units pointed out fulfillment with work and its results as a source of balance for the adversities.

As a limitation of this study, we highlight the implications of the remote interview modality on the quality of the findings with regard to their subjectivities, which can be potentiated by the interaction between the researcher and the interviewees in person, as well as non-validation of the content of interviews with the workers. Further studies are necessary to monitor the late impacts of such experiences and the harms to Nursing workers' health, as well as new research studies aimed at strengthening strategies that serve as protective and promoting resources for Nursing workers' mental health.

This study contributes to the advancement of knowledge by conferring visibility to the repercussions of the pandemic on Nursing workers' health, as well as by identifying possible subsidies to promote improvements, prevent illness and minimize harms to the workers who were active in coping with the pandemic. It also serves as a subsidy for institutional changes made by workers and managers alike, as spaces for qualified listening and welcoming of health workers, as well as in the development of strategies that allow them to be monitored, aiming at the prevention of future diseases, as they may face even more repercussions resulting from this moment in the medium- and long-term.

• a
  Article extracted from the Master's dissertation entitled “NURSING PERFORMANCE IN COPING WITH THE PANDEMIC: A multicenter study about COVID-19 and non-COVID-19 units”, Graduate Program in Nursing. Author: Larissa Fonseca Ampos. Academic Advisor: Daiane Dal Pai. Escola de Enfermagem. Universidade Federal do Rio Grande do Sul. Sustained in 2022.
• FINANCIAL SUPPORT To the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) for granting an MSc scholarship to Larissa Fonseca Ampos, Funding Code 001.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  09 Jan 2023
• Date of issue
  2023

History

• Received
  11 Aug 2022
• Accepted
  28 Oct 2022