One year of pandemic: how is the mental health of nursing professionals?

Un año de pandemia: ¿cómo es la salud mental de los profesionales de enfermería?

ABSTRACT

Objective:

To reflect on the mental health of nursing professionals one year after the outbreak of the Covid-19 pandemic.

Method:

Theoretical-reflective study based on evidence found in national and international scientific literature, on the discursive elaboration on the theme and including the authors' perception and critical analysis.

Results:

After one year facing the pandemic, nursing professionals experienced a worsening of their mental health, given the persistence and also the deterioration of the health system scenario, high risk of contamination and repercussions of the disease in professional and personal lives.

Final considerations:

Managers of health institutions are supposed to be sensitive to and understand the psychological distress faced, or to be faced, by nursing workers, by providing spaces for dialogue aimed to improve and maintain the mental health of these workers.

Keywords:
Pandemics; Mental health; Nurse practitioners; Coronavirus infections

RESUMEN

Objetivo:

Reflexionar sobre la salud mental de los profesionales de enfermería tras un año de la pandemia de coronavirus.

Método:

Estudio teórico-reflexivo, basado en la evidencia encontrada en la literatura científica nacional e internacional, a partir de la elaboración discursiva sobre el tema y sumada a la percepción y análisis crítico de los autores.

Resultados:

Luego de un año de enfrentar la pandemia, se evidenció un empeoramiento de la salud mental de los profesionales de enfermería, ante la continuidad y también el empeoramiento del escenario del sistema de salud, alto riesgo de contaminación y repercusiones de la enfermedad en la vida profesional y personal.

Consideraciones finales:

Corresponde a los gerentes de las instituciones de salud ser sensibles a la comprensión y atención de los sufrimientos existentes y también los que seguramente vendrán, permitiendo espacios de diálogo y oportunidades para la mejora y mantenimiento de la salud mental de los trabajadores de enfermería.

Palabras clave:
Pandemias; Salud mental; Enfermeras practicantes; Infecciones por coronavirus

RESUMO

Objetivo:

Refletir sobre a saúde mental dos profissionais de enfermagem após um ano da pandemia de coronavírus.

Método:

Estudo teórico-reflexivo, fundamentado nas evidências encontradas em literatura científica nacional e internacional, baseado na elaboração discursiva sobre a temática e somado à percepção e análise crítica das autoras.

Resultados:

Após um ano de enfrentamento da pandemia observou-se uma piora da saúde mental dos profissionais da enfermagem, tendo em vista a sua continuidade e também o agravamento do cenário do sistema de saúde, com alto risco de contaminação e repercussões da doença na vida profissional e pessoal.

Considerações finais:

Cabe aos gestores das instituições de saúde a sensibilidade no entendimento e no atendimento de sofrimentos já existentes e também aqueles que certamente virão, possibilitando espaços que dialoguem e oportunizem a melhora e a manutenção da saúde mental dos trabalhadores da enfermagem.

Palavras-chave:
Pandemias; Saúde mental; Profissionais de enfermagem; Infecções por coronavírus

INTRODUCTION

March 11, 2021 marks one year since the World Health Organization (WHO) declared the novel coronavirus (SARS-CoV-2) pandemic, called Coronavirus Disease-19 (COVID-19). The pandemic resulted in 5,364,996 deaths worldwide and 617,873 deaths in Brazil as of December 22, 20211. It is known that the transmission of COVID-19 occurs mainly through respiratory droplets, contact with contaminated people and objects, and old age, as well as the presence of comorbidities such as hypertension, diabetes, cardiovascular diseases, chronic respiratory diseases and cancers contribute to a worse prognosis of the disease2.

Due to the rise in increase in cases of Covid-18 in the world, measures to control and prevent the disease were implemented, such as respiratory etiquette and hand washing, use of face masks, physical distancing and rapid tests. However, large-scale contamination has not been stopped3. While 2020 was considered a year of challenges and of various consequences as a result of the pandemic and the contamination of millions of people, in 2021 the emergence of multiple variants of SARS-CoV-2 was identified, such as P.1, Delta, Omicron, among others, detected in Brazil and around the world and that have greater transmissibility, also seriously affecting young people4.

In this scenario, the pandemic revealed weaknesses and deficiencies in the health system in Brazil, causing collapse in some states due to the great demand for highly complex and technologically dense care5. Overcrowded Emergencies and Intensive Care Centers (ICUs), lack of respirators, beds, specific medications for sedation and patients waiting in queue at the hospital to be admitted were frequent.

A global outcry was sparked, and the need for a vaccine mobilized the WHO, governments, scientists, pharmaceutical industries and non-governmental institutions, leading more than 170 countries to an unprecedented movement to raise funds for the development and production of vaccines6.

Brazilians had access to the vaccine against covid-19 in January 2021, which was provided by the Unified Health System (SUS). At first, there was a delay in the availability of vaccination for priority groups and other age groups. Subsequently, there was greater capillarity in the supply and distribution of this input among the general population. This facilitated collective immunization - when people who have already been vaccinated act as a barrier, protecting others, including those who are not yet immune6.

At first, with the advent of the vaccine, there was a mistaken belief that the virus was under control, and this led to an increase in the number of cases. People gathered with large groups of people, refusing to adhere to the measures and recommendations of the Ministry of Health about the risks of collapse of the health system3, and thus control measures and social distancing were maintained, as well as increased vaccination coverage4.

One year after the outbreak of the pandemic, health services and professionals experienced critical moments. There was a chaotic scenario in health services from March to July, when the system was unable to absorb the great demand of patients with high-tech care needs. Workers also faced a chaotic situation: accrued leave, high number of work hours, extended shifts at work resulted in leaves of absence due to anxiety, panic attacks and depression. These are examples of the daily routine of many health professionals, including nurses7.

These issues that were brought up in the face of the Covid-19 pandemic have historically been faced by the nursing sector. They include precarious working conditions, long working hours, personnel undersizing and low recognition of the occupation. Moreover, especially regarding frontline health care workers during the pandemic, they faced a high risk of contamination during care due to frequent contact with patients and the fear of transmitting the disease to family members, which increased insecurity among these workers2.

These factors had a negative impact not only on the physical health of these professionals, but also on their mental health. Some consequences of COVID-19 in nurses identified in different national and international studies are related to increased levels of anxiety, stress, depression and the association between physical and mental health problems. This new scenario has caused growing concern in the labor context, especially regarding the impact on the emotional state of these workers4^-5^,8.

The psychological distress of nursing professionals was also intensified due to the need for making difficult decisions under daily pressure, the social isolation that makes it impossible to interact with family members, the growing number of deaths of patients under their care and the death of co-workers by COVID-192.

Given the challenges and difficulties experienced in a year of pandemic, reflecting on the mental health of nursing professionals is necessary. The chaotic situation experienced over a long period of time, the identification of new variants and the long working hours affected the mental health of these workers. Therefore, the guiding question of this study is: How is the mental health of nursing professionals one year after the outbreak of the pandemic?

This study aims to reflect on the mental health of nursing professionals after one year of the COVID-19 pandemic.

METHOD

Theoretical-reflective study based on the discursive elaboration on the theme and on evidence found in the national and international scientific literature, in addition to the perception and critical analysis of the authors regarding the subject addressed.

A search was conducted in the electronic databases Scientific Electronic Library Online (SciELO), PubMed, Latin American and Caribbean Literature on Health Sciences (LILACS) and Virtual Health Library (BVS), from March to May 2021. The descriptors used in the search process were selected based on consultation on Health Sciences (DeCS) descriptors, namely: Nursing, Mental Health, Pandemics and Coronavirus Infections.

The search procedure identified initially in 55 publications as potentially eligible for this manuscript. After this analysis that included evaluation of titles and reading of abstracts, 25 articles were considered eligible for full reading and 12 met the inclusion criteria. Three regulatory measures from the Ministry of Health were also included to contribute to this reflection.

Reflections on the mental health of nursing professionals one year after the outbreak of the pandemic

With the rapid increase in the incidence of the disease, the rising number of cases and deaths in the population, and complications arising after a year since the beginning of the pandemic in Brazil, Covid-19 was one of the biggest challenges faced by professionals and the health system. This health condition exposed the structural weaknesses and the collapse of the health system arising from the lack of control over physical distancing measures and the increased demand for care to those affected by the disease. These factors contributed to the scarcity of supplies and materials, intensive care beds and professionals available to work on the frontline of the fight against Covid 192^-3.

During these 12 months, states and municipalities experienced the pandemic in different ways and, despite efforts to avoid the collapse of the health system, some of them entered a crisis as early as 2020; however, it was at the beginning of 2021 that most Brazilian and countries around the world faced a chaotic reality4. There was overcrowding of hospitals and health services in general, shortage of oxygen and lack of supplies such as ventilators, lack of specialized labor and progressive growth in the number of cases and deaths, which were reported on a daily basis3.

Despite the implementation of non-pharmacological measures (physical distancing, hand washing, use of face masks), it should be noted that Brazil has different scenarios that revealed the discrepancy regarding the care provided to users. The Southern and Southeastern regions of Brazil, for example, were more able to fight the pandemic than the other regions, as they concentrate a greater number of human and material resources3.

Increased viral transmission has created greater opportunities for SARS-CoV-2 variants to emerge. Thus, although 2020 was a challenging year, 2021 appeared to be even harder, with the emergence of multiple strains of the virus that causes COVID-194.

The Coronavirus variants were another challenge for health system managers, as they had a dramatic impact on the planning of the measures to fight the pandemic, and the number of new covid-19 cases rose fast, adding to the chaotic situation. In this regard, the lack of knowledge about specific treatments for these variants required the maintenance of non-pharmacological interventions, associated with the beginning of vaccination, so that collective immunity was achieved4.

In January 2021, the first doses of vaccines were made available. They were distributed first to frontline health professionals and, later, to other priority groups, such as the elderly and residents of long-term care institutions. It is estimated that about 60 to 70% of the population need to be immunized to stop the circulation of the virus, and 70% or more to eliminate the disease4^{) .}

With the aim of diversifying the supply of vaccines and speeding up the population’s access to immunization, Brazil signed three technology transfer agreements, seeking to guarantee the expansion of the number of doses in a shorter period of time9. By May 2021, 17.82% of Brazilians and 23.11% of the population of the state of Rio Grande do Sul had received the recommended vaccine doses. By December 2021, 67% of Brazilians and 83.5% of the eligible population of the state of Rio Grande do Sul had received the recommended vaccine doses10.

In May, while most of the population did not have access to vaccination, there was a worsening of the collapse of the health system, and health workers such as technicians and nurses faced work overload and had to experience the death of patients more frequently. At that time, new care facilities had to be made available for the care of patients with suspected or confirmed disease, which led many facilities to relocate some professionals to COVID units, and, therefore, other employees had to be recruited to replace them11.

Several irregularities regarding the rights of these workers were observed, such as the requirement of availability to perform duties that they were not familiar with, employees had to acquire the PPE with their own resources, productivity allowance payment and workers hired by nomination to their positions. These situations experienced by health workers exposed weaknesses in the nursing area, since professionals had to reorganize themselves in patient care, in an attempt not to harm the quality of care provided, nor to expose themselves to greater risks in their working hours11.

Therefore, Provisional Measure No. 1,046, of April 27, 2021, was issued, which made employee hiring more flexible through temporary vacancies and day/shift payment, reorganized the workers' compensatory time off and authorized telework as viable practices during the pandemic12.

Another measure taken to ensure the hiring of the health professionals needed in the labor market was the anticipation of graduation in Medicine, Nursing, Pharmacy and Physiotherapy courses, through Ordinance No. 374, of April 3^rd, 2020, exceptionally, in order to contribute to the fight against the disease, mainly in the Southern and Southeastearn regions13.

This advancement of graduation also aimed to minimize the burden caused by absences from work, as many health workers had pre-existing health conditions and vulnerabilities and thus should be on a sick leave7.

The implementation of remote work in nursing was another way to ensure the continuity of activities. However, the wide online availability, the lack of boundaries between work and non-work time, the blurred boundaries between family and work environment7, and the emotional exhaustion generated by the lack of routine and socialization in the workplace made overload worse and impaired mental health.

Such situations maximized mental suffering, stress and emotional exhaustion of nursing workers, negatively impacting the well-being of these individuals who also deal with the consequences of the pandemic on a personal level and on family reorganization7^,14.

Most of the nursing staff in the world is composed of women. In this sense, other challenges emerged in the daily lives of nurses who are mothers, especially in view of the suspension of face-to-face school activities in an attempt to prevent the health system from deteriorating. The accumulation of functions by these women caused an increase in activities and changes in the family routine14, exacerbating symptoms of physical and mental fatigue.

The overload maximized by the need to reconcile work and care, as well as the uncertainty of how long the current situation will persist, can be configured as risk factors for the development and worsening of mental health problems in nursing professionals14.

Given the increase in the number of team workers infected by COVID-19, the precarious infrastructure conditions, the lack of adequate remuneration, in addition to the enormous stress and pressure suffered, the mental health of these professionals is identified as a major concern2 in the short, as well as in the long term.

In this regard, the Federal Nursing Council (Cofen) provided an online service, in which the feelings most reported by nurses during the pandemic were identified, as follows: anxiety, stress, fear, ambivalence, depression and exhaustion. Thus, symptoms such as a feeling of high risk of contamination, the effect of the disease on professional life and depressed mood are part of everyday life and impact the mental health of nursing professionals. Other factors are physical and mental exhaustion, difficult decision-making, and the pain of losing patients, colleagues, and family members15.

A year after the pandemic, many nursing workers lost their family members and colleagues to the disease. With that in mind, the following questions were posed: how can the nursing professional take care of someone after losing his (her) father or mother? How can he/she return to work without the presence of a team member? How to deal with the concern of having a hospitalized relative? How to work facing the risk of contamination and contaminating a family member? They have not been answered so far, but had direct repercussions on the care delivered to patients and on the mental health of professionals.

Besides identifying signs and symptoms associated with the factors that contributed to this problem, it is essential to reflect on strategies for prevention and promotion of mental health. A recent study identified the use of psychological strategies, interventions and techniques as tools to support actions in the area. To encourage the well-being of their professionals, health institutions have implemented measures related to rotating work shifts, regular rest periods, early identification of signs and symptoms, understandable communication, publication and dissemination of support services and psychosocial measures adapted to specific guidelines for each institution15.

In addition to collective strategies within the scope of health institutions, each worker must seek alternatives aimed at maintaining their mental health. According to studies, the most evident self-care strategies concern the strengthening of support networks through communication with family and friends, a balanced and healthy diet and physical activity, stress management methods such as meditation, therapeutic treatments and virtual support groups7^,15.

Regarding the search for suggestions to face this scenario, vaccination against COVID-19 renews hope for better days for society in general and for health professionals, in particular, nurses. The expectation that widespread vaccination will end the pandemic generates optimism, and has an impact on everyone's mental health.

SOME CONSIDERATIONS

This reflection paper attempted to explain the mental health status of nursing professionals one year after the beginning of the pandemic and highlighted the need for a dialogue with the population about a current and relevant topic for everyone.

As the authors of this study, we hope it will not be necessary to write a new reflection paper in the next year, on the persistence of this context experienced by society and nursing professionals at a time of uncertainty regarding the health system and how the virus will evolve over time. The expectation of a widespread vaccination against Covid-10 generates optimism that better days are coming and encourages these workers and institutions in the search for their individual and collective mental health, in the short and long term.

Managers of health institutions are supposed to be sensitive to and understand the psychological distress faced, or to be faced, by nursing workers, by providing spaces for dialogue aimed to improve and maintain the mental health of these workers.

REFERENCES

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Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  26 Aug 2022
• Date of issue
  2022

History

• Received
  14 May 2021
• Accepted
  09 Feb 2022