From caregiver to patient: in the Covid-19 pandemic, who defends and cares for Brazilian nursing?

ABSTRACT

Objective

Reflect on the health of nursing workers in the face of the pandemic crisis by Covid-19.

Method

Reflection article whose theme involves the pandemic by Covid-19 and the health of nursing workers. It was developed from two theoretical sections: i) pandemic, epidemiological aspects and recommendations for the protection of nursing workers; ii) health of nursing workers in the context of Covid-19.

Results

The risks to the health of nursing workers, which were already worrisome before the pandemic, have become alarming in the current context, especially due to the incapacity of a precarious health system existing for a long time.

Conclusions and implications for practice

This fact generates ethical dilemmas, physical and psychic suffering for nursing workers, as well as illnesses and deaths. Therefore, it is necessary to plan and operationalize material and human resources in adequate quantity and quality, considering the last time, to support health services and nursing workers. We highlight the role of class organs, the need to mobilize the professional collective and the effort of governmental and social bodies, as a way to change the situation pointed out.

Keywords:
Occupational Health; Nursing; Pandemics; Coronavirus Infections; SARS Virus

RESUMO

Objetivo

Refletir sobre a saúde do trabalhador de enfermagem diante da crise da pandemia pela Covid-19.

Método

Artigo de reflexão cujo tema envolve a pandemia pela Covid-19 e a saúde do trabalhador de enfermagem. Desenvolveu-se a partir de duas seções teóricas: i) pandemia, aspectos epidemiológicos e recomendações para proteção do trabalhador de enfermagem; ii) saúde do trabalhador da enfermagem no contexto da Covid-19.

Resultados

Os riscos à saúde do trabalhador de enfermagem, que já eram preocupantes antes da pandemia, tornaram-se alarmantes no atual contexto, especialmente por conta da incapacidade de um sistema de saúde há muito precarizado. Tal fato gera dilemas éticos, sofrimento físico e psíquico aos trabalhadores de enfermagem, além de adoecimentos e mortes.

Conclusão e implicações para a prática

Logo, é preciso planejar e operacionalizar recursos materiais e humanos em quantidade e qualidade adequadas, considerando a premência do tempo, para dar suporte aos serviços de saúde e aos trabalhadores de enfermagem. Destaca-se o papel dos órgãos de classe, a necessidade da mobilização do coletivo profissional e o esforço de instâncias governamentais e sociais, como forma de mudar a situação apontada.

Palavras-chave:
Saúde do Trabalhador; Enfermagem; Pandemias; Infecções por Coronavirus; Vírus da SARS

RESUMEN

Objetivo

Reflexionar sobre la salud de los trabajadores de enfermería ante la crisis de la pandemia por Parte de Covid-19.

Método

Artículo de reflexión cuyo tema implica la pandemia de Covid-19 y la salud de los trabajadores de enfermería. Se desarrolló a partir de dos secciones teóricas: i) pandemia, aspectos epidemiológicos y recomendaciones para la protección de los trabajadores de enfermería; ii) la salud de los trabajadores de enfermería en el contexto de Covid-19.

Resultados

Los riesgos para la salud de los trabajadores de enfermería, que ya eran preocupantes antes de la pandemia, se han vuelto alarmantes en el contexto actual, especialmente debido a la incapacidad de un sistema de salud hace ya tempo precarizado. Este hecho genera dilemas éticos, sufrimiento físico y psíquico para los trabajadores de enfermería, así como enfermedades y muertes.

Conclusiones e implicaciones para la práctica

Por lo tanto, es necesario planificar y poner en práctica los recursos materiales y humanos en cantidad y calidad adecuadas, teniendo en cuenta la urgencia del tiempo, para apoyar a los servicios de salud y a los trabajadores de enfermería. Destacamos el papel de los órganos de clase, la necesidad de movilizar al colectivo profesional y el esfuerzo de los organismos gubernamentales y sociales, como una forma de cambiar la situación señalada.

Palabras clave:
Salud Laboral; Enfermería; Pandemias; Infecciones por Coronavirus; Virus del SRAS

INTRODUCTION

We are experiencing the greatest crisis in the world after the second great war. This time, the weapon used in this new battle is the workforce of nursing professionals, and the invisible enemy challenges scientists and researchers around the world to seek effective treatments or preventive measures against Covid-19.¹

All we have until now to avoid the collapse of health services and the deaths of hundreds of thousands of people is social isolation, which is a bitter measure not only because of the deprivation of conviviality, but above all because of the enormous economic crisis that especially affects the large, most vulnerable part of society.

The exponential growth of the epidemic and the burden of health services have already been experienced in other countries, especially in Italy and the United States of America (USA), pointing to the vulnerability of health services even in rich countries. This scenario is closer and closer to the Brazilian system, which was already incapable of providing universal and equitable care due to the barrier of access to hospitals, insufficient beds, endless lines for elective surgeries, unavailability of Intensive Care Unit (ICU) beds and overcrowding in emergencies. As an example, the state of Rio de Janeiro, which has the largest contingent of public beds, had, in May 2019, a deficit of 1071 beds, of which more than 300 ICU beds.²

The Brazilian Unified Health System (SUS), a heritage of Brazilians, continuously vilified by governments that have been adopting neoliberal economic policies since the era of President Fernando Color until the current government, suffers from underfinancing, insufficient human resources and a lack of appropriate technologies. This process was aggravated by the Constitutional Amendment 95/2016, which froze health spending for 20 years.³

The crisis unleashed by Covid-19 made more evident the importance of health professionals and showed the protagonism of an army of little visibility, despite being represented by 2,283,808,⁴ who are the foundation of the health system, the Brazilian nursing.

Nowadays, due to the pandemic, the importance of nursing work is evident and, more than that, society is valuing and recognizing the profession. The press is publishing research developed by nurses, the humanized work in the services, the understanding of the complexity of nursing, nurses guiding the population on preventive measures, finally, it became clear that the space that nursing workers occupy is fundamental to face this pandemic.

However, in the wake of this process, nursing is getting sick and dying. The lack of Individual Protection Equipment (IPE), the overload of work for undersized teams, the lack of permanent education policies, poor testing, among others, may explain the situation.

The fear is that a dizzying drop in the number of professionals to deal with this pandemic may be experienced in the near future due to the growth in the number of those infected with SARS-CoV-2 and the deaths from this infection.

If it was already evident that there were insufficient human resources to operate the health services, what would be the way out of this situation? The proposal presented as a strategic action by the government entitled “Brazil counts on me - health professionals”, which provides for the training and registration of health professionals, seems to be ineffective. First, because it leaves the training of workers to the regional councils; second, because, considering that the training will be mediated by distance learning technologies, it may result in little impact on the real need for training of these teams, especially those that will be allocated in ICUs whose technological apparatus points to a professional with quite specific competencies and skills.

On the other hand, the educational system both in the training of nursing technicians and in higher education, in the graduation of nurses, has shown low capacity to offer quality training. In other words, we do not have professionals with the necessary qualification to act in the current pandemic, even with the expressive growth of nursing undergraduate courses since 2000. This growth was predominantly in the private education sector which, in 2018, held over 85% of the courses offered in Brazil.⁵

There are currently a significant number of concluding members placed on the job market, around 42,000, by the 2018 census. However, it is important to analyze the quality of this training. One of the components of the evaluation of higher education in Brazil is ENADE (National Student Performance Examination). ENADE's objective is to assess the performance of students in relation to the program content foreseen in the curricular guidelines of the respective undergraduate area, their abilities to adjust to the demands arising from the evolution of knowledge, and their competencies to understand themes outside the specific scope of their profession, linked to the Brazilian and world reality and to other areas of knowledge.⁶

The performance of each course participating in ENADE is evaluated by the students' performance and expressed through the Enade Concept, an indicator of course quality. The concept has an ordered scale of 1 to 5 levels, where level 5 represents the best performance. The classification of the course and, in turn, the learning of the students is related to the achievement of standards established by specialists in the different areas of knowledge. In this perspective, it is known that the result of ENADE 2016, in which 732 courses were evaluated, 80.3% were from private sector educational institutions, and of this percentage 75.8% obtained grades 2 and 3. In relation to public sector courses, it was identified that 69.4% achieved concept 4 and 5.⁷

This finding points to the enormous challenge that health service managers will have to face in order to allocate nursing professionals with the necessary qualifications to act on the necessary fronts and face the ongoing pandemic.

This article aims to reflect on the health of the nursing worker in the face of the pandemic crisis by Covid-19. It is understood that the contribution of this study is to highlight the pressing need to care for the health of a high and relevant contingent of nursing workers, indispensable to the work process in public and private health services, especially in combating the Covid-19 pandemic.

This workforce, which has been precarious with degrading wages and working conditions, has a knowledge that involves empathy, communication skills, technical and scientific knowledge in prevention measures and high-technology management aimed at health care, and needs to be recognized material and symbolically. In addition, it is emphasized that nursing workers are key agents in warding off the pandemic and that they need to have their health protected and preserved in such a context.

METHOD

This is a reflection article on the Covid-19 pandemic and the health of the nursing worker. This reflection was developed based on two theoretical sections, which made it possible to weave relevant discussions on the theme.

The theoretical sections had the following names: i) Pandemic, epidemiological aspects and recommendations for nursing worker protection; ii) Nursing worker health in the context of Covid-19.

Pandemic, epidemiological aspects and recommendations for nursing worker protection

Covid-19 is caused by SARS-CoV-2, identified in Wuhan, capital of China's Hubei province, the first metropolitan region to suffer an outbreak of the disease. Because it is highly contagious and widespread, it was characterized as a pandemic by the World Health Organization (WHO) on March 11, 2020.⁸

The continuous and growing number of people infected by Covid-19 has been bringing serious damage to the public and private health system, to professionals working in this sector and to the world economy. According to the bulletin of the Ministry of Health (MS), by April 19, 2020, 2,359,332 cases of Covid-19 were confirmed worldwide, with 161,950 deaths. The USA has the highest number of cases (653,397). In Brazil, the number of the occurrence has already reached a total of 38,654, with 2,462 deaths, representing a lethality rate of 6.4%.⁹

Until April 20, 2020, most cases were located in the state of São Paulo, with 14,267 confirmed cases and 1,015 deaths, followed by Rio de Janeiro, with 4,765 cases and 402 deaths, and Ceará, which registered 3,252 cases and 186 deaths, with at least one death from the disease being reported in all states.¹⁰

According to the Ministry of Health, 1,985 deaths have already been investigated and it is possible to profile the people who died from the disease. According to these findings, the majority were men (59.8%) and white (57.2%); 7 out of 10 people who died were over 60 years of age and presented at least one risk factor, such as cardiovascular and pulmonary diseases and diabetes mellitus.¹⁰

With respect to nursing professionals who work with these patients, an acceleration of contagion is also observed. On April 15, Cofen published on its website that 4,000 nursing professionals were away due to contamination by Covid-19 and 30 deaths were recorded, portraying the impact of SARS-CoV-2 infection on nurses and nursing technicians.¹¹

Despite the guidelines on protection barriers and use of PPE, the number of professionals infected by Covid-19 is increasing every day. It is worth pointing out that professionals over 60 years of age fall into the risk group, even if they do not have any pre-existing disease. In addition, workers of any age who have comorbidities such as heart disease, diabetes, pneumopathy, neurological or renal disease, immunodepression, obesity, asthma, as well as pregnant women, also need to redouble their care with preventive measures and individual protection of the coronavirus.^10,12

In this sense, Brazilian nursing needs to be attentive and conscious, since in addition to these professionals being in direct contact with suspected and/or confirmed Covid-19 patients, increasing the probability of infection, there is a considerable number of nursing staff in the professional phase considered of “deceleration”, who seek retirement or already have time to retire. In this contingent are individuals aged between 50 and 60 years (11.4%) and professionals over 60 years (2.1%), where many have at least some risk factor, making them more vulnerable to complications.¹³

Coincidence or not, precisely in the year declared International Year of Nursing, the profession gains prominence and the world is faced with the importance of health professionals, especially nursing, because it is the professional who is closest to the user of the service for an extended time. On the other hand, it is not enough just to praise, but above all, physical and psychological protective measures that can guarantee your safety and that of your family members, as well as reduce professional distance in the front line of care.

It is worth noting that in a few months of pandemic, there was an explosion of information, protocols, statistical data, training, virtual classes, various courses, pressing needs of health professionals and construction of campaign hospitals. However, working conditions have not kept pace with measures to tackle the pandemic, and precarious situations prevail in most occupational reports, which deepen the repercussions for workers' health.

Even before the present moment, studies^14,15 described that the nursing team's adherence to standard precautions and use of IPE did not follow best practice recommendations. The main factors of non-adherence were related to trust, habit, custom, lack of information, interest, unavailability, inadequacy, haste, lack of protective equipment of adequate size and inconvenience for certain procedures.¹⁴

In order to deal with the crisis that presents itself, it is necessary to create the habit of using IPE, obtain updated information regarding the correct use, create strategies to reduce discomfort, adapt them to specific situations and provide means for the quantity of materials to be sufficient for the management of care. Not only is the use of IPE and adherence to precautionary practices important, but also its withdrawal, since it is an important risk factor if performed incorrectly, greatly increasing the chance of contamination of the health team.

The professional may become contaminated during the removal of the IPE, a fact observed during a cough simulation scenario, with the use of a mannequin, in which the contamination of the apron, neck, wrist, pants and shoes of the study participants was identified.¹⁶

The working environment can also be contaminated, especially in the IPE removal antechambers, by the disposal of virus aerosols in protective clothing, on the floor and in vomits, with the possibility of re-suspension in the environment and secondary inhalation.¹⁷

Therefore, the nursing worker is faced with two paradoxical situations, one hangs for his responsibility as a professional and his importance in the health system, whether in private or public service, and the other as a human being intimidated in a field permeated by fragilities, doubts, risks, assistance changes, scarcity of inputs, where vulnerabilities in relation to his health and those of his family are touched.

The permanence of professionals essential to the functioning of the services requires the reorganization of work flows and process, as well as the efficient management of patients with suspicion and confirmation of Covid-19. Such measures also imply in making available quality and sufficient IPE, carrying out uninterrupted training in its use, maintenance, skin protection and disposal.

In addition to physical protective measures, the mental health of the nursing worker should be considered in the work environment with extension to the social. Strategies should be directed at strengthening the worker in the performance of his activities, such as fair remuneration; decent working hours and conditions; safe environment that can ensure, including, the safety of his family members; having adequate sleep, rest, and essential needs.¹⁸ All these aspects ensure the worker's health and increase protection against infections such as SARS-CoV-2.

Nursing workers´ health in the context of Covid-19

The work of nursing is complex, diverse and multifaceted. The workers who make up this professional category are inserted into the four major segments of the labor market (public, private, philanthropic and educational networks) and involved in the process of caring for different levels of health care, from basic care to high technological density levels. In carrying out their activities, these workers are continuously exposed to a number of occupational hazards: physical, chemical, biological, mechanical and accident, ergonomic and psychosocial.¹⁹

The fact is that, due to occupational risks and inadequate conditions in the work context, many nursing workers have become ill physically and mentally over the years. There are, for example, among these workers, reports of irritability, stress, altered sleep, obesity, hypertension, gastritis, altered menstrual flow, pathological anxiety, osteomuscular diseases, Burnout syndrome, voluntary servitude syndrome, among other changes that have a connection with the configuration of work in health, guided by neoliberal economic policies.²⁰

It is certain that the advancement of Covid-19 in the country and in the world imposes new and great challenges to public managers and health workers, among them the nursing professionals. But it is also certain that it will leave in greater evidence the weaknesses of the health services, as well as the suffering of these professionals, who inserted in a context of precarious work have less protection and more illness every day.

It is understood that at all levels of health care there are risks to workers. In a basic care unit, it is possible to identify all categories of occupational risks, presenting only differentiated risk factors.²¹ Such understanding is important, since when reflecting on the health of the nursing worker, the focus should not only be on the workers in the hospital context, but on the various scenarios in which these workers may be inserted.

In addition, the context of emergencies stands out, which in the face of the pandemic are also characterized by lack of material resources, shortage of labor force, excessive work activities and high demand for patients, as well as inadequate physical conditions for the work process. These situations directly affect the professional's self-esteem and emotional structure, contributing to the nursing team's exposure to decreased stimulus to perform their duties and to a feeling of powerlessness.²²

In intensive care units, there is a high nursing workload due to undersized teams and inadequate working conditions, which favors the occurrence of adverse events with serious and negative repercussions to patients.²³ On the other hand, professionals also suffer from this situation experiencing feelings of frustration and impotence in face of patient death, physical and emotional exhaustion, unexpressed anguish, emotional fragility and sadness, fear when arriving at the work environment, among others. Such aspects indicate the psychological suffering of these workers and the need for psychosocial interventions.²⁴

As a result of the pandemic, overcrowding in health services and intensification of work are expected. In a scenario with undersized teams and overloaded work, the increase in the work day by up to 24 hours and the reductions in rest time to 12 hours provided for by Provisional Measure (MP) No. 927/2020 may have even more unfavorable repercussions on the psychophysical dimensions of workers. The aforementioned Public Prosecutor's Office provides for labor measures to confront the state of public calamity recognized by the Legislative Decree and the public health emergency of international importance due to the coronavirus (Covid-19). However, it has been repudiated, including by the Federal Council of Nursing (Cofen), because it reduces protection for workers during the pandemic, increasing the risk of illness among professionals and of adverse events in care.²⁵

In addition, the fear of dealing with a new disease with high infectivity and transmissibility, which has led many health professionals to leave work and die, has had a negative impact on the worker's subjectivity.

It is clear that scarcity of resources, especially IPE, exposes workers and makes them even more vulnerable to illness. In this sense, the recommendation that the general population should wear homemade masks is justified, so that surgical masks and N95/PFF2 or equivalent are prioritized for health professionals. This measure is widely advocated, considering that health services are the places of greatest potential concentration of the virus and that the activities developed by health professionals require protection in order to ensure the maintenance of services, thus favoring professionals and patients.²⁶

It is also worth mentioning the risk of developing skin lesions associated with the use of IPE. In this context, there are moisture lesions associated with prolonged use of gloves; pressure lesions associated with prolonged use of the mask; itching, folliculitis, acne and exacerbation of pre-existing skin diseases associated with masks, protectors and caps; dermatitis and skin dryness due to constant hand hygiene. Such injuries have affected many nursing professionals.²⁷

These and other aspects highlight the risks to which nursing workers are exposed, and effective measures to protect their health are a priority and urgent. Measures that are not restricted to the theoretical field, but that have immediate application in practice, in the daily life of these professionals, so that they feel supported and protected while they are at the front fighting for life, for the quality of health care, for the patient's safety and for SUS.

It is still pertinent to emphasize that it is a nursing worker's right to exercise the profession with technical, scientific and environmental safety, in a space free of risks and damages, respecting human dignity and the protection of nursing professionals' rights. It is a worker's right to refuse to perform activities that do not offer him/her safety and even to suspend activities, individual or collective, when the workplace does not offer safe conditions for professional exercise and/or does not respect the legislation in force, except for urgent and emergency situations.²⁸ In this context, the role of class agencies, trade unions and the mobilization of the professional collective is extremely important.

It should be noted that at a time when we are fleeing from normality, such as the SARS-CoV-2 pandemic, ethical dilemmas will increase. The measures adopted to contain this pandemic involve material and economic losses for the country, which affect all workers, especially nursing professionals, who are in the front line of care and are getting sick and some dying.

In Brazil, it should always be reiterated that with the advent of the 1988 Federal Constitution, respect for the dignity of the human person has become the supreme foundation value of the democratic legal order.²⁹ And, in defense of professional dignity, the exercise of citizenship and demands for better conditions of assistance, work and remuneration, nursing workers have the right to support and/or participate in movements,²⁸ such as the “Stay at Hom”and campaign, an appeal to society for the protection of the community.

In addition, it can then lay the foundation for the recognition and redemption of human dignity that is promoted through active and proactive attitudes in a professional, competent and responsible, creative and participatory way in social health spaces. This role is fundamental to ensure equity of treatment for those affected by Covid-19 and other pathologies, which have worsened their state of health, as well as respect and information to both the individual and their families.

This role of the nurse meets the main objective of the professional council, which is to ensure the quality of nursing care, respect for the code of ethics and compliance with the law of professional practice

CONCLUSION AND IMPLICATIONS FOR PRACTICE

There are severe reasons to affirm that the health risks of the nursing worker will be aggravated, considering the fragility and incapacity of the Brazilian health system, which has been underfunded and managed inefficiently for years. The low capacity to plan and operate material and human resources in adequate quantity and quality has been a constant in public management. All the more so if we consider the urgency of the time and the complexity and seriousness of the situation that has so quickly established itself in the health sector in the face of the pandemic.

Despite society's notoriety and sense of gratitude, this situation will expose even more the devaluation and little recognition nursing has suffered for decades, both in public management and private employers. Therefore, so that more deaths of workers and patients do not occur, it is necessary to join theoretical, practical, legal and political efforts so that an even more nefarious context does not survive.

Furthermore, it is considered that the ethical dilemmas and the physical and psychic suffering of the workers will be even more forceful, if the union of these efforts is not effective. Thus, the role of class organizations and the mobilization of the professional collective for its empowerment through the knowledge of the right to human dignity and health is highlighted.

It is hoped that the suffering experienced today by thousands of citizens and, above all, by nursing professionals can bring as a legacy the recognition by society of this category of workers, who more than applause, cry out for decent living and working conditions.

REFERÊNCIAS

• ¹
  Sullivan A. As consequências da Covid 19 para a economia mundial. DW [periódico na internet]. 2020 [citado 2020 abr 15]. Disponível em: https://www.dw.com/pt-002/as-consequ%C3%AAncias-da-covid-19-para-a-economia-mundial/a-53021449
  » https://www.dw.com/pt-002/as-consequ%C3%AAncias-da-covid-19-para-a-economia-mundial/a-53021449
• ²
  Defensoria Pública do Estado (RJ). DPRJ constata déficit de mais de mil leitos em hospitais da capital [Internet]. Rio de Janeiro: DPRJ; 2019 [citado 2020 maio 13]. Disponível em: http://www.defensoria.rj.def.br/noticia/detalhes/9195-DPRJ-constata-deficit-de-mais-de-mil-leitos-em-hospitais-da-capital
  » http://www.defensoria.rj.def.br/noticia/detalhes/9195-DPRJ-constata-deficit-de-mais-de-mil-leitos-em-hospitais-da-capital
• ³
  Emenda Constitucional nº 95, de 16 de dezembro de 2016 (BR). Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União [periódico na internet], Brasília (DF), 16 dez 2016 [citado 2020 abr 1]. Disponível em: https://www2.camara.leg.br/legin/fed/emecon/2016/emendaconstitucional-95-15-dezembro-2016-784029-publicacaooriginal-151558-pl.html
  » https://www2.camara.leg.br/legin/fed/emecon/2016/emendaconstitucional-95-15-dezembro-2016-784029-publicacaooriginal-151558-pl.html
• ⁴
  Conselho Federal de Enfermagem (BR). Enfermagem em números [Internet]. Brasília: COFEN; 2020 [citado 2020 abr 1]. Disponível em: http://www.cofen.gov.br/enfermagem-em-numeros
  » http://www.cofen.gov.br/enfermagem-em-numeros
• ⁵
  Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Sinopse Estatística da Educação Superior 2018 [Internet]. Brasília: Inep; 2018 [citado 2020 abr 1]. Disponível em: http://download.inep.gov.br/educacao_superior/censo_superior/documentos/2018/censo_da_educacao_superior_2018-notas_estatisticas2.pdf
  » http://download.inep.gov.br/educacao_superior/censo_superior/documentos/2018/censo_da_educacao_superior_2018-notas_estatisticas2.pdf
• ⁶
  Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Exame Nacional de Desempenho dos Estudantes (ENADE) 2010 [Internet]. Brasília: Inep; 2010 [citado 2020 abr 1]. Disponível em: http://enadeies.inep.gov.br/enadeIes/enadeResultado
  » http://enadeies.inep.gov.br/enadeIes/enadeResultado
• ⁷
  Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira. Exame Nacional de Desempenho dos Estudantes (ENADE) 2016: relatório síntese da área de enfermagem [Internet]. Brasília: Inep; 2016 [citado 2020 abr 1]. Disponível em: http://download.inep.gov.br/educacao_superior/enade/relatorio_sintese/2016/enfermagem.pdf
  » http://download.inep.gov.br/educacao_superior/enade/relatorio_sintese/2016/enfermagem.pdf
• ⁸
  Organização Pan-Americana da Saúde. Folha informativa: COVID-19: doença causada pelo novo coronavírus [Internet]. Brasília: OPAS; 2020 [citado 2020 abr 14]. Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875
  » https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875
• ⁹
  Johns Hopkins University. Coronavirus COVID-19 global cases by Johns Hopkins CSSE [Internet]. 2020 [citado 2020 abr 14]. Disponível em: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
  » https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
• ¹⁰
  Ministério da Saúde (BR), Centro de Operações de Emergência em Saúde Pública. Doença pelo Coronavírus 2019 (COVID-19): especial vigilância epidemiológica laboratorial (Boletim COE COVID-19, No. 12) [Internet]. Brasília; 2020 [citado 2020 abr 22]. Disponível em: https://portalarquivos.saude.gov.br/images/pdf/2020/April/19/BE12-Boletim-do-COE.pdf
  » https://portalarquivos.saude.gov.br/images/pdf/2020/April/19/BE12-Boletim-do-COE.pdf
• ¹¹
  Conselho Federal de Enfermagem (BR). Brasil tem 30 mortes na Enfermagem por Covid-19 e 4 mil profissionais afastados [Internet]. 2020 [citado 2020 abr 30]. Disponível em: http://www.cofen.gov.br/brasil-tem-30-mortes-na-enfermagem-por-covid-19-e-4-mil-profissionais-afastados_79198.html
  » http://www.cofen.gov.br/brasil-tem-30-mortes-na-enfermagem-por-covid-19-e-4-mil-profissionais-afastados_79198.html
• ¹²
  Centers for Disease Control and Prevention. Coronavirus disease 2019: pregnancy and breastfeeding [Internet]. Atlanta: CDC; 2020 [citado 2020 abr 21]. Disponível em: https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html
  » https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html
• ¹³
  Machado MH, Aguiar W Fo, Lacerda WF, de Oliveira E, Lemos W, Wermelinger M et al. Características gerais da enfermagem: o perfil sócio demográfico. Enfermagem em Foco. 2016;7(ESP):9-14. http://dx.doi.org/10.21675/2357-707X.2016.v7.nESP.686
  » http://dx.doi.org/10.21675/2357-707X.2016.v7.nESP.686
• ¹⁴
  Ferreira WFS, Oliveira EM. Biossegurança em relação a adesão de equipamentos de proteção individual. Rev Univ Vale Rio Verde. 2019;17(1):1. http://dx.doi.org/10.5892/ruvrd.v17i1.4977
  » http://dx.doi.org/10.5892/ruvrd.v17i1.4977
• ¹⁵
  Ferreira LA, Peixoto CA, Paiva L, Silva QCG, Rezende MP, Barbosa MH. Adesão às precauções padrão em um hospital de ensino. Rev Bras Enferm. 2017;70(1):96-103. http://dx.doi.org/10.1590/0034-7167-2016-0138 PMid:28226047.
  » http://dx.doi.org/10.1590/0034-7167-2016-0138
• ¹⁶
  Lockhart SL, Naidu JJ, Badh CS, Duggan LV. A simulação como uma ferramenta para avaliar e evoluir seu atual equipamento de proteção pessoal: lições aprendidas durante a pandemia da doença de coronavírus (COVID-19). Can J Anaesth. 2020;67(7):895-6. http://dx.doi.org/10.1007/s12630-020-01638-z PMid:32221852.
  » http://dx.doi.org/10.1007/s12630-020-01638-z
• ¹⁷
  Liu Y, Ning Z, Chen Y, Guo M, Liu Y, Gali NK et al. Aerodynamic characteristics and RNA concentration of SARS-CoV-2 Aerosol in Wuhan Hospitals during COVID-19 outbreak. bioRxiv. 2020. No prelo. http://dx.doi.org/10.1101/2020.03.08.982637
  » http://dx.doi.org/10.1101/2020.03.08.982637
• ¹⁸
  Vieira GC, Ribeiro KV, Velasco AR, Pereira ÉAA, Cortez EA, Passos JP. Satisfação laboral e a repercussão na qualidade de vida do profissional de enfermagem. ABCS Health Sci. 2018;43(3):186-92. http://dx.doi.org/10.7322/abcshs.v43i3.1123
  » http://dx.doi.org/10.7322/abcshs.v43i3.1123
• ¹⁹
  Souza NVDO, Pires AS, Gonçalves FGA, Cunha LS, Ribeiro LV, Vieira RS. Riscos ocupacionais e agravos à saúde dos trabalhadores em uma unidade ambulatorial especializada. Rev Min Enferm. 2014;18(4):923-30. http://www.dx.doi.org/10.5935/1415-2762.20140068.
  » https://doi.org/http://www.dx.doi.org/10.5935/1415-2762.20140068
• ²⁰
  Gonçalves FGA, Souza NVDO, Pires AS, Santos DM, Oliveira CAFB, Ribeiro LV. Modelo neoliberal e suas implicações para a saúde do trabalhador de enfermagem. Rev. Enferm. UERJ [Internet]. 2014; [citado 2020 abr 3];22(4):519-25. Disponível em: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/15395/11646
  » https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/15395/11646
• ²¹
  Arcanho RVG, Chistovan BP, Braga ALS, Silvino ZR. Management of occupational risks of nursing in primary health care: a descriptive exploratory study. J. Res. Fundam. Care. 2018;10(2):351-7. http://www.dx.doi.org/10.9789/2175-5361.2018.v10i2.351-357.
  » https://doi.org/http://www.dx.doi.org/10.9789/2175-5361.2018.v10i2.351-357
• ²²
  Santos JNMO, De La Longuiniere ACF, Vieira SNS, Amaral APS, Sanches GJC, Vilela ABA. Estresse ocupacional: exposição da equipe de enfermagem de uma unidade de emergência. J. Res. Fundam. Care. 2019;11:455-63. http://www.dx.doi.org/10.9789/2175-531.2019.v11i2.455-463.
  » https://doi.org/http://www.dx.doi.org/10.9789/2175-531.2019.v11i2.455-463
• ²³
  Oliveira AC, Garcia PC, Nogueira LS. Nursing workload and occurrence of adverse events in intensive care: a systematic review. Rev Esc Enferm USP. 2016;50(4):683-94. http://dx.doi.org/10.1590/S0080-623420160000500020 PMid:27680056.
  » http://dx.doi.org/10.1590/S0080-623420160000500020
• ²⁴
  Andolhe R, Barbosa RL, Oliveira EM, Costa ALS, Padilha KG. Estresse, coping e burnout da equipe de enfermagem de unidades de terapia intensiva: fatores associados. Rev Esc Enferm USP. 2015;49(spe):57-63. http://dx.doi.org/10.1590/S0080-623420150000700009
  » http://dx.doi.org/10.1590/S0080-623420150000700009
• ²⁵
  Conselho Federal de Enfermagem. Cofen vai à Justiça contra a Medida Provisória 927 [Internet]. 2020 [citado 2020 abr 31]. Disponível em: http://www.cofen.gov.br/cofen-vai-a-justica-contra-medida-provisoria-927_78489.html
  » http://www.cofen.gov.br/cofen-vai-a-justica-contra-medida-provisoria-927_78489.html
• ²⁶
  Ministério da Saúde (BR), Secretaria de Atenção Primária à Saúde, Departamento de Saúde da Família, Coordenação-Geral de Garantia dos Atributos da Atenção Primária. Nota Informativa nº 3/2020-CGGAP/DESF/SAPS/MS [Internet]. Brasília; 2020 [citado 2020 abr 27]. Disponível em: https://www.saude.gov.br/images/pdf/2020/April/04/1586014047102-Nota-Informativa.pdf
  » https://www.saude.gov.br/images/pdf/2020/April/04/1586014047102-Nota-Informativa.pdf
• ²⁷
  Darlenski R, Tsankov N. Covid-19 pandemic and the skin: what should dermatologists know? Clin Dermatol. 2020. No prelo. http://dx.doi.org/10.1016/j.clindermatol.2020.03.012
  » http://dx.doi.org/10.1016/j.clindermatol.2020.03.012
• ²⁸
  Resolução COFEN nº 564, de 6 de novembro de 2017 (BR). Aprova o novo Código de Ética dos Profissionais de Enfermagem. Diário Oficial da União [periódico na internet], Brasília (DF), 06 dez 2017 [citado 2020 abr 25]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-5642017_59145.html
  » http://www.cofen.gov.br/resolucao-cofen-no-5642017_59145.html
• ²⁹
  Sarlet IW. Dignidade da pessoa humana e direitos fundamentais: na Constituição Federal de 1988. 10ª ed. Porto Alegre: Livraria do Advogado; 2015.

Edited by

ASSOCIATE EDITOR Antonio Jose Almeida Filho

Publication Dates

• Publication in this collection
  12 Aug 2020
• Date of issue
  2020

History

• Received
  06 May 2020
• Accepted
  25 May 2020