Acessibilidade / Reportar erro

Death and Resistance: Professionals on the Front Line Against COVID-19

Morte e Resistência: Profissionais na Linha de Frente Contra a Covid-19

Muerte y Resistencia: Profesionales de Primera Línea Contra el Covid-19

Abstract

The COVID-19 pandemic has intensely affected the quality of life and labor conditions of healthcare workers (HCWs). This study sought to understand the experiences of 16 professionals in medicine, nursing and physical therapy who work on the “frontline” of the new Coronavirus. A phenomenological design was used. Results were organized into four axes: (a) the impact of the arrival of the pandemic; (b) participants’ progressive exhaustion; (c) fear and coping; and (d) rethinking life and death. Experiences of anguish, anxiety, depression, and physical and psychological health problems stand out. It was possible to observe that the lack of national coordination, in addition to unscientific political positions, were felt as an aggravating factor for work demands, and that impotence in the face of the disease implicated in rethinking the meaning of life and death. According to the JD-R model, the need to expand resources and emotional support so HCWs can properly manage psychosocial risk factors at work is evident.

Keywords:
occupational health; stress; public health; hospital administration; phenomenology

Resumo

A pandemia vem afetando intensamente a qualidade de vida e condições laborais dos trabalhadores da saúde (TS). Este estudo teve por objetivo compreender as vivências de 16 profissionais da medicina, enfermagem e fisioterapia que atuam na “linha de frente” do novo coronavírus. Empregou-se desenho fenomenológico. Os resultados foram organizados em quatro eixos: (a) o impacto da chegada; (b) desgaste progressivo; (c) medo e enfrentamento e (d) repensando a morte e a vida. Destacam-se vivências de angústia, ansiedade, depressão, agravos à saúde física e psicológica. Foi possível observar que a falta de coordenação nacional somada a posicionamentos políticos anticientíficos foi sentida como agravante das demandas laborais e que a impotência diante da doença implicou repensar o sentido da vida e da morte. Com base no modelo JD-R, fica evidente a necessidade de ampliar recursos e suporte emocional aos TS a fim de administrar adequadamente os Fatores Psicossociais de Risco no Trabalho.

Palavras-chave:
saúde ocupacional; stress; saúde pública; administração hospitalar; fenomenologia

Resumen

La pandemia ha afectado intensamente la calidad de vida y condiciones laborales de los trabajadores de la salud (TS). Este estudio buscó conocer experiencias de 16 profesionales de medicina, enfermería y fisioterapia que trabajan en la “primera línea” del nuevo coronavirus. Se utilizó diseño fenomenológico. Los resultados se organizaron en: (a) el impacto de la llegada; (b) desgaste progresivo; (c) miedo y confrontación; y (d) repensar la muerte y la vida. Se destacan experiencias de angustia, ansiedad, depresión, problemas de salud física y psicológica. Se observó que la falta de coordinación nacional, sumada a posiciones políticas acientíficas, fue un agravante de demandas laborales y que la impotencia frente a la enfermedad implicaba repensar el sentido de la vida y la muerte. Desde el modelo JD-R, es evidente la necesidad de ampliar recursos y apoyo emocional a los TS para gestionar adecuadamente los Factores de Riesgo Psicosocial en el Trabajo.

Palabras clave:
salud ocupacional; estrés; salud pública; administración hospitalaria; fenomenología

The new Coronavirus pandemic has profoundly affected the world of work, impacting millions of people globally. Amidst an unprecedented health crisis and its subsequent social and economic impacts, healthcare workers (HCWs) require special attention due to both their proximity to the large number of patients, family members or co-workers’ cases and deaths and the significant changes to their lives and personal well-being.

Among possible tools to understand this phenomenon, Psychosociology of Work (Borges, Barbosa, & Guimarães, 2021Borges, L. O., Barbosa, S. C., & Guimarães, L. A. M. (Orgs.). (2021). Psicossociologia do Trabalho: Temas contemporâneos [Psychosociology of work: Contemporary themes]. Curitiba, PR: CRV.) and the job demands-resources model (JD-R) (Bakker & Demerouti, 2007Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
https://doi.org/10.1108/0268394071073311...
) guide this study. Psychosociology of Work analyzes psychosocial risk factors at work (PRFW), which encompass work content, load and rhythm, schedule, control, environment, equipment, organizational culture, interpersonal relationships, clarity of roles, career, and home-work interface (Leka & Cox, 2008Leka, S., & Cox. T. (Eds.). (2008). PRIMA-EF: Guidance on the European framework for psychological risk management: A resource for employers and worker representatives. Geneva, Switzerland: WHO. Retrieved from https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
https://www.who.int/occupational_health/...
). On the other hand, via the JD-R model, one can understand the quality of the relation between work demands, resources, and their respective outcomes, and how they compromise health services when unbalanced or engage them when appropriate.

Bakker and Demerouti (2007Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
https://doi.org/10.1108/0268394071073311...
) claim that work demands encompass physical, psychological, social, and organizational factors, whereas, considering these dimensions, work resources relate to what can be functional in achieving work objectives. Mojtahedzadeh, Wirth, Nienhaus, Harth, and Mache (2021Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
https://doi.org/10.3390/ijerph18073684...
) found that, amidst the pandemic, German outpatient caregivers’ main demands related to work organization and quantity, tools, tasks, environment, and social and emotional relationships. In turn, the authors found team spirit, communication, information, and recognition to be important work resources.

The first cases of contamination by the new Coronavirus appeared in China at the end of 2019 and, by the beginning of 2020, the disease had not yet spread around the world. In March 2020, however, while the World Health Organization - WHO attested to a global pandemic, COVID-19 caused its first fatality in São Paulo, Brazil. Contagion rates and adoption of sanitary measures, especially social isolation, varied across countries. This scenario included an infodemic marked by a profusion of information which merged reliable sources, fake news, materials of varied quality, and efforts to synthesize technical references, such as the guide organized by the Pan American Health Organization [PAHO] (2020Organização Pan-Americana da Saúde. (2020). Entenda a infodemia e a desinformação na luta contra a COVID-19 [Understand infodemia and misinformation in the fight against COVID-19]. Washington, DC: Author. Retrieved from https://iris.paho.org/handle/10665.2/52054
https://iris.paho.org/handle/10665.2/520...
).

Thus, problems related to work balance - personal life, economic stressors, work overload, and HCWs’ emotional demands became even more pronounced, even though they began to gain greater social prestige and be applauded in many cities (Rigotti et al., 2021Rigotti, T., Yang, L. Q., Jiang, Z., Newman, A., De Cuyper, N., & Sekiguchi, T. (2021). Work-related psychosocial risk factors and coping resources during the COVID-19 crisis. Applied Psychology, 70(1), 3-15. doi: 10.1111/apps.12307
https://doi.org/10.1111/apps.12307...
). In Brazil, pandemic management is entangled with political issues that led to three health ministers being replaced during the first year of the pandemic. The first two were physicians who diverged from government stances which defended early treatment and repeatedly attacked scientific institutions (Fernandes, Oliveira, Campos, & Coimbra, 2020Fernandes, C. M., Oliveira, L. A., Campos, M. M., & Coimbra, M. R. (2020). A pós-verdade em tempos de Covid 19: O negacionismo no discurso de Jair Bolsonaro no Instagram [The post-truth in Covid-19 times: The negationism in the government’s speech on Instagram]. Liinc Em Revista, 16(2), e5317. doi: 10.18617/liinc.v16i2.5317
https://doi.org/10.18617/liinc.v16i2.531...
).

In response to the restriction of federal data on the evolution of COVID-19, professionals from six media outlets organized a consortium to disseminate daily balances to the population. Teixeira et al. (2020Teixeira, C. F. S., Soares, C. M., Souza, E. A., Lisboa, E. S., Pinto, I. C. M., Andrade, L. R., & Espiridião, M. A. (2020). The health of healthcare professionals coping with the Covid-19 pandemic. Ciência & Saúde Coletiva, 25(9), 3465-3474. doi: 10.1590/1413-81232020259.19562020
https://doi.org/10.1590/1413-81232020259...
) warn of damage risks to HCWs’ quality of life due to a permanent crisis caused by neoliberal practices and the dismantling of the SUS (the Brazilian Unified Health System) by lack of investments.

The effects of the pandemic have been extensively researched around the world, including those impacting healthcare workers. The literature shows a prevalence of acute stress disorder, anxiety, burnout, depression, and post-traumatic stress disorder - PTSD among this population (Arafa, Mohammed, Mahmoud, Elshazley, & Ewis, 2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
; Ardebili et al., 2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
; Bennett, Noble, Johnston, Jones, & Hunter, 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
; Britt et al., 2021Britt, T. W., Shuffler, M. L., Pegram, R. L., Xoxakos, P., Rosopa, P. J., Hirsh, E., & Jackson, W. (2021). Job demands and resources among healthcare professionals during virus pandemics: A review and examination of fluctuations in mental health strain during COVID-19. Applied Psychology, 70(1), 120-149. doi: 10.1111/apps.12304
https://doi.org/10.1111/apps.12304...
; Buselli et al., 2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
; Duarte et al., 2020Duarte, I., Teixeira, A., Castro, L., Marina, S., Ribeiro, C., Jácome, C., ... Serrão, C. (2020). Burnout among Portuguese healthcare workers during the COVID-19 pandemic. BMC Public Health, 20(1), 1885. doi: 10.1186/s12889-020-09980-z
https://doi.org/10.1186/s12889-020-09980...
; Franklin & Gkiouleka, 2021Franklin, P., & Gkiouleka, A. (2021). A scoping review of psychosocial risks to health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(5), 2453. doi: 10.3390/ijerph18052453
https://doi.org/10.3390/ijerph18052453...
; Giménez-Espert, Prado-Gascó, & Soto-Rubio, 2020; Liu et al., 2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
; Mojtahedzadeh et al., 2021Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
https://doi.org/10.3390/ijerph18073684...
; Prescott et al., 2020Prescott, K., Baxter, E., Lynch, C., Jassal, S., Bashir, A., & Gray, J. (2020). COVID-19: How prepared are front line healthcare workers in England? Journal of Hospital Infection, 105(2), 142-145. doi: 10.1016/j.jhin.2020.04.031
https://doi.org/10.1016/j.jhin.2020.04.0...
; Sheraton et al., 2020Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
https://doi.org/10.1016/j.psychres.2020....
; Zhang et al., 2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
).

These conditions are associated with lack of social support and occupational risks, such as working in environments with a high risk of contagion and lack of specialized training, for example. Sheraton et al. (2020Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
https://doi.org/10.1016/j.psychres.2020....
) found anxiety, depression, occupational stress, PTSD, and insomnia among healthcare providers, the latter being more significant in them than in workers of other fields. Franklin and Gkiouleka (2021Franklin, P., & Gkiouleka, A. (2021). A scoping review of psychosocial risks to health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(5), 2453. doi: 10.3390/ijerph18052453
https://doi.org/10.3390/ijerph18052453...
) were even more specific, defining four sources of psychosocial risks, namely: (a) personal protective equipment - PPE; (b) job content; (c) work organization, and (d) social context. Based on the JD-R model, Britt et al. (2021Britt, T. W., Shuffler, M. L., Pegram, R. L., Xoxakos, P., Rosopa, P. J., Hirsh, E., & Jackson, W. (2021). Job demands and resources among healthcare professionals during virus pandemics: A review and examination of fluctuations in mental health strain during COVID-19. Applied Psychology, 70(1), 120-149. doi: 10.1111/apps.12304
https://doi.org/10.1111/apps.12304...
) consider that COVID-19 may be aggravating systemic problems in the American health system which HCW teams could more easily manage in situations without a pandemic.

Buselli et al. (2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
), in a study with 265 HCWs from a hospital in Italy, found higher levels of secondary trauma in women and an association between these levels, burnout, and professional or personal variables with depression or anxiety. Arafa et al. (2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
) found symptoms of depression, anxiety, stress, and sleep problems in a population of 426 HCWs from Egypt and Saudi Arabia. Aggravating factors include watching or reading the news on COVID-19 for more than two hours, working in shifts, and lacking social support. Duarte et al. (2020Duarte, I., Teixeira, A., Castro, L., Marina, S., Ribeiro, C., Jácome, C., ... Serrão, C. (2020). Burnout among Portuguese healthcare workers during the COVID-19 pandemic. BMC Public Health, 20(1), 1885. doi: 10.1186/s12889-020-09980-z
https://doi.org/10.1186/s12889-020-09980...
) found, in a 2008 sample of Portuguese HCWs, that health problems and direct contact with infected patients were significantly associated with the possibility of burnout.

Giménez-Espert et al. (2020Giménez-Espert, M. C., Prado-Gascó, V., & Soto-Rubio, A. (2020). Psychosocial risks, work engagement, and job satisfaction of nurses during COVID-19 pandemic. Frontiers in Public Health, 8, 566896. doi: 10.3389/fpubh.2020.566896
https://doi.org/10.3389/fpubh.2020.56689...
) observed that the most prominent risk factors among 92 nurses from hospitals in Valencia, Spain relate to emotional work and work load. In England, a survey with 158 HCWs shows that they recognize the efforts the hospitals in which they work make to provide relevant information based on the English public health agency and the WHO, but still felt unsafe when collecting and handling diagnostic samples (Prescott et al., 2020Prescott, K., Baxter, E., Lynch, C., Jassal, S., Bashir, A., & Gray, J. (2020). COVID-19: How prepared are front line healthcare workers in England? Journal of Hospital Infection, 105(2), 142-145. doi: 10.1016/j.jhin.2020.04.031
https://doi.org/10.1016/j.jhin.2020.04.0...
).

Zhang et al. (2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
) found that, in addition to greater experience relating to less tiredness, HCWs feared contracting the virus and transmitting it to family members, and felt discomfort with PPE. Work overload, however, can increase the risk of contamination. In a study by Mojtahedzadeh et al. (2021Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
https://doi.org/10.3390/ijerph18073684...
), German outpatient caregivers showed depressive symptoms and feelings of stress due to the imbalance between work demands and resources which were impacted by the characteristics of the pandemic.

Supported by an anonymous email address, 54 UK HCWs shared testimonials that were organized into four thematic groups: (a) shock of the virus; (b) team sacrifice and dedication; (c) collateral damage ranging from personal health concerns to the long-term impact on, and care of, discharged patients; and (d) a hierarchy of power and inequality within the healthcare system (NHS) (Bennett et al., 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
). Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
) conducted interviews with nine nurses and four Chinese physicians whose content analysis produced the following categories: (a) responsibility for patients/“my mission”; (b) challenges of Coronavirus wards; and (c) resilience.

Thematic analysis of interviews conducted with 97 Iranian HCWs found: (a) working in the pandemic era; (b) changes in personal life and enhanced negative affect; (c) gaining experience, normalization and adaptation to the pandemic; and (d) mental health considerations. Thus, the authors could analyze how HCWs’ psychological suffering progressed along the stages of their exposure to the pandemic (Ardebili et al., 2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
).

Pandemics, such as the COVID-19 one, involve a dramatic number of deaths: almost four million around the world; of which, more than 500,000 took place in Brazil by the end of the first half of 2021. Death is an existential theme that has gained new relevance in people’s everyday lives since it became a daily topic in news reports around the world, drawing attention not only for its statistics but also for how it began to happen. According to Coe (2019Coe, C. (2019). Meaningful deaths: Home health workers’ mediation of deaths at home. Medical Anthropology, 39(1), 96-108. doi: 10.1080/01459740.2019.1693560
https://doi.org/10.1080/01459740.2019.16...
), for death to take place in a dignified and meaningful manner, it requires care that includes family members, adequate conditions, and professional staff.

However, impositions set by the pandemic generated challenges that prevent HCWs from caring for ill and dying patients as they would like, at least at first. The suffering Benn (2017Benn, A. (2017). Dealing with death. Australian Nursing & Midwifery Journal, 24(7), 27.) described illustrates nursing professionals’ desire to humanely deal with this process. Thus, coping strategies (Granek, Barrera, Scheinemann, & Bartels, 2016Granek, L., Barrera, M., Scheinemann, K., & Bartels, U. (2016). Pediatric oncologists’ coping strategies for dealing with patient death. Journal of Psychosocial Oncology, 34(1-2), 39-59. doi: 10.1080/07347332.2015.1127306
https://doi.org/10.1080/07347332.2015.11...
) and the need for psychological support for HCWs (Schmidt, Crepaldi, Bolze, Neiva-Silva, & Demenech, 2020Schmidt, B., Crepaldi, M. A., Bolze, S. D. A., Neiva-Silva, L., & Demenech, L. M. (2020). Saúde mental e intervenções psicológicas diante da pandemia do novo coronavírus (COVID-19) [Mental health and psychological interventions during the new coronavirus pandemic (COVID-19)]. Estudos de Psicologia (Campinas), 37, e200063. doi: 10.1590/1982-0275202037e200063
https://doi.org/10.1590/1982-0275202037e...
) are even more relevant now.

As it is constituted, the context of the pandemic becomes even more complex and ambiguous regarding the control and management of the disease due to the scarcity of references that enable the analysis of phenomena of similar magnitude. Since labor demands specifically arising from the pandemic need to be managed (Bakker & Demerouti, 2007Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
https://doi.org/10.1108/0268394071073311...
; Mojtahedzadeh et al., 2021Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
https://doi.org/10.3390/ijerph18073684...
), the relevance of this study stems from the risk of damage to HCWs’ health and quality of life, a group that has experienced the imbalance between high work demands and low resources for more than a year. Thus, this study aimed to understand the experiences of 16 medicine, nursing, and physical therapy professionals who work in the “front line” of the new Coronavirus.

Method

In this to understand the nature of a phenomenon. Via our intersubjective relationship with them, the patterns and meanings of participants’ experiences were identified by this co-creation qualitative and exploratory study, comprehensive narratives were written so we could grasp healthcare workers’ experiences. This is a Husserlian phenomenological investigation that aims process. Originally, the resource comprises dialogical meetings between researchers and participants, in a climate of empathy and openness, which were initiated by a guiding question. As interaction is emphasized as the source of knowledge, we purposely did not record the interviews (Brisola, Cury, & Davidson, 2017Brisola, E. B. V., Cury, V. E., & Davidson, L. (2017). Building comprehensive narratives from dialogical encounters: A path in search of meanings. Estudos de Psicologia (Campinas), 34(4), 467-475. doi: 10.1590/1982-02752017000400003
https://doi.org/10.1590/1982-02752017000...
). Their narrative content was individually shown to participants to ensure that their meaning was properly understood.

Participants

Our group consisted of a convenience sample of healthcare providers who work in the two hospitals surveyed. It consists of four physicians, four nurses, four nursing technicians, and four physical therapists, 56% of which were female (n = 9), aged between 25 and 51 years (M = 37.9), with an average work experience ranging from 1.2 to 25 years (M = 12.3). Regarding marital status, 69% were either married, in common-law marriages or widowed (N = 11), and most (90%) had children.

Procedures

Research in the hospitals took place at different times due to the approval periods of the respective Ethics Committees on Research with Human Beings of the Universidade Católica Dom Bosco and of the Pontifícia Universidade Católica de Campinas. Dialogical meetings were held between October 2020 and January 2021 at the hospital in the state of Mato Grosso do Sul and between January and May 2021 at the one in the state of São Paulo. Contact was made via email or WhatsApp and, as a rule, meetings had to be rescheduled many times before they could actually take place due to participants’ work overload.

Data collection. In total, 16 individual dialogical meetings were held by videoconferencing (via Google Meet or WhatsApp video calls), lasting, on average, for one hour. After participants understood the ethical and technical aspects of our research, the following question was asked: “How is working amidst the COVID-19 pandemic?” Following participants’ answers, new questions were asked so their experiences could be better understood. At the end of the meetings, participants were asked to choose a pseudonym, i.e., “something or someone who represents you in relation to this theme.” What their experiences meant was also explored, contributing to the general understanding of our research.

Immediately after the meetings, individual first-person narratives were written, in which we aimed to appreciate participants’ experiences by recording their most significant elements. Each narrative was validated by their subject in a second synchronous meeting or asynchronous contact, ensuring bias control and information quality.

Data analysis. Finally, a narrative synthesis describing the structural elements of the phenomenon as a whole was elaborated by a second researcher and validated with the responsible for the meetings to provide another layer of bias control and refine our results.

Ethical Considerations

This study was approved by the Ethics Committees on Research with Human Beings of the Universidade Católica Dom Bosco and of the Pontifícia Universidade Católica de Campinas. Protocols CAAE 33696820.9.0000.5162 and CAAE 36729320.3.0000.5481.

Results and Discussion

To ensure that we understood participants’ experiences, we sought a multidisciplinary group with diverse gender functions and representativeness. Our inclusion criteria were: (a) a healthcare occupation (physicians, nurses, physical therapists, technicians or nursing assistants; and (b) availability to participate in a dialogical meeting during the research period and in a second contact for content validation. Among the 30 potential participants contacted, 16 met our inclusion criteria, as Table 1 shows.

Table 1
Participants’ characterization

The set of individual narratives produced consists of more than 50 pages of content, full of experiences which were often emotionally shared. The researchers read and reread this material in depth to identify the structuring elements of the phenomenon studied (Brisola et al., 2017Brisola, E. B. V., Cury, V. E., & Davidson, L. (2017). Building comprehensive narratives from dialogical encounters: A path in search of meanings. Estudos de Psicologia (Campinas), 34(4), 467-475. doi: 10.1590/1982-02752017000400003
https://doi.org/10.1590/1982-02752017000...
); a strategy similar to the ones in Ardebili et al. (2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
), Bennett et al. (2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
), and Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
).

Thus, the following axes emerged: (a) the impact of the arrival of the pandemic; (b) participants’ progressive exhaustion; (c) fear and coping; and (d) rethinking life and death. In general, regardless of participants’ residence or specialty, their experiences show many common elements. We found no relevant differences between genders, contradicting studies that suggest women began to suffer more from overload (Arafa et al., 2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
; Buselli et al., 2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
).

The impact of the arrival of the pandemic: it looked like a horror movie!

In general, reactions to the guiding question were quite uniform; loaded with expressions such as “challenging!” or “a very tense process,” similar to English physicians and nurses’ experiences of “feeling broken” or “the horror that is COVID-19” (Bennett et al., 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
). After a brief calmness mixed with concern, such as when one observes the change in weather preceding a storm, participants saw the arrival of the pandemic as a battle to which they were summoned, as in Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
). They felt a fearful heroism: “I’ll be useful, I’ll be able to help!” thought one of the physical therapists.

At first, insufficient facilities and equipment, especially PPE, were critical issues that required an immediate reaction from hospitals. Entire wings were created to treat COVID-19, and functions of whole teams were redirected, bothering HCWs. Ardebili et al. (2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
) and Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
) also report that spaces which were not previously reserved to treat infectious diseases were rapidly transformed into COVID wards, and that health teams lacked adequate equipment and felt discomfort with the necessary apparel.

As in Bennett et al. (2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
), our participants were concerned with areas which were left unassisted, such as care for chronic patients or accident victims, for example. This whole scenario significantly worsened psychosocial risk factors at work (Leka & Cox, 2008Leka, S., & Cox. T. (Eds.). (2008). PRIMA-EF: Guidance on the European framework for psychological risk management: A resource for employers and worker representatives. Geneva, Switzerland: WHO. Retrieved from https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
https://www.who.int/occupational_health/...
) because it abruptly and intensely unbalanced the relation between work demands and resources, causing suffering to both HCWs and patients’ relatives. Britt et al. (2021Britt, T. W., Shuffler, M. L., Pegram, R. L., Xoxakos, P., Rosopa, P. J., Hirsh, E., & Jackson, W. (2021). Job demands and resources among healthcare professionals during virus pandemics: A review and examination of fluctuations in mental health strain during COVID-19. Applied Psychology, 70(1), 120-149. doi: 10.1111/apps.12304
https://doi.org/10.1111/apps.12304...
) found that, in epidemics, PPE supply and colleague and institutional support are essential resources to reduce HCWs’ tension.

The high lethality rate of the pandemic, associated with the lack of an effective vaccine during its first year, caused insecurity and exhaustion, even in cases in which HCWs recognized the care taken with the available information (Prescott et al., 2020Prescott, K., Baxter, E., Lynch, C., Jassal, S., Bashir, A., & Gray, J. (2020). COVID-19: How prepared are front line healthcare workers in England? Journal of Hospital Infection, 105(2), 142-145. doi: 10.1016/j.jhin.2020.04.031
https://doi.org/10.1016/j.jhin.2020.04.0...
; Zhang et al., 2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
). One physician reported feeling “as if I had just graduated and in my first residence year,” whereas her colleague stated that “even the simplest things seemed threatening” (Physician).

There were reports of embarrassment among hospital professionals regarding the use of masks since those who wore them were considered overzealous at first. “I’m the only one walking like an astronaut in the hospital! They ask me if I don’t have any faith!” (Nurse). Similarly, both HCWs and one of the hospitals studied showed divergent behavior, in which they refrained from wearing masks to avoid “stressing patients.”

Arafa et al. (2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
) argue that governments and the WHO should make a greater effort to promote adequate information and curb the dissemination of incorrect content about COVID-19 on social media and television. However, the opposite took place in Brazil. Lack of accurate and adequate information exacerbated tensions in our health team, and the news published by the media “caused more apprehension than guidance,” according to one of the physicians we heard, showing evidence of the deleterious effects of the infodemic.

Note that guides such as the one published by PAHO (2020Organização Pan-Americana da Saúde. (2020). Entenda a infodemia e a desinformação na luta contra a COVID-19 [Understand infodemia and misinformation in the fight against COVID-19]. Washington, DC: Author. Retrieved from https://iris.paho.org/handle/10665.2/52054
https://iris.paho.org/handle/10665.2/520...
) were yet unavailable at the time, and the Brazilian President had repeatedly criticized social distancing and the isolation measures adopted by governors, which he deemed “exaggerated” (Fernandes et al., 2020Fernandes, C. M., Oliveira, L. A., Campos, M. M., & Coimbra, M. R. (2020). A pós-verdade em tempos de Covid 19: O negacionismo no discurso de Jair Bolsonaro no Instagram [The post-truth in Covid-19 times: The negationism in the government’s speech on Instagram]. Liinc Em Revista, 16(2), e5317. doi: 10.18617/liinc.v16i2.5317
https://doi.org/10.18617/liinc.v16i2.531...
). One nurse stated that she felt like “an inadequately used tool,” and a nursing technician found that “results only improved when the hospital began to adopt its own conduct protocol, irrespective of Ministry of Health recommendations,” which is very serious.

A physician expressed feeling sorry for rulers, because “no one knew what to do then.” Others, however, were more critical in their comments, especially on the politicization of the disease, and lack of support and federal articulation. This type of discomfort is consistent with the outburst of a British nurse who stated that “the government failed us all” (Bennett, 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
p. 5) and the criticism in Teixeira et al. (2020Teixeira, C. F. S., Soares, C. M., Souza, E. A., Lisboa, E. S., Pinto, I. C. M., Andrade, L. R., & Espiridião, M. A. (2020). The health of healthcare professionals coping with the Covid-19 pandemic. Ciência & Saúde Coletiva, 25(9), 3465-3474. doi: 10.1590/1413-81232020259.19562020
https://doi.org/10.1590/1413-81232020259...
). Public health policies and national decision-making are contextual collective factors which can directly affect risk perception and exhaust resources to cope with work demands.

Progressive exhaustion: I cannot stand beating a dead horse anymore!

Their feeling of heroism gradually gave way to frustration and tiredness. Experiences began to have a chronic character, especially regarding exhaustion, consistent with the progression described by Ardebili et al. (2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
), which ranged, in the early stages of exposure, from fear, anxiety and a feeling of loss of control to long-term results such as depression and PTSD.

Since our meetings took place between the end of the second and the beginning of the third semester of the pandemic, they seem aligned with the crisis peak and with symptoms of helplessness, hopelessness, and depression. One physical therapist vented: “I can’t stand beating a dead horse anymore” and one physician said, “Then, I stuff myself with antidepressants and I don’t know when and if this is going to end.” In addition to psychological suffering, these statements reflect a concern for the future, which Ardebili et al. (2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
) also observed.

In general, participants reported that their insecurity and anxiety gradually decreased: “I was alert 24 hours a day, always tense” (Nurse), and were replaced by exhaustion: “The next day is the same thing... I come home exhausted” (Physician). To mitigate these kinds of effects, Britt et al. (2021Britt, T. W., Shuffler, M. L., Pegram, R. L., Xoxakos, P., Rosopa, P. J., Hirsh, E., & Jackson, W. (2021). Job demands and resources among healthcare professionals during virus pandemics: A review and examination of fluctuations in mental health strain during COVID-19. Applied Psychology, 70(1), 120-149. doi: 10.1111/apps.12304
https://doi.org/10.1111/apps.12304...
) highlight the need to understand which work resources and demands are at stake to protect HCWs, in line with the models in Bakker and Demerouti (2007Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
https://doi.org/10.1108/0268394071073311...
), Borges et al. (2021Borges, L. O., Barbosa, S. C., & Guimarães, L. A. M. (Orgs.). (2021). Psicossociologia do Trabalho: Temas contemporâneos [Psychosociology of work: Contemporary themes]. Curitiba, PR: CRV.), and Leka and Cox (2008Leka, S., & Cox. T. (Eds.). (2008). PRIMA-EF: Guidance on the European framework for psychological risk management: A resource for employers and worker representatives. Geneva, Switzerland: WHO. Retrieved from https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
https://www.who.int/occupational_health/...
).

Guilt, irritability, stress, impotence, anguish, anxiety, and extreme tiredness were also frequently cited. Results which agree with the findings of systematic reviews (Franklin & Gkiouleka, 2020Franklin, P., & Gkiouleka, A. (2021). A scoping review of psychosocial risks to health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(5), 2453. doi: 10.3390/ijerph18052453
https://doi.org/10.3390/ijerph18052453...
; Sheraton et al., 2020Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
https://doi.org/10.1016/j.psychres.2020....
) and of empirical studies (Arafa et al., 2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
; Ardebili et al., 2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
; Buselli et al., 2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
; Duarte et al., 2020Duarte, I., Teixeira, A., Castro, L., Marina, S., Ribeiro, C., Jácome, C., ... Serrão, C. (2020). Burnout among Portuguese healthcare workers during the COVID-19 pandemic. BMC Public Health, 20(1), 1885. doi: 10.1186/s12889-020-09980-z
https://doi.org/10.1186/s12889-020-09980...
; Liu et al., 2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
).

Schmidt et al. (2020Schmidt, B., Crepaldi, M. A., Bolze, S. D. A., Neiva-Silva, L., & Demenech, L. M. (2020). Saúde mental e intervenções psicológicas diante da pandemia do novo coronavírus (COVID-19) [Mental health and psychological interventions during the new coronavirus pandemic (COVID-19)]. Estudos de Psicologia (Campinas), 37, e200063. doi: 10.1590/1982-0275202037e200063
https://doi.org/10.1590/1982-0275202037e...
) and Teixeira et al. (2020Teixeira, C. F. S., Soares, C. M., Souza, E. A., Lisboa, E. S., Pinto, I. C. M., Andrade, L. R., & Espiridião, M. A. (2020). The health of healthcare professionals coping with the Covid-19 pandemic. Ciência & Saúde Coletiva, 25(9), 3465-3474. doi: 10.1590/1413-81232020259.19562020
https://doi.org/10.1590/1413-81232020259...
) express concern about this type of suffering in HCWs and highlight the importance of offering resources for adequate care. According to Zhang et al. (2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
), professionals with greater overburden tend to wash their hands less often, raising contagion risks, which, in this case, may be lethal.

Most participants expressed discomfort and indignation with how a portion of society showed lack of care by participating in agglomerations or refusing to wear masks. For example: “they are not aware, they do not live what we live... I’m more intolerant of people” (Physical therapist). The lack of a clear position by Brazilian authorities (Fernandes et al., 2020Fernandes, C. M., Oliveira, L. A., Campos, M. M., & Coimbra, M. R. (2020). A pós-verdade em tempos de Covid 19: O negacionismo no discurso de Jair Bolsonaro no Instagram [The post-truth in Covid-19 times: The negationism in the government’s speech on Instagram]. Liinc Em Revista, 16(2), e5317. doi: 10.18617/liinc.v16i2.5317
https://doi.org/10.18617/liinc.v16i2.531...
) and the possible frustration of participants’ sense of self-sacrifice seem to relate to these occurrences, as Ardebili et al. (2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
) also observed. On the other hand, studies show HCWs perceived greater social recognition, an attenuating factor for psychological suffering (Buselli et al., 2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
; Rigotti et al., 2021Rigotti, T., Yang, L. Q., Jiang, Z., Newman, A., De Cuyper, N., & Sekiguchi, T. (2021). Work-related psychosocial risk factors and coping resources during the COVID-19 crisis. Applied Psychology, 70(1), 3-15. doi: 10.1111/apps.12307
https://doi.org/10.1111/apps.12307...
).

Participants also considered medium and long-term effects: “I worry about the chronic stress that will arise from this” (Nurse) and “it will leave a scar” (Physician). Buselli et al. (2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
) and Franklin and Gkiouleka (2021Franklin, P., & Gkiouleka, A. (2021). A scoping review of psychosocial risks to health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(5), 2453. doi: 10.3390/ijerph18052453
https://doi.org/10.3390/ijerph18052453...
) consider such impacts and recommend immediate interventions to promote the resilience of health teams and systems.

Participants reported leaves of absence due to COVID-19 contamination or stress. One of them considered stop working for some time; another, upon returning from post-contamination leave, said: “I panicked! I freaked out!” (Physician). These situations reinforce warnings by Schmidt et al. (2020Schmidt, B., Crepaldi, M. A., Bolze, S. D. A., Neiva-Silva, L., & Demenech, L. M. (2020). Saúde mental e intervenções psicológicas diante da pandemia do novo coronavírus (COVID-19) [Mental health and psychological interventions during the new coronavirus pandemic (COVID-19)]. Estudos de Psicologia (Campinas), 37, e200063. doi: 10.1590/1982-0275202037e200063
https://doi.org/10.1590/1982-0275202037e...
) and Teixeira et al. (2020Teixeira, C. F. S., Soares, C. M., Souza, E. A., Lisboa, E. S., Pinto, I. C. M., Andrade, L. R., & Espiridião, M. A. (2020). The health of healthcare professionals coping with the Covid-19 pandemic. Ciência & Saúde Coletiva, 25(9), 3465-3474. doi: 10.1590/1413-81232020259.19562020
https://doi.org/10.1590/1413-81232020259...
) of the need to care for HCW teams.

Fear and coping

Among the elements that emerged in our meetings, the most intense and unanimous one was fear of contracting COVID-19 and contaminating family members, as several international studies also show (Arafa et al., 2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
; Ardebili et al., 2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
; Bennett et al., 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
; Buselli et al., 2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
; Duarte et al., 2020Duarte, I., Teixeira, A., Castro, L., Marina, S., Ribeiro, C., Jácome, C., ... Serrão, C. (2020). Burnout among Portuguese healthcare workers during the COVID-19 pandemic. BMC Public Health, 20(1), 1885. doi: 10.1186/s12889-020-09980-z
https://doi.org/10.1186/s12889-020-09980...
; Liu et al., 2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
; Zhang et al., 2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
). A nursing assistant hid among the plants in his backyard and used a garden hose to bathe before entering his home. A nursing technician, infected with COVID-19, had to stay away from her family for a month and a half, whereas a nurse rented an apartment in which she lived alone.

The wife of one of the physicians in our sample moved to another city with their daughter for more than a year: “I didn’t see my daughter’s tooth erupt,” he laments. An English physician reported a similar situation, claiming it had a huge impact on his life (Bennett et al., 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
). Two physical therapists who were contaminated expressed great relief over supposedly becoming immune to the disease and thus, unable to transmit it to their loved ones, in line with what an Iranian physician stated: “if we’re going to become infected, it’s better to be early” (Ardebili et al., 2020Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
https://doi.org/10.1016/j.ajic.2020.10.0...
, p. 552).

The same authors also describe participants’ guilt and remorse, such as a nurse who stated that if she had another job, her husband would not have died. Such elements corroborate the considerations of Sheraton et al. (2020Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
https://doi.org/10.1016/j.psychres.2020....
) and Zhang et al. (2020Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
https://doi.org/10.1016/j.jhin.2020.04.0...
). This situation represents a violent impact on their home-work interface, configuring psychosocial risk factors at work of a very important magnitude (Leka & Cox, 2008Leka, S., & Cox. T. (Eds.). (2008). PRIMA-EF: Guidance on the European framework for psychological risk management: A resource for employers and worker representatives. Geneva, Switzerland: WHO. Retrieved from https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
https://www.who.int/occupational_health/...
) for at least two reasons. First, because it shows not only a psychological negative work-home spillover on their families (due to HCWs’ high stress), but also a concrete one (due to the risk of illness and death). The second reason concerns the lack of family support, which acts as an important attenuator for exhaustion, as Arafa et al. (2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
) point out.

Among coping strategies, the most evident one was to try to disconnect from events. Participants avoided watching or coming into contact with the news, which meant creating a space of refuge in their off-duty time. They also sought psychotherapy, support in spirituality, practiced physical activities, and meditated, activities in agreement with Arafa et al. (2020Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
https://doi.org/10.1016/j.jad.2020.09.08...
), Granek et al. (2016Granek, L., Barrera, M., Scheinemann, K., & Bartels, U. (2016). Pediatric oncologists’ coping strategies for dealing with patient death. Journal of Psychosocial Oncology, 34(1-2), 39-59. doi: 10.1080/07347332.2015.1127306
https://doi.org/10.1080/07347332.2015.11...
), and Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
).

The possibility of remote psychological care can be a good alternative in contexts of restrictions and emotional distress such as these (Schmidt et al., 2020Schmidt, B., Crepaldi, M. A., Bolze, S. D. A., Neiva-Silva, L., & Demenech, L. M. (2020). Saúde mental e intervenções psicológicas diante da pandemia do novo coronavírus (COVID-19) [Mental health and psychological interventions during the new coronavirus pandemic (COVID-19)]. Estudos de Psicologia (Campinas), 37, e200063. doi: 10.1590/1982-0275202037e200063
https://doi.org/10.1590/1982-0275202037e...
). When present, experiences of success and recovery were cited as a source of motivation and resilience. Buselli et al. (2020Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
https://doi.org/10.3390/ijerph17176180...
) and Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
) observed the same, with the caveat that participants’ experiences were ambivalent and varied according to patients’ conditions.

Despite a few mentions to specific conflicts, most participants, especially nurses, noticed an increase in team cohesion, as well as an improved multidisciplinary perspective permeated by exchange and dialogue. According to the JD-R model (Bakker & Demerouti, 2007Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
https://doi.org/10.1108/0268394071073311...
), these are examples of resources that enable work to be done, and are in line with the observations in Mojtahedzadeh et al. (2021Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
https://doi.org/10.3390/ijerph18073684...
).

These findings reinforce the adoption of a preventive approach to psychosocial risk management - since this process takes time - in addition to the challenge of integrating professionals used to working with different protocols (Liu et al., 2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
). Giménez-Espert et al. (2020Giménez-Espert, M. C., Prado-Gascó, V., & Soto-Rubio, A. (2020). Psychosocial risks, work engagement, and job satisfaction of nurses during COVID-19 pandemic. Frontiers in Public Health, 8, 566896. doi: 10.3389/fpubh.2020.566896
https://doi.org/10.3389/fpubh.2020.56689...
) and Sheraton et al. (2020Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
https://doi.org/10.1016/j.psychres.2020....
) also value the importance work environments have on the tasks to be performed, especially in an extreme context as such.

Thus, even though death is a recurring theme in hospital scientific literature, the way it has been experienced in this specific context needs to be better understood, as it seems to gain new nuances. In a study by Giménez-Espert et al. (2020) the most evident risk category was emotional work, which implies the effort of having to deal with emotional expression during work. Statements such as “I have to turn cold to keep going and I don’t know if doing that is humane” (Nurse) are an example of this sort of stressful demand.

Rethinking life and death

“When you work in a hospital, life and death go hand in hand,” said a nursing assistant. However, the number of deaths and how they took place led many participants to make an analogy with a battle. This same professional explains that removing corpses began to make up much of his work: “I carry them on my shoulders!” A Chinese nurse, when describing the entire care protocol, which involved wrapping bodies in several layers of clothing, packed into two bags, and sprayed with disinfectant, states: “It is a little hard to accept this form of death” (Liu et al., 2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
). A physician in our sample claims that “living with death is not easy” (Physician), illustrating the statistical data in Giménez-Espert et al. (2020). “It’s distressing... the person ends up dying practically alone” (Nurse).

A physical therapist describes, with deep regret, the desperation of patients who asked her not to let them die: “I say I won’t, but only few survive.” She explains the ethical dilemma of telling the plain truth or trying to comfort patients as best as possible. This type of experience is very close to Benn’s testimony (2017Benn, A. (2017). Dealing with death. Australian Nursing & Midwifery Journal, 24(7), 27.) about her deep suffering in the face of a buildup of deaths in a brief period of time.

Death is part of the life cycle, but providing conditions for it to happen humanely requires care and special preparation. The pandemic harshly imposed a cruel contrast with the proposal in Coe (2019Coe, C. (2019). Meaningful deaths: Home health workers’ mediation of deaths at home. Medical Anthropology, 39(1), 96-108. doi: 10.1080/01459740.2019.1693560
https://doi.org/10.1080/01459740.2019.16...
), which values patients passing away at home, mediated by specialized caregivers at a time of deep alliance. Several participants were very moved by testimonies of loneliness and family distancing at the time of death, a sorrow also described by Bennett et al. (2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
).

Therefore, it is essential to place great emphasis on the approach this theme is to receive in continuous training, team meetings, and development of adequate coping strategies (Granek et al., 2016Granek, L., Barrera, M., Scheinemann, K., & Bartels, U. (2016). Pediatric oncologists’ coping strategies for dealing with patient death. Journal of Psychosocial Oncology, 34(1-2), 39-59. doi: 10.1080/07347332.2015.1127306
https://doi.org/10.1080/07347332.2015.11...
). In this study, participants sought coping strategies, but they are still incipient in the face of such exhaustion and suffering.

As mentioned, participants are already used to living with death due to their professional experience. However, our meetings allowed us to infer that perhaps death was also differently experienced, and in a more stressful manner, because participants saw it as something unnatural, especially in relation to patients’ ages. An indignant nursing technician said: “I see people in their 30s and 40s passing away!,” as did an English physician: “And young people!” (Bennett et al., 2020Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
https://doi.org/10.1136/ bmjopen-2020-04...
, p. 3).

In addition to the age issue, most participants felt the death of friends and team members as a severe blow, often referred to as something very painful, intense and revolting: “When I found out, I started crying” (Physician). A nurse was dismayed by the loss of a friend: “He was fine! He passed away in a week!” The week before, that same person had invited him to a barbecue. These experiences led to reflections about life and the review of personal values: “our time is short... I will not argue with my mother” (Nurse), in line with the findings of Liu et al. (2020Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
https://doi.org/10.1016/s2214-109x(20)30...
p. e796): “I cherish life, because I don’t know when an accident will happen.” “Life is very short and must be enjoyed,” concludes one of the nurses in our sample.

This study aimed to understand the experiences of 16 medical, nursing, and physical therapy professionals working on the “front line” of the new Coronavirus. These experiences enabled us to see how participants reacted to the sudden and unexpected arrival of an unprecedented pandemic. They described the progressive physical and emotional exhaustion they increasingly experienced, permeated by technical difficulties, social clashes, and political uncertainty. In general, participants felt that the population’s lack of guidance was an important burden in the face of an already incredibly challenging scenario.

Fear, especially of infecting loved ones, was very evident, as was the sorrow from being deprived of contact with them. Participants tried to distance themselves from newscasts, and sought psychological care, physical activity, meditation, and spiritual support as strategies to cope with adversity. More intense contact with death, especially of co-workers, made them rethink what life means, and we noted how sensitized they were about the issue.

Our results also corroborate international qualitative studies, in line with experiences recorded in the United Kingdom, China, Iran, and Germany, and are compatible with data from numerous quantitative studies in Portugal, Egypt, Spain, England, China, and Iran. The set of information on different coping strategies is coherent in portraying a global phenomenon.

We should consider the limitations of our methodological design. The content produced is not intended to be generalizable because it does not derive from statistical population samples. However, it comprised a multicenter effort and involved two reputable regional hospitals in different Brazilian regions. Moreover, the careful, balanced, and representative composition of the group of participants ensured the robustness and quality of our findings. Regardless of locality, function or gender, the great affinity between the reported experiences draws our attention even when we compare them with international studies.

Among the main contributions of this study, we can highlight two additional ones. First, it is evident the importance that psychosocial risk factors at work and the respective balance between work demands and resources have on the quality of life of HCWs working in this peculiar context of a pandemic. Second, this study innovates by adopting a phenomenological method to Work Psychology, allowing participants to play a greater role in co-creating scientific knowledge from their intersubjective relationship with researchers.

It is essential to watch over the psychosocial environment of work, understanding it and enabling resources at its different levels: contextual, institutional, group, and individual. Public policies based on scientific knowledge must form the basis of the entire national health system, and cannot be entangled with ideologies or political interests. Information campaigns, definition of protocols, and the acquisition of inputs and vaccines are fundamental resources which need to come from national strategies. Otherwise, the physical and mental health of frontline professionals is put at risk.

At the institutional level, hospitals are responsible for defining care guidelines and protocols, as well as providing their employees with work resources (e.g., protective equipment, training, communication, social support, and leadership). The absence of some factors, such as requiring HCWs to wear masks, was a component that generated conduct ambiguities and stress for participants.

At the group level, the need for social support and strengthening teamwork proved essential. Moreover, amplifying interdisciplinarity, communication, and relevance of the entire team, giving voice to all professionals, proved to be fundamental, since some participants reported not having been heard. Finally, but as important as the other intervention levels, contemplating strategies to strengthen personal resources (e.g., resilience and self-care) becomes essential. Individual or group formal support strategies are support factors which concretely indicate concern with the health and well-being of those who care.

References

  • Arafa, A., Mohammed, Z., Mahmoud, O., Elshazley, M., & Ewis, A. (2020). Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic? Journal of Affective Disorders, 278, 365-371. doi: 10.1016/j.jad.2020.09.080
    » https://doi.org/10.1016/j.jad.2020.09.080
  • Ardebili, D. M. E., Naserbakht, D. M., Bernstein, C., Alazmani-Noodeh, M. F., Hakimi, M. H., & Ranjbar, D. H. (2020). Healthcare providers experience of working during the COVID-19 pandemic: A qualitative study. American Journal of Infection Control, 49(5), 547-554. doi: 10.1016/j.ajic.2020.10.001
    » https://doi.org/10.1016/j.ajic.2020.10.001
  • Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328. doi: 10.1108/02683940710733115
    » https://doi.org/10.1108/02683940710733115
  • Benn, A. (2017). Dealing with death. Australian Nursing & Midwifery Journal, 24(7), 27.
  • Bennett, P., Noble, S., Johnston, S., Jones, D., & Hunter, R. (2020). COVID-19 confessions: A qualitative exploration of healthcare workers experiences of working with COVID-19. BMJ Open, 10(12), e043949. doi: 10.1136/ bmjopen-2020-043949
    » https://doi.org/10.1136/ bmjopen-2020-043949
  • Borges, L. O., Barbosa, S. C., & Guimarães, L. A. M. (Orgs.). (2021). Psicossociologia do Trabalho: Temas contemporâneos [Psychosociology of work: Contemporary themes]. Curitiba, PR: CRV.
  • Brisola, E. B. V., Cury, V. E., & Davidson, L. (2017). Building comprehensive narratives from dialogical encounters: A path in search of meanings. Estudos de Psicologia (Campinas), 34(4), 467-475. doi: 10.1590/1982-02752017000400003
    » https://doi.org/10.1590/1982-02752017000400003
  • Britt, T. W., Shuffler, M. L., Pegram, R. L., Xoxakos, P., Rosopa, P. J., Hirsh, E., & Jackson, W. (2021). Job demands and resources among healthcare professionals during virus pandemics: A review and examination of fluctuations in mental health strain during COVID-19. Applied Psychology, 70(1), 120-149. doi: 10.1111/apps.12304
    » https://doi.org/10.1111/apps.12304
  • Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., ... Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. doi: 10.3390/ijerph17176180
    » https://doi.org/10.3390/ijerph17176180
  • Coe, C. (2019). Meaningful deaths: Home health workers’ mediation of deaths at home. Medical Anthropology, 39(1), 96-108. doi: 10.1080/01459740.2019.1693560
    » https://doi.org/10.1080/01459740.2019.1693560
  • Duarte, I., Teixeira, A., Castro, L., Marina, S., Ribeiro, C., Jácome, C., ... Serrão, C. (2020). Burnout among Portuguese healthcare workers during the COVID-19 pandemic. BMC Public Health, 20(1), 1885. doi: 10.1186/s12889-020-09980-z
    » https://doi.org/10.1186/s12889-020-09980-z
  • Fernandes, C. M., Oliveira, L. A., Campos, M. M., & Coimbra, M. R. (2020). A pós-verdade em tempos de Covid 19: O negacionismo no discurso de Jair Bolsonaro no Instagram [The post-truth in Covid-19 times: The negationism in the government’s speech on Instagram]. Liinc Em Revista, 16(2), e5317. doi: 10.18617/liinc.v16i2.5317
    » https://doi.org/10.18617/liinc.v16i2.5317
  • Franklin, P., & Gkiouleka, A. (2021). A scoping review of psychosocial risks to health workers during the Covid-19 pandemic. International Journal of Environmental Research and Public Health, 18(5), 2453. doi: 10.3390/ijerph18052453
    » https://doi.org/10.3390/ijerph18052453
  • Giménez-Espert, M. C., Prado-Gascó, V., & Soto-Rubio, A. (2020). Psychosocial risks, work engagement, and job satisfaction of nurses during COVID-19 pandemic. Frontiers in Public Health, 8, 566896. doi: 10.3389/fpubh.2020.566896
    » https://doi.org/10.3389/fpubh.2020.566896
  • Granek, L., Barrera, M., Scheinemann, K., & Bartels, U. (2016). Pediatric oncologists’ coping strategies for dealing with patient death. Journal of Psychosocial Oncology, 34(1-2), 39-59. doi: 10.1080/07347332.2015.1127306
    » https://doi.org/10.1080/07347332.2015.1127306
  • Leka, S., & Cox. T. (Eds.). (2008). PRIMA-EF: Guidance on the European framework for psychological risk management: A resource for employers and worker representatives. Geneva, Switzerland: WHO. Retrieved from https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
    » https://www.who.int/occupational_health/publications/PRIMA-EF%20Guidance_9.pdf
  • Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., ... Yang, B. X. (2020). The experiences of health-care providers during the COVID-19 crisis in China: A qualitative study. The Lancet Global Health, 8(6), e790-e798. doi: 10.1016/s2214-109x(20)30204-7
    » https://doi.org/10.1016/s2214-109x(20)30204-7
  • Mojtahedzadeh, N., Wirth, T., Nienhaus, A., Harth, V., & Mache, S. (2021). Job demands, resources and strains of outpatient caregivers during the COVID-19 pandemic in Germany: A qualitative study. International Journal of Environmental Research and Public Health, 18(7), 3684. doi: 10.3390/ijerph18073684
    » https://doi.org/10.3390/ijerph18073684
  • Organização Pan-Americana da Saúde. (2020). Entenda a infodemia e a desinformação na luta contra a COVID-19 [Understand infodemia and misinformation in the fight against COVID-19]. Washington, DC: Author. Retrieved from https://iris.paho.org/handle/10665.2/52054
    » https://iris.paho.org/handle/10665.2/52054
  • Prescott, K., Baxter, E., Lynch, C., Jassal, S., Bashir, A., & Gray, J. (2020). COVID-19: How prepared are front line healthcare workers in England? Journal of Hospital Infection, 105(2), 142-145. doi: 10.1016/j.jhin.2020.04.031
    » https://doi.org/10.1016/j.jhin.2020.04.031
  • Rigotti, T., Yang, L. Q., Jiang, Z., Newman, A., De Cuyper, N., & Sekiguchi, T. (2021). Work-related psychosocial risk factors and coping resources during the COVID-19 crisis. Applied Psychology, 70(1), 3-15. doi: 10.1111/apps.12307
    » https://doi.org/10.1111/apps.12307
  • Schmidt, B., Crepaldi, M. A., Bolze, S. D. A., Neiva-Silva, L., & Demenech, L. M. (2020). Saúde mental e intervenções psicológicas diante da pandemia do novo coronavírus (COVID-19) [Mental health and psychological interventions during the new coronavirus pandemic (COVID-19)]. Estudos de Psicologia (Campinas), 37, e200063. doi: 10.1590/1982-0275202037e200063
    » https://doi.org/10.1590/1982-0275202037e200063
  • Sheraton, M., Deo, N., Dutt, T., Surani, S., Hall-Flavin, D., & Kashyap, R. (2020). Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review. Psychiatry Research, 292, 113360. doi: 10.1016/j.psychres.2020.113360
    » https://doi.org/10.1016/j.psychres.2020.113360
  • Teixeira, C. F. S., Soares, C. M., Souza, E. A., Lisboa, E. S., Pinto, I. C. M., Andrade, L. R., & Espiridião, M. A. (2020). The health of healthcare professionals coping with the Covid-19 pandemic. Ciência & Saúde Coletiva, 25(9), 3465-3474. doi: 10.1590/1413-81232020259.19562020
    » https://doi.org/10.1590/1413-81232020259.19562020
  • Zhang, M., Zhou, M., Tang, F., Wang, Y., Nie, H., Zhang, L., & You, G. (2020). Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. The Journal of Hospital Infection, 105(2), 183-187. doi: 10.1016/j.jhin.2020.04.012
    » https://doi.org/10.1016/j.jhin.2020.04.012

Edited by

Wanderlei Abadio de Oliveira

Publication Dates

  • Publication in this collection
    28 Mar 2022
  • Date of issue
    2022

History

  • Received
    26 July 2021
  • Reviewed
    20 Sept 2021
  • Accepted
    03 Dec 2021
Universidade de São Paulo, Faculdade de Filosofia Ciências e Letras de Ribeirão Preto, Programa de Pós-Graduação em Psicologia Av.Bandeirantes 3900 - Monte Alegre, 14040-901 Ribeirão Preto - São Paulo - Brasil, Tel.: (55 16) 3315-3829 - Ribeirão Preto - SP - Brazil
E-mail: paideia@usp.br