Contents related to nursing professionals during the COVID-19 pandemic on the Youtube TM platform

e20200581 http://dx.doi.org/10.1590/0034-7167-2020-0581 11 of ABSTRACT Objective: to characterize the content of YoutubeTM videos related to nursing professionals during the COVID-19 pandemic. Method: a qualitative study that examined 47 videos on YoutubeTM posted between 11/03 and 11/04 2020, which were subjected to thematic analysis. Results: four categories emerged: “the role of nurses in care production during the pandemic”, which addresses the management of services and individual care; “Overview of the pandemic from the perspective of nurses in different countries”, presenting experiences and encouraging physical distance; “Tributes and motivation to mobilize the category”, in addition to targeted tributes, calls for nurses to claim their rights; “Criticisms and demands to improve working conditions”, which highlights the insecurity of care provision settings. Final considerations: nursing work conditions in different countries, recognition of the importance of professionals during the pandemic, and claims of the category to improve working conditions were the main content found on YoutubeTM. Descriptors: Nursing; Pandemic; Mass Media; Audiovisual Aids; COVID-19.


INTRODUCTION
The COVID-19 pandemic brought great visibility to the performance of health professionals, especially in countries that rapidly reached high numbers of cases of the disease and alarming mortality rates (1)(2)(3) .
Nursing workers (nurses, technicians, and assistants) work at the forefront of this pandemic providing critical care to patients admitted to hospitals and play key roles in collaboration with health surveillance services and with epidemiological research. Nurses, in particular, have been instrumental in educating patients, family members and the general population, especially with regard to measures to prevent and control SARS-CoV-2 infection. They have corrected distorted information about the virus and its transmission (4) , which also lead health work process organization, in protocol development and in pandemic-related health policy management and planning (5) .
Due to the nature of nursing work, which requires very close contact with patients, whether in community, outpatient and hospital settings, occupational risks increase substantially in care provision during the COVID-19 pandemic. This contact threatens not only the physical integrity of workers, but also their psycho-emotional health, which has implied limits for health organizations to respond to the pandemic in an appropriate and safe manner (1,(5)(6)(7)(8) .
In times of physical distancing, the internet has been the most used means of communication for updating data on the overview of the pandemic worldwide. Moreover, it provides access to the opinions of experts and analysts from different areas and, as a result, its ability to disseminate images, build narratives, and discourses on the representations of the pandemic and its leaders.
YouTube™ is a platform for publishing and sharing videos, allowing positive or negative comments and expressions from the people who watch them (9)(10) . With the popularization of smartphones, YouTube™ (10) has become an important health search and education tool (11) , mainly promoted by the live broadcasts used frequently during the pandemic.Thus, through social networks, nursing work has been noticed by the population that is in social isolation, and has mostly received expressions of recognition and applause (12)(13) , justifying the choice of YouTube™as the setting for this study.
Like the Ebola outbreak in 2014 (14) and the Zika virus outbreak (15)(16) in 2016, the videos contained on YouTube™ may contain content that express society's thoughts and positions regarding the current situation; therefore, examining what is published on YouTube™ in the current pandemic context can assist in understanding human behavior during events of great social impact (17)(18) . Therefore, we seek to answer the following research question: how are the contents of YouTube™ videos related to nursing professionals characterized during the CO-VID-19 pandemic?

OBJECTIVE
To characterize the content of Youtube™ videos related to nursing professionals during the COVID-19 pandemic.

Ethical aspects
This research followed the ethical standards of the platform (https:// www.YouTube.com/yt/copyright/pt-BR/fair-use.html.) and recommendations of Resolution 510/2016 of the Brazilian National Health Council (Conselho Nacional de Saúde) and of Federal Law 12.527/2011 (19)(20) . As they are publicly accessible videos and the study does not involve contact of any kind with the characters in the videos or channel owners, it was not necessary to submit to a research ethics committee (21) .

Type of study
This is an exploratory study with a qualitative approach applied to videos posted on YouTube™ (www.youtube.com), carried out between March 11 and April 11, 2020, according to the COREQ tool criteria for qualitative studies.

Study setting
Up to the second day of February, 21,288,856 cumulative video views on COVID-19 in English and Mandarin were recorded on YouTube™, reaffirming the platform's popularity and assuming it as an important virtual space for disseminating information during the pandemic (17) .
Videos that address content related to nursing and COVID-19, posted between March 11 and April 11, 2020, comedy or subtitles in Portuguese or English, and Spanish were included. Videos with audio problems leading to misunderstanding of the reports, with duplicate content, presenting dubious content (fakenews), and containing personal stories that are not narrated by themselves (e.g., reporters) were excluded.

Data collection and organization
Two video search strategies were carried out, first on 12/04/2020 using the tags "nursing, nurse, Covid-19, coronavirus" and then on 4/14/2020 with the tags "nursing, nurse, Covid-19, coronavirus". These terms were entered in the search box available by the platform itself. Next, we assigned filters available on YouTube™to select videos related to the purpose of this study. The filters were: upload date we chose the option this month -period between the WHO pandemic declaration and the data collection start date; type of publication we chose video; presentation of results classified by relevance.
The videos' contents were subjected to veracity verification, as recommended by the British Broadcasting Corporation for verification of "fakenews" (https://www.bbc.com/portuguese/geral-45967195). This system adopts a scoring system of 0, 1 or 2 for each criterion (channel, content and comments), 0 for unreliable/harmful, 1 for doubtful/questionable and 2 for reliable/it looks good. In summary, after adding the score, the videos were classified as unreliable (0 to 2 points), doubtful (3 to 5 points), and reliable (6 points).
The videos found from the first and second searches can be found through the links https://www.youtube.com/results?search _query=enfermagem+nurse+covid-19&sp=CAASBAgEEAE%253D (https://www.youtube.com/results?search_query=enfermagem+ nurse+covid-19&sp=CAASBAgEEAE%253D.Initially, 144 videos were found treated from reading the titles, advanced visualization and of Contents related to nursing professionals during the COVID-19 pandemic on the Youtube™ platform Carvalho ESS, Vale PRLF, Pinto KA, Ferreira SL. veracity verification, resulting in 47 videos in the corpus of study. This stage of data collection and organization was performed by author X (identification omitted) and author Y (identification omitted). The synthesis of the methodological process of corpus constitution is shown in Figure 1.

Data analysis
The 47 videos were organized in an Excel spreadsheet, identified by title, author, posting date, duration and access link. This enabled their access and visualization for analysis. Then each video was analyzed individually and identification of themes, synthesis of its content and categorization (22) . The themes and categories were validated by the researchers/authors, with two postdoctoral professionals (identifications omitted), a PhD (identification omitted) and a PhD student with experience in research on social networks (identification omitted).

RESULTS
The videos listed in Chart 1 had their content characterized from common themes and organized into four categories: "the role of nurses in care production during the pandemic"; "Overview of the pandemic from the perspective of nurses in different countries"; "Tributes and motivation to mobilize the category"; "Criticisms and demands to improve working conditions", represented in Figure2
As a manager in the organization of a university hospital, a nurse details the structuring and preparation for the care of patients with COVID-19, the bed distribution process and constant staff training (28) .The plans to implement services indicate that these are exclusive for receiving patients with COVID-19, involving patient inflows and outflows and staff training in Portugal (28) .
Other videos portray nurses' work routine in Intensive Care Units, highlighting the excess of patients and strategies to reduce the chances of contamination among health professionals (28)(29) . In one of them, a tutorial on dressing and de-dressing is shown, while another presents the hand washing technique (29) .
Part of the videos in this category presents measures adopted to restrict direct contacts between professionals and patients at COVID-19, such as the experiences of separating areas considered "dirty" and "clean" and restrictions on free movement in a hospital in Napoli, Italy (30) ; use of robot nurses to provide simple care such as delivering food and medicines to hospitalized patients (30,35) .
This category also concerns nursing care directed to the population to prevent the virus from spreading, the care adopted by institutions that care for the vulnerable (32,67) , individual care to improve ventilatory conditions (video 9) and spiritual care of professionals working on the front line of the pandemic (25,32) .
Among the measures adopted by a home care company, nurses record environment care, medication transport and those followed by the multidisciplinary staff that provides care to elderly people at home (37) . It is shown the transit of materials taken to patients' homes, an increase in the frequency of disinfection of surfaces, door handles, countertops, and monitoring of any professional with flu-like symptoms and monitoring of these by teleconsultation (37) .
In this category, one of the videos presents care that enables communication between family members and patients hospitalized with COVID-19 by means of remote calling through iPads donated by volunteer companies. This measure was adopted due to the ban on visits to hospital units during the pandemic (36) .
A professional teaches the population to start a cycle of 6 deep breaths with a time of retention of air in the lungs when they know they have been infected with the coronavirus, which, according to him, can prevent pneumonias that arise after CO-VID-19 infection (46) . This technique was created by a nurse, present in the video, but is being presented by a physician. Finally, in this category, a set of videos is presented that focus on professionals in moments of prayer and religious songs, indicating the search for strengthening the spirituality of professionals during the pandemic (25) .

Overview of the pandemic from the perspective of nurses in different countries
This category includes videos in which nurses from the United States of America, Portugal, Switzerland and Italy report their experiences (38,41,(44)(45)(46)(47)(48) . In order to raise awareness and reduce the number of cases due to COVID-19, nurses present content about the natural history of COVID-19, the viral structure of SARS-COV-2 and the incubation time, main signs and symptoms of illness, clarification of the criteria that define the risk groups to COVID-19 and the rates of transmissibility and lethality of the disease (41)(42)44) .
Hospital overcrowding, the scarcity or absence of Personal Protective Equipment (PPE) for health workers and repercussions  of legal measures for flattening the COVID-19 contamination curve are highlighted (45)(46)(47) . In addition to providing an overview of the situation in their countries, nurses encourage people to adopt physical distance and prevent contagion by COVID-19 through measures such as hand washing for 30 seconds and using alcohol gel for situations in which hands can be washed (48,50) . They recommend increasing water intake to avoid dehydration and cleft lip, avoid touching nose, eye and mouth frequently, cover nose and mouth with handkerchief or with the own forearm when sneezing or coughing, turn off the tap with the paper that has dried hands and avoid the presence of footwear used outside the home in home environments (45) .

CONTENTS RELATED TO NURSING PROFESSIONALS DURING THE COVID-19 PANDEMIC ON THE YOUTUBE™ PLATFORM
To raise people's awareness, the videos show empty streets in Italy, while a nurse reports that only essential pharmacy and supermarket services are allowed to operate (42,(44)(45) . She sadly reports the impossibility of family members to watch over the bodies of people who die from COVID-19 and the high number of funeral coffins carried by the army (45) . In this category, nurses express their perceptions of how people are behaving amidst the pandemic. They report panic reactions in the population of cities in the United States (51) and the United Kingdom (43) , with people buying in excess items such as toilet paper, paper towels, disinfectants, alcohol gel, etc.
On the other hand, in these same countries, nurses denounce the neglect on the part of people who continue to frequent public spaces that remain open, disregarding the recommendations for physical distance, revealing little awareness of the seriousness of the pandemic and the imminent risk of shortages (38,43,51) .
Nurses also express different feelings: fear of not knowing about various aspects of the disease; pressure for the need to mediate contacts between patients and family members and watch the suffering experienced by them; fear for life itself when realizing the absence of safe environments for careprovision; indignation at the neglect observed in population's behavior. Guilt is also identified for having acquired the new coronavirus, despite having adopted all measures of protection and regret for having delayed the search for assistance after finding hospital overcrowding (38,41,(46)(47)51) .

Tributes and motivation to mobilize the category
This category brings together two relevant themes: the tributes addressed to health professionals and the call for the nursing category to take advantage of the current moment of evidence to react, empower the profession and claim their rights (52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63) .
As tributes are paid by a representative entity of the category, people from society who pay tribute with music, reciting poetry, praying and reading messages to motivate the staff of a hospital (52)(53)55,(58)(59) . There is also a video of professionals honoring a colleague who died from COVID-19 (54) and even the delivery of pizzas to hospitals as a way of thanking, recognizing and valuing the appropriate local work and respect for rest during working hours (60) .
As for the reactions in the search for empowerment and professional valorization, two institutional videos use slogans and campaigns, like NursingNow, using the coat as a symbol, to reaffirm that professionals continue "wearing the coat", in a reference to "wearing the shirt" to take care of the other (56)(57)(58) . Empathy and altruism are evoked to motivate professionals to care and reaffirm that protecting nursing is protecting the country's life and health (60)(61)(62) .
Another video criticizes the reference to health and nursing professionals to the status of heroes, while denouncing the working conditions and low wages to which they have historically been subjected (63) . It is also noted in the same video a tone of outburst from professionals when they claim that the sudden visibility during the pandemic is more linked to the lack or death of nursing professionals, since the honors and praise do not correct the disparities reported, nor do they survival (63) . They demand salary changes that ensure meeting the category's needs such as food, housing, education and structural measures in the work contexts as an appropriate place and respect for rest during working hours (56,63) .

Criticisms and demands to improve working conditions
The videos that make up this category, in general, denounce the working conditions of nursing professionals amidst the pandemic and contexts include the United States of America, Switzerland, Portugal, Spain (64)(65)(66)(67)(68)(69) .
One of them calls attention to the need for a care plan for nursing professionals, with four important points: equipment in quantity and quality to reduce the risks of exposure; shift time and time between shifts, paying attention to tiredness and rest time necessary to restore energy; creation of a listening space so that these professionals can make mature and ethical decisions; continuous training to meet the real needs (64,67) .
A TV show features an Ecuadorian nurse who describes a day in the life of the staff and the difficulties they face everyday ata hospital in New York (69) . In another, a nurse in an Intensive Care Unit in Switzerland compares the two realities (Switzerland and Portugal) at an early point in the pandemic. He points out that even in a developed country there is negligence regarding the working conditions of nursing professionals, so he assesses that Portugal has control over the pandemic because it has adopted appropriate measures since the arrival of the first cases in Europe (49) .
In one of the videos, a representative of a professional inspection institution emphasizes the need to value nursing work, calling on authorities and politicians to take a different look at those who dedicate their lives and expose themselves daily to care for the other (64) .

DISCUSSION
The action of nursing through expressions contained in the videos exemplifies the social accountability of the category so that its guidelines reach the largest number of people, an act characterized solely as a commitment by nursing to the empowerment of people (70) and the common good of society, other motivations for constructing the videos are not noticeable.
It is known that nursing uses awareness, stimulus and motivation skills to enhance its interventions and achieve positive impacts on the well-being of individuals (71) . To this end, subjective and scientific guidelines that access psychoemotional and of Contents related to nursing professionals during the COVID-19 pandemic on the Youtube™ platform Carvalho ESS, Vale PRLF, Pinto KA, Ferreira SL. rational dimensions are adopted by nursing and made explicit in the category The role of nurses in care production during the pandemic. They built personal narratives, expressing their feelings to access the subjectivity of the video recipients and reporting in detail the nursing care that should be performed to prevent contagion such as hand hygiene. Despite the contribution of nursing to the society identified in this study, it is worth noting that YouTube™ is not a scientific or educational platform, which ensures posts of technically and scientifically validated content (21) . That is why YouTube™ users should check information veracity, such as conducting searches on sites that are intended to check information validity and/or seek the reputation of the source of the information and similar news on the main search sites available on the internet (72) .
Historically, nursing workers are faced with the precariousness of their work, expressed in the type of bond, salary, working hours and other conditions that characterize a work of secondary value, especially in societies where the biomedical model of health care is prevalent (73) . Increase in the need for nursing care due to the increase in life expectancy worldwide is a recognized reality; however, this finding has not necessarily resulted in a social and economic appreciation of this work, at least even before this pandemic.
In this study, working conditions are reported in various contexts, not only in Brazil, but also in European and North American countries, showing that, regardless the countries' economic wealth, the situations in which nursing professionals find themselves submitted put them in vulnerability to illness. Working conditions refer to the workforce, i.e., the specifics of those who perform it, the qualification required, the division of labor, contractual relations (contract type, working hours, benefits, social protection). They also involve the socio-technical environment for carrying out the work, including adequate instruments, in quantity and quality, as well as the knowledge to operate them and the physical space (74) .
Resolution 543/2017 of the Federal Nursing Council (75) , which deals with staff sizing, determines that adequate number of professionals for quality care in ICUs, for instance, must be one for each patient. The contamination of health professionals by the new coronavirus also increases the risk of reduction of these professionals, considering that they need to be quarantined when contaminated.When nurses denounce that situations of unprotection for work with critical patients have existed since before COVID-19 and persist despite it, it demonstrates that these workers have been going through situations of vulnerability for some time and that the pandemic served as an alert/limit, taking them to react and claim for their own lives. Illness and death are more frequent due to a phenomenon that still has no control or cure.
The lack of protection perceived by nursing is a consequence of adopting a neoliberal model by the State both in Brazil and in other countries, which makes public services and their workforce precarious, freezing salaries, inhibiting tenders and expanding outsourcing (76)(77) .
As the pandemic progresses, the growing number of health workers infected with the new coronavirus is evident. In China, in early March 2020, more than 3,300 workers were reported as positive for SARS-CoV-2 infection, and in Lombardy, Italy, infections were reported in 10% of all physicians and nurses (78)(79) .
In Brazil, the Federal Council of Nursing (Conselho Federal de Enfermagem) recorded an increase from March 30 to April 15, 2020 from five to 4,089 cases (confirmed and suspected) of COVID-19 and approximately 30 deaths of nursing professionals. Another 4 thousand professionals are on sick leave, 552 with a confirmed diagnosis and more than 3.5 thousand under investigation. In the same period, the entity received more than 4,800 complaints for lack of PPE in health units (80) .
When working in a pandemic, professionals are subject to risks, including exposure to pathogens, prolonged working hours, psychological stress, physical fatigue, professional exhaustion, stigma and physical and psychological factors, violence (81) in addition to compassionate fatigue (82) . In this regard, tributes, although directed to alleviate the pain and suffering of exposure caused by work, to a certain extent, "touch a sore point" of exhausted workers, exploited, overworked, under continuous stress, and exposed to precarious employment ties. The tributes remind them of all the risks to which they are exposed daily without their claims finding an echo in the society that does not seem to value their work.
The pandemic increased the visibility of nursing professionals and brought up a discussion about their working conditions. In Brazil, this political moment is opportune to demand safe working conditions and decent wages, as well as to revise the rules that regulate working hours and the nature of employment relationships, such as Provisional Measure 927, which in addition to changing labor relations, allows for extending the workday by up to 24 hours, reducing the rest time to 12 hours (83) .

Study limitations
Due to broad access to YouTube™ and the beginning of the pandemic in China, videos in Mandarin are believed to have been produced; however, the lack of mastery of this language by the authors limited the expansion of the research corpus. It is possible that data collection did not reach videos on the pandemic setting on all continents, considering the different time perspective of the countries' involvement in relation to the sustained internal transmission of SARS-CoV-2 to the number of hospitalized patients and to mortality indexes.

Contributions to nursing, health, and public policies
The role of nursing in several countries during the pandemic makes it possible to compare the performance in different locations, indicating the need to expand research on professional performance in the management of global health crises in order to build a more consistent theoretical corpus. Likewise, the organization and implantation of new health units in a short period of time and raising the population's awareness of how to deal with pandemics are relevant topics for theoretical study.
It is important to highlight that in this context of crisis, the ability of nursing to articulate and strengthen collaborative networks between health managers and other areas of knowledge is paramount. Certainly, inter and multidisciplinary coexistence in teaching, research and extension and daily work already constitute a differentiated practice that needs to be better studied. This study also points out the importance of nursing having ideal working of Contents related to nursing professionals during the COVID-19 pandemic on the Youtube™ platform Carvalho ESS, Vale PRLF, Pinto KA, Ferreira SL.
conditions, with updated and qualified professional training in structuring themes such as treatment and destination of infectious waste, proper use of PPE and patient safety.

FINAL CONSIDERATIONS
This study characterized the content related to nursing professionals published on the Youtube™ platform. Nursing working conditions in different countries and the recognition and demands regarding working conditions of professionals during the pandemic stood out.
During the researched period, the videos propagate particularities of professional experience and enable the expansion of the view on nursing in the context of the pandemic of COVID-19. With a diversity of approaches, they keep in common the content of each video, densified by the seriousness of the situation and the high social impact of the pandemic.
Excellence training for nurses has the potential to have a positive impact on society, considering that, of health professions, nursing has a vast curriculum in disciplines that provide a diversity of competencies for human being care. Considering the situation and the potential for contamination of workers in the context of providing nursing care, it is essential that self-care is a priority among these professionals, paying attention to their physical, mental and spiritual health.
The political organization of the category is also urgent in order to occupy spaces for deliberation, expanding the conquest of rights and conditions that value nursing. Moreover, the nature of work and the category guidelines need to be publicized and understood by society, helping to build a less romanticized image about these workers and broadening the understanding that providing health care in safe conditions makes it possible to offer care that meets the demands of the community, especially in situations of health crisis.