Psychopathological symptoms and work status of Southeastern Brazilian nursing in the context of COVID-19

Abstract Objective to evaluate the relationship between psychopathological symptoms and the work situation of nursing professionals in the Southeast Region, Brazil, in the context of the COVID-19 pandemic. Method an observational and cross-sectional study with virtual and snowball data collection from April to July 2020. A questionnaire containing socio-demographic and labor data and the psychopathological symptoms assessment scale (psychoticism, obsessiveness/compulsivity, somatization, and anxiety) were applied. Descriptive and inferential statistics were used to analyze the data. Results among the 532 participants, there was a relationship between weekly workload and psychoticism. All domains of the scale were associated with embarrassment and/or violence in the course of work and receiving psychological/emotional support from the institution where the individual works/studies. Conclusion the age group, heavy workload, experienced violence and lack of psychological support during the pandemic were associated with increased psychopathological symptoms among nursing professionals. It is suggested the creation of institutional guidelines aimed at the reception and follow-up of these demands.


Introduction
The rapid transmission of the SARS-COV-2 virus from its dissemination in large urban centers, the high attack rates (ratio of total cases to total exposed) and mortality from COVID-19 in the various regions of Brazil (1)(2) required adaptation of the public and private systems, as well as of the human resources in health, to meet the emergency demands (3) . In São Paulo State the first cases of COVID-19 were confirmed in February 2020 (1)(2) . Thus, from then on, a new work routine was established for health professionals.
Evidence shows that health care professionals, namely nurses, working on the frontline of care for people with COVID-19, were exposed to a high risk of infection by the virus and presented severe degrees of psychological distress (4) . In Brazil, mapping of the index of this risk at the beginning of the pandemic showed the alarming figure of 97 to 100% of infection (5) . From the labor point of view, the country accounts for an expressive total number of deaths among nursing professionals, with the Southeast Region having the highest number (n=838, in July 2021), and the State of São Paulo, the most lethal (6) .
The new work reality imposed probably accentuated, even more, the significant risks of physical and mental illness already inherent in the performance of nursing work in the national reality (7)(8) . In relation to mental health, work in the context of COVID-19 was found to have the potential to affect health workers' attention, understanding and decision-making capacity and to generate lasting impacts on their overall well-being (9) . Specifically, pictures of depression, anxiety and stress have increased, not only in the general population, but especially among health professionals (4) .
Measures to mitigate the impacts of mental suffering due to the pandemic of COVID-19 cannot be neglected (10)(11) , since previous experiences have shown that these can last longer and be more prevalent than the epidemic itself, thus having incalculable psychosocial ramifications (12)(13) .

Method Study design
Observational and cross-sectional study, guided by the tool STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) (14) .

Sample
Non-probabilistic sample, using the snowball technique, composed of nursing professionals (nurses, technicians, nursing assistants and midwives) from the Southeast Region of Brazil who met the following eligibility criteria: exercising activities at any level of health care, regardless of the activity (direct assistance and/or administrative/managerial) or who worked in teaching and research during the COVID-19 pandemic, residents of the Southeast Region of Brazil. A heterogeneous sample was chosen in order to show the predisposition to secondary traumatization of nursing professionals due to their identification with the suffering of their peers in front-line work (12) and, also, because in March 2020 the Strategic Action "Brazil counts on me (15) and with it many nursing education workers have been supervising care in order to expand the coverage of care to the population at all levels of care.

Data collection
The data was collected, virtually, in the period from April to July 2020 through Google ® Questionnaires,  (16) which was adapted and validated for Brazil in 2001 (17) . In this study, we used the 40-item version (SAS-40); it is a selfreport screening scale for psychopathological symptoms based on the last fourteen days. It was validated for www.eerp.usp.br/rlae   (18) .

Data treatment and analysis
The information was recorded in Excel spreadsheets test was used. The confidence interval was 95% and the significance level adopted was 5% for all tests (p ≤ 0.05).

Ethical aspects
The research met the standards of Resolution no:466/2012, of the National Health Council, approved by the National Research Ethics Committee (opinion no. 3,954,557 and CAAE: 30359220.4.0000.0008 of 2020).
The FICT was entered into Google ® Questionnaires so that the participant could accept or refuse/stop participation before accessing the questions. The participant proceeded to the step referring to the collection instruments when he selected the acceptance option in the FICT and inserted an e-mail for sending a copy. The participant was given the option to print the FICT form if he/she wished to do so. All participants accepted the FICT prior to responding to the data collection instruments.

Results
A total of 532 nursing professionals between 20 and 87 years of age participated in the study (mean age of 37 years, with standard deviation of ±10.72). Of these, 474 (89.1%) were female, most lived with a partner, being 210 (39.5%) married and 70 (13.2%) in a stable union. Singles totaled 211 (39.7%), 39 (7.3%) were divorced or separated and 2 were widowed (0.4%). The Catholic religion was predominant with 186 (35.7%) of the participants. Table 1 shows the socio-demographic, clinical and pandemic context characterization of the nursing professionals who participated in the study.    Table 3, "embarrassments and/or violence"); receiving psychological/emotional support from the institution where they work/study in the context of the pandemic ("Support/support" in Table 3) and the weekly workload. As for Obsessiveness/Compulsivity, an association was found between suffering embarrassment and/or violence in the course of work since the beginning of the pandemic and receiving psychological/emotional support from the institution in which you work/study in the context of the COVID-19 pandemic.   Table 4) and receiving psychological/ emotional support or support by the institution where they work/study in the context of COVID-19 ("Support/ support" in Table 4). Regarding Anxiety, it was also   (19) . In this perspective, we point out the alarming factor that involves the nursing professional whose work with patients infected by the virus is added to the fact of being more prone to the comorbidities presented by the disease, if they are over 60 years old, which contributes to worsen the situation.
Clinical outcomes and length of hospitalization correlated directly with the underlying conditions and age of the COVID-19 patient. Similar findings to these were found in a study in China of 633 COVID-19 patients, which concluded that those older than 60 years are more likely to exhibit a more severe form of the disease, as during the study, 25 patients with a median age of 69.3 years died, inferring an effective mortality rate of 3.77% (20) . differences were found regarding socio-demographic and labor variables between participants with and without somatic symptoms (21) .
A study prior to the pandemic of COVID-19, however, conducted in the context of the acute respiratory syndrome outbreak in China showed that the occurrence of psychiatric symptoms among nurses was related to younger age and poor family support (22) .
As for gender, there was an association with the Another study conducted with health professionals in China shows that they had long working hours, performed several consecutive shifts, facts that had a direct impact on physical and mental fatigue (9) . Thus, it is important to emphasize that the health situation increased both mental stress and physical fatigue conditions, since the professionals carried out their activities in situations of overload of functions, extensive workload, risky situations, inadequate physical structure, scarcity of material resources and lack of professional training (26) . It is also worth remembering the importance of social support and collective coping strategies as a protective factor for workers exposed to intense work overload (27) .
Chinese research that used the SCL-90-R and compared psychopathological symptoms between medical and non-medical professionals found that physicians had a higher prevalence of insomnia, anxiety, depression, somatization, and obsessivecompulsive symptoms (28) . Although the present research did not focus on prevalence, the results also showed the presence of psychoticism, obsessive-compulsive disorder, somatization and anxiety among nursing professionals in Southeastern Brazil.
The variable suffering from constraints and/or violence in the course of work since the beginning of the pandemic COVID-19 was associated with all domains of the scale used in this study, which is derived from the aforementioned one. Health professionals represent a quarter of all cases of violence perpetrated at work, of these, nursing workers were the most affected (29)(30) .
The In the survey, 28.7% of professionals said they had been exposed to violence during their work. In the present study, 24.6% of the participants claimed to have suffered some kind of embarrassment and/or violence at work. Similar data were also found in a study conducted in São Paulo (31) , where 32.8% of the participants reported having experienced, at least, one episode of violence in the year prior to the survey.
Professionals exposed to violence at work develop more symptoms of psychopathological distress than those not exposed (32) . This violence, most often committed by users, is pointed out by the workers themselves as impacting their health and is associated with Minor Mental Disorders, Burnout Syndrome, and reduced well-being at work (30,33) . Besides compromising the mental and physical health of the professionals, these acts of violence reflect negatively on the work processes of the health services (34) .
Most participants in the present survey, 391 (73.5%), stated that they did not receive psychological/emotional support from the institution where they work or study and this lack of support was also associated with all domains of the SAS-40 scale. This is an interesting finding, since although the State of São Paulo pioneered the detection of SARS-CoV-2 in Brazil (2) , did not, simultaneously, pay attention to mental suffering from COVID-19 in various population groups.
In this path, the United Nations highlights that the preservation of the mental health of health workers is a fundamental element in the actions of pandemic preparedness, response, and recovery instigated by COVID-19 (35) . And, those on the front lines of care for patients with COVID-19 may develop mental disorders and other mental health symptoms (4) .
Thus, it is of utmost importance that health services aim to guarantee biosafety, protection, organization and appropriate working conditions for all professionals, regardless of their category or institutional relationship.
increased levels of stress during the epidemic, can impair the attention and decision-making of workers, which impacts not only the management of actions against COVID-19 but also has an effect on their well-being after the epidemic period (9) . By

Conclusion
In this study, the factors that were most related to psychopathological symptoms in the group working in the Southeast Region were: age group; weekly workload; and suffering embarrassment and/or violence in the course of work, since the pandemic state was declared by COVID-19.
The aforementioned results pointed out the importance of increasingly earlier psychological interventions during and after the pandemic. Thus, it is suggested the creation of guidelines for the reception, adherence, and follow-up of nursing professionals through institutional proposals of support for emotional demands.