A total of 77 health professionals were interviewed: 40.2% physicians, 27.3% nurses, 24.7% nursing technicians and 7.7% physical therapists. Women constituted the majority of the sample (57.1%); 66.1% were between 31 and 50 years of age; 96.1% worked in the state capitals; 64.9% worked in public hospitals; 53.2% reported having been infected with COVID-19 and 25.9% reported complications from the disease (Table 1).
Table 1
Characterization of health professionals' professionals. N = 77
Variables | n | % |
Age group | | |
21 to 30 | 15 | 19,4 |
31 to 40 | 25 | 32,4 |
41 to 50 | 26 | 33,7 |
51 to 60 | 11 | 14,2 |
Sex | | |
Female | 44 | 57,1 |
Male | 33 | 42,9 |
Professional category: | | |
Physician | 31 | 40,2 |
Nurse | 21 | 27,3 |
Nurse Technician | 19 | 24,7 |
Physiotherapist | 6 | 7,8 |
Job location | | |
Capital city | 74 | 96,1 |
Metropolitan region | 9 | 11,7 |
Workplace* | | |
Basic Health Unit | 6 | 7,8 |
Urgent care clinic | 4 | 5,2 |
Public Hospital | 50 | 64,9 |
Private Hospital | 19 | 24,7 |
Emergency ambulance services | 5 | 6,5 |
Doctor’s office/ home visits | 8 | 10,3 |
Other | 12 | 15,6 |
Number of places worked | | |
1 | 35 | 45,4 |
2 | 29 | 37,6 |
3 | 8 | 10,3 |
4 | 5 | 5,1 |
5 or more | 2 | 2,5 |
Re-assigned to COVID-19 services | | |
Yes | 18 | 23,3 |
No | 17 | 22,1 |
No response | 42 | 54,6 |
Comorbidities* | | |
Diabetes | 6 | 7,8 |
Hypertension | 14 | 18,1 |
Overweight/Obese | 12 | 15,5 |
Coronary Disease | 2 | 2,6 |
Kidney Disease | 1 | 1,3 |
Asthma | 4 | 5,2 |
None | 49 | 63,6 |
Previously infected with Sars-Cov-2 | | |
Sim | 41 | 53,2 |
Não | 36 | 46,7 |
Complications of COVID-19* | | |
Physical | 20 | 25,9 |
Neurological | 1 | 1,3 |
Psychological | 6 | 7,8 |
None | 19 | 24,6 |
No Response | 38 | 49,3 |
* More than one workplace or more than one comorbidity or more than one complication of COVID-19 |
Three major themes emerged in analysis: the acceleration of the pandemic and the shock and lack of preparedness of health services; overlapping risk inside and outside the workplace; and anxiety and suffering among health workers.
Pandemic acceleration and the shock to services
According to our respondents, even though the world and Brazil have experienced other contagious diseases, nothing in the last 100 years could be compared to the COVID-19 pandemic. The pandemic generated a sudden change in both work and family routines for workers who had to adapt quickly to this new threat full of uncertainties.
The emergency presented by the epidemic, the rapid transmission and the sheer lethality of COVID-19 meant that modifications to the physical infrastructure and the training of work teams was incomplete. To some extent, “war strategies” were used, with the opening of field hospitals, participation of newly graduated staff, early graduation and recruitment of student health professionals, and assignment of staff with no training or experience in clinical care in infectious disease settings, including assigning administrative health staff to care services. The response of the health system was improvisatory and amateurish, with inadequate physical structure, lack of personal protective equipment (PPE), diagnostic kits and medications, routine exposure to infection, little formal training about the disease and procedures and uncertain poorly implemented requirements for clinician isolation.
It was a sudden, radical change, due to the fear of the unknown (...). It was hopeless (...) it was a feeling that you knew you were on the precipice and at any time you could die or fall. It was a very strange feeling (N, 48y, POA).
The worst moment was April 2020 (...). All of a sudden, in a week, it was chaos! Nobody believed this was happening. Then a lot of people died. We didn't know how to treat [them]. (M3, 26y, FOR).
As a new disease, there was limited scientific evidence on how to properly treat patients. This triggered a feeling of impotence, and the fear of not responding adequately to the patients' needs.
Not having a theoretical base to support decisions ... Seeing such serious cases made us extremely insecure. Colleagues abusing medication without any scientific evidence… (M2, 4 4a, BEL).
Regarding preparation for COVID-19, most professionals reported receiving some type of training, mainly on donning and removing PPE. However, most respondents considered this training inadequate, referring to the absence of protocols for work routines and biosecurity, and their subsequent need to rely on colleagues and varied sources for self-education.
Brazil’s federal government's negligence in confronting the pandemic, which engendered a sense of chaos, had broad repercussions on health and health care workers generated great anger, mildly and carefully expressed here:
I felt politicians' neglect of human beings. The president dismissed the disease. It was a disappointment (TE5, 56y, SP).
Overlapping risks inside and outside the workplace
Staff pointed out many points of vulnerability in work routines that increased their risk of infection. Respondents highlighted the insufficiency and poor quality of the PPE, their restricted access to testing, the inadequacy of their physical infrastructure, the insufficiency of their training, and sheer physical exhaustion:
The work overload, the physical exhaustion, the discouragement, the situation in which we don and remove [PPE], all of this influences us to let down our guard and infect ourselves (E4, 37y, REC).
Discomfort using PPE was a recurrent complaint. The limited availability, often limited to two sets for the long hours on duty, were not enough. Thus, health workers could not remove their gowns and equipment as often as necessary to cool down, hydrate or to use the toilet. Some female staff complained of urinary infections. Masks were also too rare for appropriate use, for example one nurse reported that N95 masks were reused for seven days, even under extremely hot conditions in her clinic.
Regarding procedures and the risk of infection, any proximity to patients, but especially physical exam and blood draws were considered a time of great risk:
The physical exam is very stressful. Collecting tests (…) any situation where you need to be in a closed environment with the patient is stressful. When you enter the hospital, the emergency, you already feel a tension, a feeling of insecurity. (M1, 43y, POA).
Risks were competitive and there was no uniformity among professionals about which clinical services would be at higher risk. Some cited the Emergency or the ICU, others, primary care or home visits. In general, each professional category considered the service or workplace they work in as the one with the greatest risk:
Patients are using non-invasive ventilation, which generates aerosol. So I believe that we have high risk, high exposure, but we also receive all the necessary equipment. (E2, 48y, POA)
We go to people's homes and assist the sick person... [this means] we often serve needy populations, where the demographic density within the household is large (...) This is a type of risk that we are involved in (NT1, 33y, STR).
While hospitals received the most ill patients, they were also better equipped. However, insufficient beds in main hospital wards meant that patients have a prolonged stay in ambulances where visiting and more peripheral staff have an increased risk of infection.
The risk of infection is not only present in patient care environments, but also in lavatories and in cafeterias where masks are removed:
Infection occurs a lot among colleagues, touching door handles, using the same bathrooms, and sleeping in the same room…For meals, the dining area is very small, and they take off their masks. (TE6, 49y, REC).
Anxiety and suffering among health professionals
Maintaining distance, especially emotionally, from patients that providers are trained in, embedded in a mechanistic and rationalist vision of the body and disease is core to medicine. With high levels of disease and death among health professionals COVID-19 challenged this distance, generating great fear, anxiety, and sadness among health care workers. Often these feelings are repressed because they are seen as signs of weakness and incompetence. When fear overwhelms many practioners, remarked several respondents, they stop practicing.
The rationalist view of health is, in itself, a generator of suffering, especially when there is no one listening to their needs and suffering at work. Left alone, with no planful systems in place, there is a greater risk of the people seeking refuge in alcohol, in smoking, or even in the use abuse of psychotropic drugs as strategies to cope with stress and low vitality.
Several days we had to choose between an older patient and a 30-year-old. There were days when I came home sad and drank more, because I couldn't stand it. (M3, 26y, STR).
I went back to smoking (I was quitting). (...) Other colleagues were in the same situation. (M1, 50y, SP).
Another common symptom was sleeplessness:
When I went to sleep at home, I kept thinking: My God, am I doing it wrong? Should I be isolated? I didn't even sleep well. (...) I kept reviewing the cases in my head. (M1, 41y, BEL).
The fear of infecting family members was recurrent, being one of the main causes of emotional distress. Many health professionals left their homes, especially multigenerational households (which are not uncommon) and rented apartments or stayed in hotels, which led to greater anxiety and suffering.
When I contracted COVID-19, I decided not to go to my parents' house, to protect them. It was April 2020. The pandemic was raging. (…) I decided to go to a hotel (…) At the hotel, we couldn't leave the room. (…) It was bad to be isolated. I spent 30 days there. You look crazy (…) [ I] cannot study, read, or exercise (M3, 26y, STR).
The workload to which the teams of professionals were submitted greatly contributed to problems such as physical exhaustion, with frequent complaints of burnout.
I went into burnout diagnosed by a psychiatrist and I'm taking medication. If I talk a lot about it, I start to cry... (M9, 33y, SP).
Dealing with deaths, many of them preventable, were moments of intense suffering, with projections of their own vulnerability and limitations:
The hardest moment was not being able to provide assistance to patients. (...). In a fateful shift, I started the shift with 7 dead. When I received the containers [for bodies] they were all over. No one else could fit. (M3, 26y, FOR)
In this stressful environment with an overwhelming workload, conflicts between workers are natural. Management underscored how challenging it was to deal with recurrent conflicts in the work team. This requires an ability, especially from leaders, to manage differences and personal boundaries.
There is the issue of conflicts in the team. Knowing who you can count on, who is the most difficult, who is most afraid; in respecting people's limits more, because each one has a limit of what they can achieve. There are people who became very psychologically ill (E1, 37y, POA).
On the other hand, staff encountered barriers in communicating with managers and a fear of reprisal. Many health professionals are contracted, temporary or part-time with precarious links to the system:
Professionals are afraid to complain and come to complain to me [as co-workers, not management]. They cry in anguish, afraid of getting sick, afraid of transmitting the virus to their children, because they see and know how high the lethality is... I feel very lonely. (E6, 48y, REC)
Our participants were emphatic about the benefits of participating in the study, that it provided an opportunity to express silent and silenced needs, giving visibility to the numerous shortages experienced, and to hidden feelings.
I think it's very good, because in this research we are going to externalize what we experience, how we behave in an unknown situation, our fears (...). The professional will have his voice. (E3, 44y, BEL).
Taking care of the caregiver, in this case, the health professionals, was a need that was abundantly expressed. Comprehensive care also applies to professionals. Taking care of professionals is not only providing PPE and staff.