Work process in a mental health service during the Covid-19 pandemic: a qualitative study
Natália de Magalhães Ribeiro Gomes1, Maria Odete Pereira1, Daniela Leite Garcia Silva1, Rosiane Azevedo Faleiro Rodrigues1, André Bárbaro Abrão1, Amanda Márcia dos Santos Reinaldo1
1 Federal University of Minas Gerais, MG, Brazil
ABSTRACT
Objective: The objective of this study is to understand the work process of a Psychosocial Care Center in Minas Gerais during the COVID-19 pandemic. Method: This is an interpretive case study of a qualitative nature. Results: The analysis of the interviews resulted in four thematic categories: impacts on the work process generated by the COVID-19 pandemic; adaptations in the work process during the pandemic; difficulties faced during the pandemic; and preparation for the resumption of in-person activities. Conclusion: The COVID-19 pandemic prompted several changes in the scenario of the health services, which needed to adapt, quickly and effectively to ensure continuity of the treatments.
Descriptors: COVID-19; Mental Health Services; Work; Mental Health; Process Evaluation.
INTRODUCTION
In early 2020, the world population faced a new pandemic caused by COVID-19. Initially notified in China, the new coronavirus (SARS-CoV-2) spread rapidly around the world. In March 2020, the World Health Organization decreed a global health emergency(1).
The emergence and extent to which COVID-19 spread around the world affected the way of life in society, as well as it caused a significant reduction in access to health services and support. In several countries, lockdowns were decreed and social isolation and distancing were adopted as means to try to contain spread of the virus. In addition to the impacts on public health, immense challenges and possibilities for social transformations put the world population to the test(2).
With the advance of the pandemic in Brazil, governmental necessary policies and actions to reduce the dissemination speed of the disease and to mitigate its results in people's health were implemented(3). In addition to that, states and municipalities declared a state of public calamity through decrees, creating and regulating the adoption of sanitary measures and other precautions to face the pandemic(4).
In this scenario, the health services had to weave strategies quickly and effectively to meet the requirements enacted to contain the spread of the new coronavirus(5-6). In this context, the municipality of Carmópolis de Minas, located in the Midwest region of Minas Gerais, needed to readjust its health network to meet the demands of the population that emerged from the pandemic.
The municipality implemented a COVID-19 coping committee, comprised of health professionals and local management, which was responsible for monitoring the patterns of virus dissemination in the municipality and for establishing coping measures. Among the measures to combat the pandemic, the health services had to reorganize their way of working. These changes affected the Psychosocial Care Center (Centro de Atenção Psicossocial, CAPS) of the municipality, which needed to adapt its work process.
The pandemic disrupted essential mental health services in 93% of the countries worldwide. A study carried out in August 2020 showed that in at least 60% of the countries, mental health institutions, which assisted children and young people (72%) as well as older adults (70%), had to interrupt their activities. In addition, 30% of the countries reported that access to psychotropic drugs for the treatment of mental disorders and substance use was hampered(7).
Given the pandemic scenario, the objective of this study was to understand the work process in a CAPS from Minas Gerais during the COVID-19 pandemic. It is justified by the need to share the practices developed in mental health, promoting the visibility of these services.
In addition, the results may promote the professionals' assertion to strengthen mental health services in the country, since the pandemic and its social, political and economic consequences have generated many mental health demands.
METHOD
This is an interpretive case study of a qualitative nature.
To ensure rigor in the study, the Consolidated Criteria for Reporting Qualitative Research (COREQ) were used as a support tool. This is a checklist to promote the reporting quality of qualitative studies, leading to a better course of action and to their recognition as a scientific effort(8).
As a theoretical framework, the authors adopted the Donabedian service evaluation model(9). For the author, the act of evaluating is to constantly monitor health institutions to identify possible failures that can be corrected in order to favor improvement in the processes and development of the service.
To develop a systematic assessment of the health services, the aforementioned author adapted a system of indicators focused on three dimensions: structure, process and results. This study focused on process evaluation.
Process evaluation portrays the activities of the health care service. This type of assessment is mainly oriented towards the analysis of care practices involving health professionals and users(9).
This study was developed in a typology I CAPS from a small municipality located in the Midwest region of Minas Gerais. According to the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE)(10), the municipality has a population of 19,335 inhabitants. Within the scope of the Unified Health System (Sistema Único de Saúde, SUS), for the health actions and services the municipality has six Family Health Strategy units: Family Health Support Center (Núcleo de Apoio à Saúde da Família, NASF I); Santa Casa de Misericórdia; Center for Women's and Children's Health; Medical Specialties Center; Municipal Laboratory and CAPS I.
The population of this study were higher level professionals: nurses; psychiatrist; social worker; psychologist and occupational therapist; technical level professional; two workshop coordinators and the service manager, who is a nurse. It is noted that, in all, the nine professionals who made up the CAPS technical team were invited. All agreed to participate in the research and signed the Free and Informed Consent Form (FICF). To maintain the participants' anonymity, the statements were coded using names of precious stones.
Data collection took place during October 2020, having been carried out through an unstructured interview. According to Minayo(11), in this data collection technique, the interviewer allows the participant to speak freely about the theme under discussion, in order to confer more depth to the reflections.
The interviews were conducted through an online platform, during their shift in the CAPS. The schedules were agreed upon in advance, so as not to harm the development of the activities. They lasted a mean of 60 minutes, were recorded and later transcribed for data analysis.
To guide the interview, open questions regarding the work process in the CAPS during the COVID-19 pandemic were presented to the participants. The professionals were able to express themselves and, given the need to deepen on certain aspect, new questions were asked.
For the analysis of the results, the MAXQDA software, version 20.2.1, was used. The analysis methodology employed was the Thematic Analysis technique(11). Therefore, the following stages were carried out: pre-analysis, exploration of the material and treatment of the results obtained.
The research was approved by the Research Ethics Committee of UFMG under opinion No. 4,329,244 and complied with the ethical principles set forth in Resolution No. 466/2012 of the Brazilian National Health Council.
With data organization, four thematic categories were defined: (1) Impacts on the work process generated by the COVID-19 pandemic; (2) Adaptations in the work process during the pandemic; (3) Difficulties faced during the pandemic; and (4) Organization for the resumption of in-person activities.
RESULTS
The technical team at the service was comprised by a nurse, a psychiatrist, a social worker, a psychologist, an occupational therapist, a nursing technician, two workshop coordinators and a manager, also with training in Nursing.
In the characterization of the nine participants' sociodemographic profile, the following prevailed: female gender (n=8); married individuals (n=7); residents in Carmópolis de Minas (n=6) and monthly income from 1 to 3 minimum wages (n=5). The age group varied between 31 and 64 years old and the schooling level showed an equal division (n=3) between complete higher education and graduate education.
The impacts of the pandemic on the work process
In view of the pandemic scenario, the impacts of COVID-19 on the work process were recurrent in the speeches by the service professionals, as expressed by this professional:
Agate: The pandemic impacted everything, the service had to stop. I was the first person to be distanced, because I was part of the COVID-19 risk group, with age as a factor. Most of the users are also part of the risk group, aged over 60. So both parties had to back off and it was a difficult process.
It was also evidenced that some service activities had to be suspended, as highlighted by some participants:
Emerald: During the pandemic, all of the users' stays here in the CAPS were suspended during the day.
Sapphire: At the moment, matrixing is suspended because of this issue of the pandemic, as the volume of people participating is not adequate for the maximum number in the same environment.
Onyx: We can't meet with Primary Care professionals here in the CAPS.
With the suspension of these key activities, the professionals reported work overload, as expressed by Onyx:
We now have to keep the users here in the CAPS, because, with the impossibility of the matrixing meetings, even those users who were more stable, we couldn't refer them to Primary Care, without explaining the case and management to the professionals there.
In addition to that, the impacts were also observed in the process for the care of users monitored by the service, as evidenced by the professionals:
Emerald: [...] at the beginning, the users felt very sorry about this issue of not being able to come to the CAPS.
Amethyst: It was a very strong impact, as the users were accustomed to the service. With the Pandemic, the users didn't come anymore and many had relapses, returned to drinking, went back to being on the street, they were very weakened.
Quartz: [...] we saw that most of them who stayed at their homes had relapses, those who were doing well, they were having positive results.
Adaptations in the work process for care continuity during the COVID-19 pandemic
In view of the impacts on the work process arising from the pandemic, the professionals adopted the necessary changes for care continuity. Among these changes, home visits were one of the alternatives found to offer care continuity to the users who were monitored by the service, as explained by the professionals:
Sapphire: in this pandemic situation, not everyone can come to the CAPS, in this case I go to everyone's house. Outside the pandemic, I normally do this assessment of users in the CAPS.
Emerald: We started to assist them at their homes and in psychiatry outpatient care, when necessary.
From this perspective, in addition to offering care continuity to the users already assisted by the service, the guarantee of assistance to the population and health professionals in the municipality was also mentioned in the following speeches:
Tourmaline: We started the online service to serve the population, employees, in short, anyone who wanted psychological care at a time of insecurity and despair. This online service works like a “911”. They call at any time and get the appointment, whether a user or a professional.
Sapphire: during the pandemic, I have been providing online assistance to the users.
Ruby: I started providing the online service, but actually it wasn't very good, I didn't like it. So, when I saw that it was a case demanding more, I attended to it in person.
Difficulties faced in the work process during the pandemic
Among the difficulties expressed in the professionals' speeches in relation to the work process during the pandemic, the concern with the possibility of transmitting the virus to users and family members during the home visits stood out.
Emerald: the team's care had to be at home and there wasn't much I could do, because at the beginning I couldn't even enter the users' homes. I had to talk from the outside, so we had a lot of difficulties. I was always accompanied on the visits, but it was difficult because of the contamination, we had to think about the user too.
In addition, the professionals highlighted the limitations found in online care, implemented in the municipality, such as instability of the Internet connections, which exerted an impact on the services, leaving users and professionals frustrated, as follows:
Sapphire: we're very limited in terms of therapeutic resources, in carrying out a specific therapeutic activity. In some cases, when there was a very high level of cognitive impairment, we were unable to provide online assistance. In addition to that, during online assistance, due to oscillation of the Internet signal, which interferes a lot, “it drops or cuts the call”, the users get frustrated in trying to do something, unable of doing it.
Organization for the resumption of the in-person activities
With the epidemiological monitoring of virus spread, the municipality adopted measures related to the resumption of the activities, in the different sectors. Among these, the health services had to reorganize themselves for resumption of the in-person activities, according to the expressions below:
Ruby: We will return with the day stay. There was a meeting to discuss which users should remain in the CAPS, because they were more serious and need to be included, and how each unique therapeutic project would be. In the day stay there will be four users this week.
Tourmaline: [...] we started to serve the users who were in some urgency, those who were in home care, but those who aren't getting any response, they need monitoring in the CAPS.
Given the return to the in-person activities, the professionals reported the necessary strategies for this return to be safe for them and for the users.
Agate: We now also have PPE for use when returning to service. We will respect social distancing, two meters between one another, in a very spacious and airy room. I believe that we'll have a lot of safety when we return.
Sapphire: The planning of which activities will be promoted to these users is also taking place. From there, we'll select the individual material for each one, for example: colored pencils, each one will have their own kit.
DISCUSSION
With the advent of the COVID-19 pandemic, the impacts on the work processes and the need for adaptations in the health services are evident. However, as this is an ongoing event, the literary production that addresses the work process in health services is scarce, especially in mental health services.
As highlighted by Silva et al.(12), the work environments play an important role in the spread of the virus, as a variety of activities can promote and facilitate it. In this sense, the importance of characterizing the work processes in the health services is highlighted, taking into account the working conditions.
Filho(13) complements noting that, to ensure working conditions in which the spread of the virus is mitigated, organizational measures to minimize the transmission risk must be implemented in the various work environments of the institution, in addition to considering workers' health.
From this perspective, services from the public and private sectors adopted risk governance measures that included from closure or modification of the service routine to suspension or reorganization of public administration activities. These measures were adopted by most of the federative units (89%). The central objective involved reducing transmission to curb mortality due to the COVID-19 pandemic and avoiding collapse of the health system. It simultaneously sought to minimize its socioeconomic and health impacts(14).
However, in favor of the reorganization of the institutional routines, especially for the health services, the professionals report work overload. In the face of pandemic situations, health professionals are more likely to experience stressors such as overload and fatigue(15). In addition to that, the authors infer that this condition can be related to personal conflicts due to the uncertainty of what is to come and to the recent knowledge about the disease.
It should be noted that work in mental health lacks the relationship between health service professionals and users, in addition to the formal organization of the service and work processes. In this sense, it is important to think that organizing the service for remote appointments, with no in-person meetings, generates a disruption in the necessary relationships for monitoring in mental health. In addition, the bond built over time becomes mediated by a communication technology. The adaptation of the service and the work process became necessary in the face of something unexpected, but that imposed the need for collective care.
Caring for the other, in this case the service user, can be considered only one aspect of the necessary movement to accommodate the actions of the service, by the logic of distancing. Another important issue is the care provided by the health professionals, who should be distanced when they belong to risk groups, or because they have been contaminated, as was the case in the CAPS in question. In this case, it is interesting to think that this displacement of the workforce to remote work, or the maintenance of professionals in services, contingent on care, generates emotional and work overload perceived by the professionals.
In this study, work overload was reported by higher level professionals, who associated it with the existence of clinically stable users, able to be monitored by Primary Care but, due to the suspension of matrixing meetings for the BHU teams, follow-ups in the service were maintained, given that it would not be possible to effectively transfer care.
On the other hand, the professionals also showed the concern of the users who were monitored by the service in relation to access to treatments during the period of social isolation and the intensification of the symptoms of mental disorders.
Corroborating the results found in this study, Li(16) stated that, due to traffic restrictions and isolation measures, mental health users in outpatient care were facing difficulties receiving maintenance treatments, which could trigger a psychological crisis, with psychomotor agitation.
As a consequence of the pandemic, an increase in the number of individuals experiencing higher stress levels is expected; as well as anxiety; ineffective coping responses to stress, such as the use of psychoactive substances and the increased prevalence of mental disorders in society.
In this sense, a study carried out in Korea, during the Middle East Respiratory Syndrome (MERS) epidemic in 2015, evidenced that people with pre-existing mental disorders were more susceptible to the effects of stress associated with their living situation at that time. The disruption of social support and care in health services during the COVID-19 pandemic can lead to psychological crises in people with mental ailments.(17).
The mental health service should not be central in the subject's life, and this is an important principle when psychosocial rehabilitation is a guide for care. At the same time, it is the psychosocial care network that operates, articulates and coordinates care, represented by its devices, as long as there is a need on the part of the user. In this sense, it is understandable that the very displacement of the subjects from their homes to the service is an autonomous possibility of care management.
When the services close their doors due to a health need, the flow of users in this care network and its devices is interrupted, generating insecurity and, consequently, an increase in the number of service users experiencing helplessness in relation to care, as well as new actors presenting themselves with mental health demands associated with the pandemic.
A research study conducted in the United Kingdom showed that most of the participants reported having experienced some mental illness during the COVID-19 pandemic. The most prevalent concerns reported by the participants included lack of access to mental health services, with exacerbation of pre-existing mental disorders and increased anxiety and depression symptoms(18).
Following this logic, in order to ensure care to the mental health users in the CAPS participating in this study, online appointments were implemented during the period of social isolation, which was also reported by Wells et al.(19), considering that several health systems and services had to adapt to the restrictions imposed by the pandemic. Among the ways used to ensure access to psychotherapies, video conferences were adopted by the higher level professionals, allowing users and professionals to meet synchronously, respecting social isolation.
Online care during the COVID-19 pandemic was used in other countries with relative success and limitations. In China, mental health monitoring and psychological counseling to health professionals were carried out through social networks or cell phone apps(13). This type of service is characterized as one of the “Telehealth” possibilities and the format offers the users care in a virtual way and, at the same time, it respects social distancing(19). Therefore, it can be asserted that the digital platforms were important allies in social support and access to mental health and psychological counseling services during the COVID-19 pandemic(5).
However, although the studies point to the use of information and communication technologies as devices for the maintenance of care, it is necessary to emphasize that these tools have their limitations. One of the difficulties reported by the professionals was the challenges to provide online care, given the lack of access to good quality Internet.
According to Schmidt et al.(15), the circulation restrictions and the need to provide psychological assistance through digital platforms during the COVID-19 pandemic in Brazil were challenging. Among the challenges, lack of Internet access stood out, which limits the offer of support. In addition to that, even though part of the population has Internet access, many have difficulties in using the technology and in handling cell phones and computers, in short, in the use of digital technologies and media.
It was also noticed that this remote work model did not apply to all the activities present in the CAPS, since the digital platforms limit the possibility of developing collective activities that are essential for the users' therapeutic, socialization and rehabilitation process. In this sense, it is highlighted that, although communication technologies are allied in the care process, they do not replace the need for in-person contact between professionals and users.
The professionals reported fear of contamination and transmission of the virus to users and vice versa. The sudden emergence of COVID-19 poses a threat to the mental health of the people affected and of their close contacts. Health professionals, even those who do not work on the front lines, may experience fear of contagion by the virus and transmission to family members, friends or others close to them. In addition to that, these professionals also face the fear of death(1).
The insecurity generated by the unknown triggered anxiety among the professionals, which is understandable. Despite the rapid response given by researchers around the world about the natural history of the disease and other information associated with uncertainty about the future, this can be understood as a risk factor to the health of professionals in the service.
In addition, the planning for the resumption of in-person activities, even if partial and for cases that warrant them, is surrounded by uncertainties, insecurities and tensions that must be considered when planning the return to the activities, especially in relation to the supply of personal protective equipment; periodic diagnostic tests; tracking of contacts in case of contamination; and early access to the vaccine for the professionals.
In this sense, for the resumption of in-person activities in the service, several strategies were resorted to, such as the use of Personal Protective Equipment (PPE); making materials available for individual use by the users; reduced service and social distancing, in order to ensure the safety of professionals and users alike.
In China, governmental authorities released a warning document about strengthening the treatment and management of people with severe mental disorders during the pandemic. Among the actions, the adoption of measures to prevent nosocomial infections by mental health institutions and the provision of treatment and community care for users at their homes are pointed out(16). These actions, adopted in China, are in line with the measures employed by the mental health service in the municipality of Carmópolis, which adopted home visits to monitor the users and sought preventive strategies against COVID-19, for the resumption of in-person activities in the service.
Home visits minimize the issues related to social distancing and isolation since, when taking the team to the users' homes, a symbolic movement is made that signals accountability, on the part of the team and the service management, with the people undergoing treatment and their well-being. It is about strengthening the bond, despite the difficulty of carrying out home visits, when there is a need for social isolation. In this sense, this initiative is an indication that the service is clear about the importance of social contact for the users.
The literature reinforces that guidelines about the prevention measures are essential for managing the stress caused by the work practices. In addition, the provision of adequate PPE, in sufficient numbers, associated with training that follows the guidelines of established protocols, can help prevent and reduce the risk of infection in health workers(20).
Finally, this study has non-generalization of its results as a limitation, considering that it involves data referring to a specific service. However, the results of this study may contribute to improving the care practices of the local CAPS and services with a similar profile, in addition to causing other studies to be carried out involving a significant number of services of this nature, which allow generalization of their results.
CONCLUSION
The COVID-19 pandemic prompted several changes in the panorama of the health services. This study evidenced that the pandemic exerted an impact on the work routine of the professionals working in the CAPS from the municipality of Carmópolis de Minas, with the temporary suspension of most of the in-person activities, including important activities for organizing the work processes, such as technical team meetings and matrixing to the PHC teams, which resulted in work overload.
However, to ensure mental health care, the service's technical team adapted the work process so that care was provided remotely, respecting the social isolation imposed by the pandemic, in order to prevent possible contamination.
From this perspective, it was verified that the digital platforms were important allies to ensure care continuity, by enabling psychotherapeutic care to be carried out, even if remotely. However, the professionals had difficulties adapting to the transition from in-person to online care and, in this sense, the brain plasticity of everyone involved was fundamental to adjust to the new reality, acknowledging that communication technologies constituted mediating tools for the care practices. In addition, an important extrinsic factor limiting the adaptation process at that time was limited access to Internet.
However, it was observed that only home visits and virtual assistance were not sufficient to meet the demands of the severe cases, which were monitored by the service's technical team. Therefore, it was necessary to reorganize the physical structure and the material resources available, in order to prepare the team and the service for the resumption of the in-person activities.
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Natália de Magalhães Ribeiro Gomes - Conception of the project; Data acquisition; Data analysis and interpretation; Textual writing; Final approval of the version to be published; Responsibility for the text in ensuring the accuracy and completeness of any part of the paper.
Maria Odete Pereira - Conception of the project; Data analysis; Critical review of the intellectual content; Final approval of the version to be published.
Daniela Leite Garcia Silva - Data acquisition.
Rosiane Azevedo Faleiro Rodrigues - Data acquisition.
André Bárbaro Abrão - Data analysis; Critical review of the intellectual content.
Amanda Márcia dos Santos Reinaldo - Critical review of the intellectual content.
Submission: 04/08/2021
Approved: 08/18/2021