Challenges faced by Nursing in the post-pandemic context:
a reflection
Professional appreciation and fight against burnout are at the heart of the challenges of a world on its way to winning over COVID-19
Manoel Carlos Neri da Silva1
1 Regional Nursing Council of Rondônia, RO, Brazil
The fact that the COVID-19 pandemic emerged exactly in 2020 was a great irony. That year had been chosen by the World Health Organization (WHO) as the International Year of Nursing and Midwifery Professionals. The profession could not have been in greater evidence – but also vulnerability.
Those 366 days (2020 was a leap year), which were supposed to defend the appreciation of the largest class of health professionals in the world, ended up witnessing one of the greatest challenges for the exercise of a profession in times of peace. COVID-19 has put the entire planet into an ominous state of alert. And, as in a global conflict, it generated trauma and consequent stress, especially in the Health teams that dealt with pain and death on a daily basis. With most of its workers in the front lines, Nursing felt this shock more intensely.
The first confirmed case of SARS-Cov-2, or “new coronavirus”, was recorded in Brazil in February of that year and, in the following month, the WHO officially declared the world pandemic(1). After a local outbreak in Wuhan, China, the first city to record infections, the disease began hospitalizing and killing hundreds of people daily in European countries, especially Italy. The hundreds of daily victims quickly escalated to thousands. In a hyperconnected world, the virus eventually spread to other regions and caused more deaths in the Americas, imposing a health emergency on the entire planet.
To the chronic problem of reduced teams, strenuous working hours and in relation to the need to accumulate more than one job to overcome financial obligations, a number of challenges were added, such as lack of Personal Protective Equipment (PPE) so that Nursing professionals could face the threat of an airborne virus. Images of overcrowded Italian emergency units would soon be repeated in Brazil, where COVID-19 claimed many more victims than in Italian lands. There was lack of oxygen in big cities like Manaus, causing a sensation of impotence in those who take care of the sick, clinging to them and, with despair, constantly watching their patients die in agony, asphyxiated little by little.
The drama of Nursing, composed in its vast majority of women, involved either preventive separation from the closest family members – with special importance given to young children and aged parents – or constant coexistence with the fear of infecting them. Seeing colleagues also getting infected and dying, in addition to the patients, as well as the lack of equipment, caused an exponential increase in the burnout syndrome, or extreme professional strain.
Aware of the problem, the Federal Council of Nursing (Conselho Federal de Enfermagem, COFEN) started to provide a permanent psychological support service that is still offered today(2), in addition to the emergency purchase and distribution of masks. In the care provided to these professionals, general exhaustion, cases of drug abuse and uncontrolled alcohol consumption, and the desire to give up their duties were found, which ended up not happening because nurses need their wages to live and to support their families.
The population of several countries, including Brazil, recognized the health professionals' efforts and organized, through social networks, demonstrations of support in the form of an applause round from balconies and windows. However, in Brazil, the federal government's choice to lead the country by denying the pandemic ended up translated into hostility acts by its supporters against health professionals who advocated isolation.
Hospital workers were asked to distance from the condominiums where they lived for fear that they might contaminate their neighbors. In May 2020, a protest of the category in the Três Poderes Square, Brasilia, was interrupted by aggressive militants. In São Paulo, there were reports of violence against nurses in public transportation. Those who were supposed to stay at their homes tried to deny the right to come and go of the health professionals who went out to save lives in hospitals.
In addition to the discourse that minimized the disease, medications without proven efficacy, such as hydroxychloroquine and ivermectin, had their use encouraged by the federal government's communications and official discourse. This bet on the so-called early treatment also meant a delay in the acquisition of vaccines and dismantling of the national vaccination policy, which was only accelerated after the initiative of the São Paulo government to bring Sinovac production to the country (started to be called “Coronavac”) and the implementation of a Parliamentary Inquiry Commission (Comissão Parlamentar de Inquérito, CPI). Conclusion of the works identified crimes against humanity by several actors directly or indirectly linked to the federal government.
The pressure exerted by the CPI had positive effects and vaccination of the Brazilian population ended up being accelerated between the end of 2020 and mid-2021. More vulnerable groups were immunized with the first, second and, later, even a third dose of the vaccine. The numbers of deaths and hospitalizations decreased and the isolation measures were relaxed. In early November 2021, there was the first record of 24 hours without new deaths due to COVID-19 in São Paulo and, in addition, 70% of the Brazilians declared themselves “safe” with the advance of vaccination in the country. The climate indicates that the worst of the disease is over. And now?
In a world in which the pandemic appears to be on its way to being defeated, old problems with new aggravations emerge in the Nursing practice. Deficient working conditions and low investment in training lead to a shortage of labor that worsens internationally. A global study by the International Council of Nursing (ICN) shows that 90% of the national Nursing councils and associations fear a rise in the profession abandonment rates(3).
It would be necessary to train 13 million new professionals to ensure the provision of health services in the years to come, as assessed by the ICN. The most critical situation is that of developing countries, witnessing a “brain drain” — that is, the most qualified professionals choose to move to richer nations, where remuneration is more attractive.
In Brazil, in addition to not helping the appreciation of more than 2.5 million nursing professionals, the pandemic context ended up resulting in a reduction of almost 12% in their mean income, according to figures from the DIEESE. A problem that is exacerbated by the proliferation of distance learning courses, which make training cheaper and flood the market with new professionals who are not always properly trained in the practice.
The Nursing Profile in Brazil survey indicated that 70% of the Nursing professionals earned less than R$ 3,000(4). Among them, more than 280,000 professionals earn less than a minimum wage. The approval of a National Minimum Wage, a historic demand for the category, gained momentum during the pandemic, with PL 2,564/2020.
It also still necessary to tackle the burnout problem for those working in care. A central issue is the lack of adequate resting places in the work environment. A Law Bill (Projeto de Lei, PL) is being processed in the Federal Senate that would guarantee decent rest in public and private institutions for Nursing professionals during their working hours. Among the items to be regulated, the rest rooms must be ventilated, equipped with adequate furniture, supplied with thermal and acoustic comfort, furnished with appropriate sanitary facilities and with a useful area compatible with the number of professionals in service.
The Working Conditions of Health Professionals in the Context of COVID-19 survey(5), carried out by Fiocruz, points out that the pandemic significantly changed the lives of 95% of these workers. The survey also confirms harms to the mental health of the professionals, who mention sleep disorders (15.8%), irritability/frequent crying/disorders in general (13.6%), inability to relax and/or stress (11.7%), difficulty concentrating or slow thinking (9.2%), loss of satisfaction in their careers or with life/sadness/apathy (9.1%), a negative sensation about the future and/or negative and suicidal thinking (8.3%) and changes in appetite/weight (8.1%).
Nothing indicates that the world will be prepared for another global pandemic. The constant investment in remuneration, appropriate working conditions and improvement in the qualifications of the professionals who provide outpatient and hospital care to the patients is an obvious preparation measure for a new health emergency similar to the COVID-19 pandemic.
We may just hope that lessons have been learned from the disastrous experience of managing the pandemic as an adventure with ineffective medications and the bet on the so-called herd immunization as a public policy to fight against the disease. There are no shortcuts in health care, only investment in public systems may be able to avoid a new health disaster like the one in the past two years.
REFERENCES
1. Organização Mundial da Saúde (OMS), Organização Pan-americana da Saúde (OPAS). Folha informativa sobre COVID-19 [Internet]. Brasília (DF): OPAS; 2020 abr [cited 2021 Nov 13]. [about 10 p.]. Available from: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875
2. Humerez DC, Ohl RIB, Silva MCN. Saúde mental dos profissionais de enfermagem do Brasil no contexto da pandemia Covid-19: ação do Conselho Federal de Enfermagem. Cogitare Enferm [Internet]. 2020 [cited 2021 Nov 13];25:e74115. Available from: http://dx.doi.org/10.5380/ce.v25i0.74115
3. Conselho Federal de Enfermagem (COFEN). 90% dos Conselhos de Enfermagem do mundo veem risco de aumento no abandono da profissão [Internet]. Brasília (DF): COFEN; 2021 Jul 13 [cited 2021 Nov 14]. Available from: http://www.cofen.gov.br/90-dos-conselhos-de-enfermagem-do-mundo-veem-risco-de-aumento-no-abandono-da-profissao_88606.html
4. Silva MC, Machado MH. Sistema de Saúde e Trabalho: desafios para a enfermagem no Brasil. Cienc Saúde Colet [Internet]. 2020 [cited 2021 Nov 14];25(1):07-13. Available from: https://doi.org/10.1590/1413-81232020251.27572019.