ORIGINAL

Feelings of the nursing team in the face of COVID-19 in the care of the first patients: descriptive study

Antonio Marcos Tosoli Gomes1, Theia Maria Forny Wanderley Castellões2, Virginia Paiva Figueiredo Nogueira1, Sergio Corrêa Marques1, Pablo Luiz Santos Couto3, Magno Conceição das Mercês4, Manuela de Mendonça Figueiredo Coelho5, Michell Ângelo Marques Araújo5

1 University of the State of Rio de Janeiro, Faculty of Nursing, RJ, Brazil

2 Americas Medical City Complex, RJ, Brazil

3 State University of Southwest Bahia, Postgraduate Program in Nursing and Health, Brazil

4 State University of Bahia, BA, Brazil

5 Federal University of Ceará, CE, Brazil

ABSTRACT

Objectives: to analyze the feelings and conflicts experienced by nursing professionals in the care of patients with COVID-19; to analyze the implementation of nursing care for the first patients with COVID-19 in an intensive care unit in the city of Rio de Janeiro. Method: qualitative, descriptive and exploratory research. Participants were 71 professionals from the nursing team who develop work activities in the fight against COVID-19 in an intensive care unit in the city of Rio de Janeiro, through online collection. Descriptive statistics and thematic content analysis were used for the analyses. Results: the content analysis revealed feelings in the face of the unknown virus, fear of getting infected, fear of losing one's life and care aspects in the face of the COVID-19 phenomenon. Conclusion: nursing presented feelings and conflicts, such as insecurity and fear. The group built knowledge and skills to handle the realization of this care in the pandemic, including creative aspects and collective construction.

Descriptors: Coronavirus Infections; Nursing Care; Nursing Team.

INTRODUCTION

The year 2020 presented itself, in its first months, as a challenge to global public health due to the emergence of the New Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2 - SARS-CoV-2), which causes COVID-19 (coronavirus disease), which was first reported in China. In a short period of time, it spread all over the world, causing deaths, health system failures and challenges to the health care process. From pneumonia of unknown causes located in a territory, it came to be considered a Public Health emergency of international importance and, finally, in March 2020, it was declared a pandemic by the World Health Organization(1).

In addition to the physical involvement and sequelae arising from infection or health interventions, its impact on mental health worldwide is still not completely clear. Likewise, the social, community, economic and environmental consequences are still being analyzed and understood, constituting a major challenge. The fact that it is an infection transmitted directly between humans, with a higher incidence through the respiratory route, explains its easy spread and difficult containment.

As a result, it has a rapid spread with symptomatic and asymptomatic patients, with variation in its incidence in human populations. The situation becomes even more complex when one considers that there are no therapies that demonstrate efficacy and the vaccination process is below what would be necessary to cope with it(2). One of its characteristics is the diversity of clinical manifestations, in many cases with rapid and severe evolution, requiring assistance in intensive care units.

In view of this situation, it is important to look at the care routine of intensive care units, as well as to seek to understand the care, technological, technical, human, administrative and interpersonal impact due to the reception and care process for the first cases of the infection. The challenge of the new, the need to develop new knowledge and skills, professional insecurity, feelings about the possibility of becoming ill, the use of personal protective equipment in a more constant and essential way and the drama of the possibility of being the vector of transmission for the infection to the family and social environment are some of the issues that can be listed.

It is necessary to highlight the challenge of psychological pressure on health professionals in the pandemic context, as well as the reality of longer work shifts, physical and emotional exhaustion, the high possibility of transmission in the hospital environment and the need for decisions for unexpected situations that can occur(3). For the nursing team, which is always very close to the patient and keeps their organic and psychic daily life as close to normal as possible, COVID-19 is a biological, symbolic, biomedical, human and professional complex like few others in the last century.

From the first cases, in different parts of the world, it is considered that the number of contaminated, deaths and suspected cases among health professionals in Brazil is increasing(4). In April 2021, the Federal Nursing Council pointed out that 776 nurses lost their lives due to COVID-19 since the beginning of the pandemic, with the months of April and May 2020 and March 2021 being the months with the highest occurrences of death. The month of April 2021, however, showed a drop of more than 70% in the number of deaths, possibly due to the advance of vaccination in the category, in addition to other secondary factors(5).

In view of this context, the objectives of this study were defined: to analyze the feelings and conflicts experienced by nursing professionals in the care of patients with COVID-19 and to analyze the implementation of nursing care for the first patients with COVID-19 in an intensive care unit in the city of Rio de Janeiro.

METHOD

This is a qualitative, descriptive and exploratory research. We tried to work this type of research from some of its theoretical bases, such as, (1) the construction of meanings and senses to social reality, (2) the need to highlight the procedural and reflective character of reality, (3) the concreteness of everyday life that gains importance and contours from the subjective meanings and (4) the reality of communicability of the social reality that allows the sharing of this same reality, as well as its collective construction(6).

This article is part of an umbrella project, and the data used for its production were collected with 71 professionals, 33 of whom are nurses and 38 nursing technicians, who carry out their work activities with the victims of COVID-19, from the first moments of the pandemic to the present day, in an intensive care unit of a private hospital in the city of Rio de Janeiro. Data collection took place through a Google form stored virtually in its link with the Research Group email. The data collection period was from May 15 to 25, 2021.

The data collection form consisted of two parts, the characterization of the participants and the answer to an open question. In the first part, the following variables were collected: profession, education and sex. In the second part, participants were asked to answer the following question: For you, how were the first moments caring for people with COVID-19? Participants took an average of 10 minutes to respond and the data were saved in a Microsoft Excel for Windows® file with all the answers provided.

The analysis of the group's characterization data was performed through simple and descriptive statistical analysis, in order to understand who the study participants are. As for the open question, thematic content analysis(7) was adopted, with the purpose of accessing the contents present in the discursiveness exposed in the virtual form. Content analysis can be defined as “a set of communication analysis techniques”(7), working on the word, the conditions of its production and the practice of the sender's language. For this, it makes use of semantics and lexicology, in order to coherently decode the signs, signifiers and meanings present(7).

It should be noted that any material, written or spoken, is susceptible to content analysis. In this process, the number of people involved, the nature of the code, the support of the message, the influence and the social and psychological context of the producer of the message and its receiver are highlighted(7). The smallest discursive excerpt that presented any content related to the objectives of the study was adopted as the registration unit, and each of these excerpts was related to a specific participant, identified by the alphanumeric system (P. 1 refers to participant 1 and so on).

Next, the different registration units were grouped according to their thematic affinities and similarities, generating the four categories that made up the study and which will be deepened below. During the entire process of operationalization of the research, the authors complied with the standards and criteria of quality rigor, guided by the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ). The project underwent analysis by the ethics committee and was approved under CAAE number 31169120.1.0000.5282 and opinion number 4,021,453. All the ethical assumptions of Resolution 466/2012 of the Ministry of Health were adopted and duly obeyed.

RESULTS

The characterization of the participants showed that 81% (58) of the participants are women, 46% (33) are nurses and 54% (38) are nursing technicians. Of the total number of participants, 39% (28) have specialization as the highest level of education, 27% (9) have undergraduate degrees and 33% (12) have secondary education.

The content analysis was structured from 238 registration units that were grouped into four categories that will be deepened below, they are, (1) feelings about the possibility of attending to the first cases of COVID-19, (2) the coping with the unknown and the new knowledge to do it, (3) the possibility of getting infected, infecting family members and losing one's life in the care process and, finally, (4) the care aspects in the face of the COVID-19 phenomenon.

Regarding the feelings faced with the possibility of treating the first cases of COVID-19, those related to uncertainties, insecurity, fear, suffering, despair, impotence, sadness and uselessness stand out, as shown in the discursive excerpts quoted below.:

A very difficult time, full of uncertainties, insecurity, fear and suffering. (P. 2)

It was scary, a mixture of feelings, fear, uncertainties. (P.5)

Fear of contagion, fear of death, despair, insecurity. At each discharge, there was a motivation to continue, the deaths were very much felt, the feeling that it would not end. Powerlessness in the face of deaths, the manifestations of the virus. Feeling of uselessness next to the encouragement for those we save! (P.25)

It was a desperate moment to see so many sick people. (P.34)

There were moments of fear and sadness. (P.68)

Regarding the second category, facing the unknown and the new knowledge to accomplish it, the reality of dealing with a new and different, threatening, contagious infection that challenged the knowledge and manual skills of professionals is shown:

Tense. The fear was too great! Much was said about the disease, but no one really knew what could happen! In fact, we had severe patients, who every hour presented new characteristics, challenging signs and symptoms. (P.18)

A lot of fear of the unknown, amazed by the number of deaths and by the rapidity of the worsening of the patients. (P.20)

Desperate. Fear of the new, of risks. Very difficult. (P.31)

Dark and conflicted. After all, we weren't sure how to deal with the disease. (P.57)

There were moments of insecurity, of not knowing what I was dealing with, of not knowing what COVID-19 really was. (P.63)

Tired, difficult, we were learning to take care of a new disease, which we had no knowledge of, paving the way for the future. (P.32)

The third category concerns the possibility of becoming infected, infecting family members and losing one's life in the care process. There is, in this case, facing the possibility of becoming infected in the exercise of nursing care and, as a complicating factor, infecting other people or presenting a worsening of the situation with death as a possible scenario.

I was afraid, afraid of death, afraid of contaminating others, afraid of loneliness. I was too scared to keep doing what I love so much. (P.16)

I was very afraid of catching the disease and taking it to my family. (P.17)

It was very difficult. Fear of contaminating myself, of contaminating my family. Also, we've never seen so many critically ill patients at the same time. People of all ages and often progressing to death even with all the care provided. (P.26)

I panicked, I thought I was going to die and leave my daughter! (P.29)

Knowing that I was putting my life on the line to save lives. (P.9)

The fourth category, referring to care aspects in the face of the COVID-19 phenomenon, addresses the challenges of the nursing team in implementing care for critically ill patients in the context of an unknown and threatening disease. Aspects such as the beginning of the professional career in the face of the pandemic, the tension between the offer of comfort and the affective and psychological balance of professionals, the constant changes in therapeutic indications and the need to use the attire as one of the main protection technologies, but unlike anything that had been available until then:

A huge responsibility, my first experience in Nursing was at the beginning of the pandemic. I felt a little lost because everything was new, but I managed to carry on because there was an exceptional team by my side to help me. (P.11)

The feeling of fear took over me, I felt very vulnerable, I did my best, I had empathy with the patient, I was very afraid, I cried, I had a phobia. There were moments that my life passed like a video in my mind, this happened on the first day on duty in the isolation sector, at the moment of the first vestment. It was very difficult, I asked God to protect me. That day took so long to pass, I felt my heart racing. When the shift was finally over, I couldn't believe that, even though I was afraid, I took care of and cried for my patients, I took care of them with affection and with a lot of love. (P.37)

It was very confusing at first, as we had behaviors that changed all the time. (P.40)

Scary, at first everyone was very scared and the vestments were unbearable! (P.56)

I never lived or imagined a scenario like covid, I was afraid and cried and thought about never going back on duty. (P. 70)

What bothered me the most were the PPE. (P. 68)

These four categories explain different facets of feelings and conflicts experienced by nursing professionals, as well as the process of nursing care and coping with the first cases of COVID-19 in the context of an intensive care unit.

DISCUSSION

Facing the reality of COVID-19 and caring for patients who presented it at the beginning of the pandemic are configured, for professionals, in a continuum that goes from the affective reaction to the contact they will have with patients to the practical demands of the implementation of nursing care. It also involves the process of facing the unknown, building new knowledge for such an endeavor and considering the possibility of getting infected with the virus, infecting people you love and even dying as a result of the care provided. The risk of contamination and the challenge of psychological well-being in this context are some of the elements present in findings from other studies developed in the context of the pandemic(8-9).

In this sense, it is considered that the world of work, its organization and its daily development present themselves, at this time of care for people with COVID-19, as a “monstrous complex”(2) for nursing professionals, constituting a challenge to be integrated into everyday practices and overcome with technique, technology, science, human relations of support, reception and creativity. This complexity can present itself even more acutely in the intensive care unit, which ends up generating a situation with a tendency to considerable severity for nursing professionals who work in its context(3).

Regarding the feelings in the face of the pandemic and the work carried out in its context, it is noteworthy that this whole set, which can be described as boiling, is related to the possibility of contagion, getting sick and dying, taking the disease to the Family, and the social group and the constant challenges of daily care, including the possibility, in an imminent and constant way, of the failure of the health system(8). As a result, health professionals in general and nurses in particular have high anxiety, aggression to mental health, depression and stress(2,10).

Some of the causes of these feelings are related to physical and emotional exhaustion, the pressures of the world of work, the symbolic constructions of the pandemic in the media, the number of patients in health units, the constant confrontation of deaths, including those of fellow workers, and the need of separation from the family(2,11). An interesting issue is the ambiguous relationship that the social groups of coexistence have with the professionals: if, on the one hand, they hold them in high esteem and respect, on the other, they report a physical and concrete distance as a result of the fear of contamination(2).

A study developed in China(12) revealed that more than half of health professionals had general psychological problems and that nurses were the professionals with a higher percentage of impairments. At the same time, this study demonstrated that professionals who were on the front lines of COVID-19 care were at greater risk for anxiety, insomnia and general disorders. A national study, corroborating these findings, reported a high presence of anxiety and depression among nurses and technicians who work in medium and high complexity settings during the COVID-19 pandemic(3).

Another recurring issue in different studies(8,13) is the high risk of being contaminated during work, as a consequence, the possibility of seeing oneself in the place of patients cared for and facing the physical, spiritual, personal and social suffering that professionals try to cope with in their daily lives. But this weight and this “monstrous complex” acquires even more difficult contours when one considers the possibility of transmission to the family and the social circle, as is recurrently perceived in this same discussion(14).

This issue of social contact with family members and other close people can be ambiguous for health professionals, since living with them can generate anxiety and other consequences due to the possible and silent risk of infecting them, while the not living together generates isolation, loneliness, lack of meaning and feelings related to mental suffering. A study developed in Brazil(3) pointed out that professionals who live with family members at this time of the pandemic are more prone to depression.

In addition to the above, other factors presented as stressors for health professionals were working in the scenario with pathogens of direct transmission between humans, caring for critically ill patients and limited resources and beds for care(3). It is pointed out, in parallel, that the professional profile of the nursing team in providing assistance and working in critical care units is related to a higher level of anxiety in the performance of activities(15).

Other stressors for health professionals, pointed out in another study, showed, among these, the need to play new professional roles, adopt new protocols and develop new practices in the midst of the tumultuous context of the pandemic in the care of critically ill patients; the need to develop expanded workloads to cope with the moment; and the impossibility or limitation of access to mental health services to deal with mental and psychological suffering(16).

As a result, it is essential and urgent to establish mental health care, in different modalities and dimensions, for nursing professionals who work on the front line of care for people with COVID-19(9). Nursing care, encompassing that provided in the context of suffering, loss and death, needs to be considered as a space-time with the potential to generate physical and psychological exhaustion, subjective and spiritual suffering and other more complex situations in those who face them(2).

Given this situation, the importance of rescuing the discussion about compassion fatigue in the context of the COVID-19 pandemic(17)  should be highlighted, since it can be a common event and go unnoticed due to its non-discussion. Compassion fatigue is a syndrome characterized by a condition of exhaustion in the biological, psychological and social dimensions that affects people and professionals who use psychic energy with activities in the form of compassion for other human beings without feeling rewarded for this process of exhaustion(18).

This understanding is important for the nursing team in the context of the pandemic, due to their effort to promote humane and quality care(9) and their professional practice, which is crossed by multifaceted requirements. These crossings can be the presence of pain, suffering, deaths, different losses, unfavorable considerations about their work, low remuneration and the overload of activities in the shortest possible time(2).

The pandemic, in addition to all the technical, technological and administrative-management demands, requires the nursing team to face the challenge of establishing human and empathetic relationships with patients and their families(8), in an innovative way, such as, for example, the use of the professional's own portable telephone device to make visual and audible contact between the patient and their family members. As a result, there are greater chances of developing relationships between professionals and family members, creating closer and lasting bonds and, as a consequence, also of emotional and psychological suffering.

Another aspect still to be considered, even if the data do not address it in an important way, is the use of personal protective equipment by professionals, which is seen as a challenge, both due to its availability and its correct use in care and proper handling in dressing and undressing(19). In the context of the pandemic, in addition to the above and the characteristics of the equipment used, it became necessary to develop light technologies in nursing care to detect the professional's facial expression by the patients, to identify the professionals themselves and their category by the team and to reduce the discomfort and stress caused by using them in such particular contexts.

As examples of these patient and staff care actions, one can cite the use of badges with large-sized photos and faces that express joy, show their children or their pets. Posters attached to the PPE were also used, in which the name of the professional and scenes from films or photos of famous artists were written.

In this scenario, the important role of nursing in facing it is perceived, as it has also been at other times throughout history, in other pandemics and moments of social instability, such as wars, for example(9).

Simultaneously, when visiting intensive care units that care for people with COVID-19 or talking to nurses who work in them, one can see the importance of rescuing Florence Nightingale's theoretical propositions, especially care for the environment, the air and its circulation more specifically, and the need to offer the necessary support for the organism to recover in the best possible way(20).

The balance between patient care and self-care in the midst of the pandemic is essential, as well as the challenge of health unit management to take care of this binomial, so that better results, greater comfort and raising the quality of life can be achieved. Nurses and their teams are human beings who are exposed to the greatest health and epidemiological challenge of the last hundred years, which requires a specific look and different studies over time from the beginning of the pandemic to better understand its effects and demands.

The reception of professionals, the creation of spaces for the verbalization of affections, fears and desires, the recognition of some personal limits in carrying out the work in this specific context, psychological support from the institution and the creation of solidarity networks between the professionals are some of the examples of actions that can be adopted in the institutional routine.

The proposition of stimulating the self-motivation of professionals in the midst of the pandemic can be configured as important, as well as investing in well-being in the workplace. Demands that arise over time must also be accommodated(8). The memory of facing the pandemic as a response to the poignant challenges of the time in which we live is another dimension that can be addressed, not to domesticate workers, but to reflect together with them and promote the joint elaboration of proposals for ways of caring for others and for oneself in an effective and safe, modern and humane way.

CONCLUSION

This study analyzed personal and subjective feelings and conflicts experienced by the members of the nursing team in the first moments of the COVID-19 pandemic, deepening its practical complexity, its human and humanitarian contradictions, such as the emergence of ambiguous feelings determined by the will to care and the fear of being contaminated by a little-known disease. Furthermore, when analyzing the implementation of nursing care, it was seen that facing the unknown required new possibilities of demands for comprehensive care, offered to the set of social actors involved, such as the inclusion of techniques and technologies in an assistance and emergency context, as well as the imperative to remain dignified and allow dignity as essential for existing, continuing to exist or dying in an intensive care unit.

The feelings of professionals and their attitudes towards the health situation that emerged, the way of recognizing the new threatening and including it as a requirement for daily practice, the ever-present risk of becoming infected and infecting others with whom they live and the assistance challenges present in the care of this specific clientele. In this journey of experiencing the pandemic, the study revealed that nursing built its own knowledge to deal with this unfamiliar reality, which included creativity, accumulated scientific knowledge, acquired and consolidated practical skills and the institutional possibility to carry it out.

Among the limitations of this study, we highlight its performance in only one unit with a limited number of professionals. However, it is believed that its results point to an important discussion that still requires further investigation, with new studies of different typologies. It indicates that nursing continues to face the challenge of being and reinventing itself in the face of world and life events in the face of new care demands from people, communities and populations.

CONFLICT OF INTEREST

The authors have declared that there is no conflict of interest.

FINANCIAL SUPPORT

Productivity grant in research CNPQ level 1D process number 311631/2020-7; nota 10 FAPERJ post- doctoral grant process number e-26/202.429/2019 (246805); FAPERJ/UERJ procientist grant.

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Submission: 06/01/2021

Approved: 11/22/2021