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The voice of those who provide care during the pandemic - a lexicographic study in Brazil-Portugal

La voz de quienes brindan atención durante la pandemia - un estudio lexicográfico Brasil-Portugal

ABSTRACT

Objective:

To analyze the most frequent words in interviews given by nurses during the coronavirus pandemic.

Method:

This is a qualitative, exploratory, descriptive study, carried out with 45 interviews granted by nurses to newspapers of great circulation in Brazil and Portugal. The data were processed using the ATLAS.ti® software and analyzed using the word cloud tool.

Results:

The seven most frequent words were: “home” (respect for isolation), “nurses” (valuing of the profession and structural problems), “patients/diseased” and “care” (referring to the severity of the disease), “family” (missing her own family/emotional stress) and “fear” (fear of contamination of oneself and others).

Final considerations:

The word cloud revealed how straining nurses’ experiences have been and reinforced the urgent need to rethink nursing work and the risks faced. Reflections like this contribute to the construction of more valued nursing and public policies for the protection of nurses.

Keywords:
Nursing; Working conditions; Communications media; Coronavirus infections; Occupational stress

RESUMEN

Objetivo:

Analizar los términos más frecuentes en entrevistas dadas por enfermeras durante la pandemia de coronavirus.

Método:

Estudio cualitativo, exploratorio, descriptivo, realizado con 45 entrevistas concedidas por enfermeras a periódicos de gran circulación en Brasil y Portugal. Se procesó los datos con el software ATLAS.ti® y se les analizó con la herramienta de nube de palabras.

Resultados:

Las siete palabras más frecuentes fueron: “hogar” (respeto al aislamiento), “enfermeras” (valoración de la profesión y problemas estructurales), “pacientes/enfermos” y “cuidados” (referido a la gravedad de la enfermedad), “familia” (nostalgia/estrés emocional) y “miedo” (miedo a la contaminación de uno mismo y de los demás).

Consideraciones finales:

La nube de palabras reveló el sufrimiento en la experiencia de las enfermeras y reforzó la urgente necesidad de repensar el trabajo de enfermería y los riesgos que enfrenta. Reflexiones como esta contribuyen a la construcción de políticas públicas y de enfermería más valoradas para la protección del enfermero.

Palabras clave:
Enfermería; Condiciones de trabajo; Medios de comunicación; Infecciones por Coronavirus; Estrés laboral

RESUMO

Objetivo:

Analisar os vocabulários mais frequentes em entrevistas concedidas por enfermeiros durante a pandemia de coronavírus.

Método:

Trata-se de estudo qualitativo, exploratório, descritivo, realizado com 45 entrevistas concedidas por enfermeiros para jornais de grande circulação no Brasil e em Portugal. Os dados foram processados com o auxílio do software ATLAS.ti® e analisados pela ferramenta nuvem de palavras.

Resultados:

Sete léxicos com maior frequência foram: “casa” (respeito ao isolamento), “enfermeiros” (valorização da profissão e problemas estruturais), “pacientes/doentes” e “cuidados” (referente à gravidade da doença), “família” (saudades/estresse emocional) e “medo” (temor pela contaminação de si e dos outros).

Considerações finais:

A nuvem de palavras revelou o quão sofrida tem sido a experiência dos enfermeiros e reforça a urgente necessidade de repensar o trabalho da enfermagem e os riscos enfrentados. Reflexões como esta contribuem para a construção de uma enfermagem mais valorizada e políticas públicas para a proteção dos enfermeiros.

Palavras-chave:
Enfermagem; Condições de trabalho; Meios de comunicação; Infecções por Coronavirus; Estresse ocupacional

INTRODUCTION

The year of 2020 had a different beginning. The entire world was confronted with a new and alarming public health situation, the COVID-19. The first record of the disease was from the end of 2019, in a patient from the Chinese hospital Wuhan Jinyintan, indicating a viral pneumonia with characteristics of the coronaviruses1World Health Organization (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. Geneva: WHO; 2020 [cited 2020 Jul 20]. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf .
https://www.who.int/docs/default-source/...
. The disease advance, in regard to its dissemination, was fast, and in less than two months, more than 75 thousand cases were reported in China1World Health Organization (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) [Internet]. Geneva: WHO; 2020 [cited 2020 Jul 20]. Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf .
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The World Health Organization (WHO) declared that the situation was pandemic on March 11, 2020, with Italy being the new focus of contamination. The disease spread rapidly into many European countries, especially, Spain, France, and England, also reaching other continents, transforming the United States and Brazil in its most recent epicenters, with the highest death tolls in the planet.

In Brazil, the Ministry of Health diagnosed and registered the first case on February 26, 2020. Then, the spread of the disease increased intensely, and on August 10, 2020, more than three million Brazilians were contaminated and more than 100 thousand had already been killed by the disease2Ministério da Saúde (BR) [Internet]. COVID-19 no Brasil. 2020 [cited 2020 Jul 27]. Available from: https://qsprod.saude.gov.br/extensions/covid-19_html/covid-19_html.html .
https://qsprod.saude.gov.br/extensions/c...
. The dramatic situation in Brazil not only results from the potential the virus has to spread and to its lethality; it is also influenced by complex social determinants. The severity of the dissemination and mortality of the disease were strongly determined by the lack of a clear and articulated planning between the sectors of the government to fight against the disease.

Social isolation measures, the use of masks by the population as a whole, mass testing, and the availability of resources to care for the diseased are very different between states and cities, which makes it more difficult for the population to become involved with scientifically-based sanitary practices. The result were thousands of avoidable deaths. The actions of the president of the country himself are sanitary hazards, provoking large gatherings, denying the severity of the disease, and disseminating guidance with no scientific bases. This has led to manifestations and reports from labor, religious, scientific, and health worker organization, be it in scientific literature3COVID-19 in Brazil: "so what?" [editorial]. Lancet. 2020;395(10235):1461. doi: https://doi.org/10.1016/S0140-6736(20)31095-3.
https://doi.org/10.1016/S0140-6736(20)31...
, on national or international press, or in international tribunals.

Portugal, in turn, had its first confirmed case in March 2, 2020. In the same week, the complexity of the situation experienced in some European countries, especially Italy, was divulged through many different media, which contributed to alert society and mobilize the government and the health institutions to plan an effective response. Knowing that the health resources of the country were scarce, efforts were gathered, that is, the necessary attention to some needs was anticipated4Direção-Geral da Saúde (PT). Plano nacional de preparação e resposta à doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020 [cited 2020 Jul 06]. Available from: https://www.dgs.pt/documentos-e-publicacoes/plano-nacional-de-preparacao-e-resposta-para-a-doenca-por-novo-coronavirus-covid-19-pdf.aspx .
https://www.dgs.pt/documentos-e-publicac...
. At a moment when the number of cases still allowed for a fast response from the National Health System, field hospitals were organized, with the main goal to avoid the overcrowding of the hospitals with people with mild symptoms, which would correspond to approximately 80% of cases4Direção-Geral da Saúde (PT). Plano nacional de preparação e resposta à doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020 [cited 2020 Jul 06]. Available from: https://www.dgs.pt/documentos-e-publicacoes/plano-nacional-de-preparacao-e-resposta-para-a-doenca-por-novo-coronavirus-covid-19-pdf.aspx .
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Considering the fast evolution of the pandemic in the world and, particularly in the European Union, and with the awareness that Portugal would not be immune to this reality, the president of Portugal declared, on March 18, 2020, a national emergency5Portugal. Presidência da República. Decreto do Presidente da República n.º 14-A/2020, de 18 de março. Declara o estado de emergência, com fundamento na verificação de uma situação de calamidade pública. Diário da República. 2020 mar 18 [cited 2020 Jul 06];55/2020(3 Supl.):13-(2)-13-(4). Available from: https://dre.pt/application/conteudo/130399862 .
https://dre.pt/application/conteudo/1303...
. Despite the implications of this declaration from a social and economic standpoint, and considering the need to prioritize the health of the population, the prevention and treatment of COVID-19, and the efficient response of the health system, the emergency state was reinstated twice. From May 3, 2020, the situation was declared to be a public calamity, which, considering the success of the measures implemented earlier, have allows the Portuguese government to elaborate a legal framework that can regulate the gradual suspension of confinement measures6Portugal. Presidência do Conselho de Ministros. Decreto-Lei n.º 2020/2020, de 1 de maio. Altera as medidas excecionais e temporárias relativas à pandemia da doença COVID-19. Diário da República. 2020 maio 1 [citado em 2020 jul 06];85-A/2020:2-10. Available from: https://dre.pt/application/conteudo/132883356 .
https://dre.pt/application/conteudo/1328...
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Aware of the efforts of the government, and, particularly, of the health institutions, it did not take long before the Portuguese population noticed that there are similarities with the measures from other countries, considering the nonexistence of a vaccine and/or an efficient treatment, the focus was on preventing contamination. Social isolation, washing the hands frequently, and care with regard to respiratory etiquette were repeatedly encouraged and presented as the only solution. Although Portugal met some obstacles in dealing with the pandemic, a certain amount of control was achieved. Until August 10, 2020, a total of 52,825 infections and 1,759 deaths by COVID-19 were recorded7Direção-Geral da Saúde (PT) [Internet]. Ponto de situação atual em Portugal. Lisboa: DGS; 2020 [cited 2020 Aug 10]. Available from: https://covid19.min-saude.pt/ .
https://covid19.min-saude.pt/...
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Nurses are in the front line of prevention, treatment, and recovery of the victims of the coronavirus around the world, together with the other professions in the field of health8Miranda FMDA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impact on the health of the nursing profissionals in the context of Covid-19. Cogitare Enferm. 2020;25:e72702. doi: http://doi.org/10.5380/ce.v25i0.72702.
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. They suffer the consequences of the pandemic, including infections and death. In Brazil, until August 10, more than 32 thousand nursing workers had been infected, and 340 lost their lives in the struggle against the virus9Conselho Federal de Enfermagem (BR) [Internet]. Observatório da enfermagem. 2020 [cited 2020 Aug 10]. Available from: http://observatoriodaenfermagem.cofen.gov.br/ .
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. Although the statistics in Portugal are significantly lower, which could be justified by the way in which the country has been facing the pandemic, nurses are still under the imminent risk of infection.

This pandemic increased greatly the visibility of the profession, also showing a reality that has existed for a long time: the serious deficits in the working conditions of nurses. In the current moment, which is highly influenced by communication in its many forms, and especially by the strength of social media, online newspapers and television, that reach most of the population in the country, nurses have been using these resources to tell their story, express their feelings and denounce the difficulties experienced in the setting of their practice. Therefore, with two countries who are going through the same pandemic but are in such different situations concerning the damage to the population and to the health care workers, what have nurses expressed as they talk to society through the press?

Considering the above, this study aimed to analyze the most used words in interviews given by nurses during the coronavirus pandemic.

METHOD

This is a documentary research with qualitative, exploratory, and descriptive approach, using interviews given by nurses to high circulation newspapers in Brazil and Portugal, from March 2 to May 31, 2020. The countries were chosen considering the experience of the pandemic with differences in its impact over society and on nursing professionals, in addition to fact that the countries share the same language. The vocabulary of the same language is necessary to carry out a lexicographical analysis.

The study included publications from high-circulation newspapers, as defined by criteria from each country. The publications had to be available online and free of charge, and show interviews with nurses who reported their daily work during the coronavirus pandemic. Newspapers that required paid subscriptions, interviews with other nursing team members, and entities that represented the class of nurses or were from other orders were excluded.

To seek the interviews, a Google News® search was carried out using the words: nursing, nurses, covid, pandemic, coronavirus, interview. All interviews were saved in a single file and input in the software ATLAS.ti (Qualitative Research and Solutions), version 8.5.6. Data collection was interrupted when empirical and theoretical saturation were reached, indicating a satisfactory sample that attended to the objective.

For data analysis, a lexical analysis was carried out using the ATLAS.it, which makes it possible to carry out an analysis using a word cloud. The discussion of the data was inspired in the theory of the nursing work process10Pires D. A enfermagem enquanto disciplina, profissão e trabalho [ensaio]. Rev Bras Enferm. 2009;62(5):739-44. doi: https://doi.org/10.1590/S0034-71672009000500015.
https://doi.org/10.1590/S0034-7167200900...
.

The data were organized and prepared for the text to be fluid, with no identification of the individuals and/or newspapers, while also eliminating information that is unnecessary for this analysis, such as dates, times, name of the journalist, and ads. Then, the data were read in full so there could be a general perception about the information. Finally, the data was processed using a word cloud in a simple lexical analysis, in which the words are grouped considering the frequency showing: the higher the frequency, the greater the font.

Considering the word cloud, the words in the text were analyzed and interpreted, retrieving the segments where the most frequent words were mentioned to understand the meaning. The results are divided in the characterization of the interviewed nurses, and in the organization of what was shown in the reports, according with the lexical analysis of the word cloud.

To guarantee the anonymity of the newspapers and nurses, the following codes were used: N - Nurse, B - Brazil, and P - Portugal, followed by a cardinal number indicating the order in which the information was collected.

This research followed the steps recommended by the COREQ (Consolidated Criteria for Reporting Qualitative Research), respecting all ethical precepts in accordance with Resolution 466/2012 from the Brazilian Committee of Research Ethics in the National Council of Health, Brazil. There was no need for the analysis and approval of an Ethics Committee, considering that the source of data collection was in the public domain.

RESULTS

The study has included the analysis of 45 interviews, being 17 from Portugal and 28 from Brazil. Regarding the characterization of the nurses interviewed, most are female (37-82.2%), their age varied from 24 to 58 years old, 31 (68.8%) had been working as nurses for more than five years while 14 (31%) had done so for less than five years. Regarding their field of work, 28 (62.2%) work in Intensive Care Units, 12 (26.6%) in Emergencies and Pre-hospital Care, and 5 (11.1%) in other hospital inpatient units.

Using the word cloud, seven words were the most frequent: "home", with 90 occurrences; "nurse", with 58; "patients/diseased" and "care" with 52 each; "family" with 51; and "fear" with 44.

Figure 1 shows the word cloud generated by the ATLAS.ti® 8.5.6, with the positioning of the other words according with the frequency in which they appear (larger than the others) and with a stronger color.

Figure 1 -
Word cloud generated using ATLAS.ti®

In regard to the published news, in which the word "home" appears repeatedly, two perspectives were found concerning the coronavirus pandemic. One is related to the repeated times the nurses asked people to stay home and respect social isolation; the other was relative to their own distance from their homes, far from their family and friends in order to protect them.

So, what we can do is ask people to stay home as much as they can, to try and help us who are here in the front lines. Because what I can do is to go to the ICU and help the people who are there. If you don't work with this, you can do your part by staying home (NB22).

The nurse asks everyone to stay home (NP4).

My real issue is with the children, it's the fear to bring this thing home (NB13).

The children went to live with their father temporarily, and we talk via FaceTime or WhatsApp to deal with how much we miss each other (NP7).

The word "nurses" is connected to two issues: the valorization of the profession and the problems faced in regard to the structure of health services. In general, in both countries, terrible working conditions were found in the health services. This includes insufficient personal protective equipment and lack of materials, equipment, and supplies to care for coronavirus victims.

The profession isn't valued. When I came back to work, I knew I'd find a really bad a shocking scenario. But the market is worse and worse, it's cruel with the worker, and they want to hire nurses with lower pay or even as voluntaries. I felt very unfairly treated and even a bit despised. You feel like you're worth nothing. There is really no valorization (NB17).

We know that our profession demands this, that we cannot be isolated as other people can. We nurses should be more valued! (NB9).

This pandemic, at this moment, was only useful for us to understand how urgent it is to define the nurses' profession as a very wearing and high-risk one (NP1).

I know of colleagues from hospitals in the region who had to reuse personal protective equipment, and lack workers. However, that's how it's always been [...] terrible conditions that put us under even more risk (NB19).

The weapons of the nurses are the personal protective equipment. Please, don't take these away too! (NP2).

We, nurses, are used to seeing "everything", and working in conditions that "normal" people don't even dream of (NP5).

Regarding "patients/diseased" and "care", nurses refer to the seriousness of the situation the coronavirus imposes on them, especially due to fact that it is not a previously known respiratory infection, it is something entirely new and frightening.

It is terrible to be on duty, the patients were in terrible conditions and the improvement was slow, most patients are intubated and unconscious (NB8).

The patients are in really severe conditions and the team is giving its all 24 hours a day and the improvement you see is very little, sometimes, so slow that it seems that nothing is happening, and the patients have high demands because they are in really bad conditions, so it's a huge tiredness, physical and mental (NB26).

People arrive here as fishes out of the bowl, dying without air. I saw a 35-year-old young man with no history of illness, no comorbidities, a beautiful boy, die overnight. I took him to the ICU and he died (NB25).

I was used to dealing with diseased people in serious conditions, but not so many at once who need so much care (NP11).

These diseased people are a challenge. We want to save everyone (NP14).

I have worked with intensive care for 15 years, but I wasn't prepared for the demands of care from the new coronavirus (NP6).

The word "family" connoted sadness and missing, together with an idea of protection. The nurses highlighted the absence of relatives and good moments with their loved ones.

I'm away from my parents and my family, who are isolated in another city. My father closed his business and left, crying. It was hard to watch. My sister, who's also a nurse, she 'threw in the towel'. We don't have the means to deal with all this (NB10).

What everyone needs to consider is that the worker, to care for people, is exposing his own life and that of his family (NB5).

I have been sleeping in my car for almost two months to protect my family. Our greatest concern is not getting sick, it's taking the disease to our family, to our loved ones (NB16).

I'm scared because I don't know when I'll see my children again. Yesterday, when I heard the declaration of the President of the Republic, I only felt like crying. This has barely started, I don't know when it will stop (NP13).

Not being with family and friends is very difficult, because I'm formed by people (NP15).

This fear led me to make a hard and difficult choice: leaving my family and staying in a hotel made available for health workers, very close to the hospital (NP8).

The word "fear" is spread throughout the experience of the nurses during this period of pandemic, and manifests in distinct ways. The nurses fear for their lives and those of their family and friends, the lives of their colleagues and their own, since they are so much more exposed to the virus.

Yes, I'm afraid. But right now, I face the fear as fuel to stay alert and watchful, to guarantee that I can react and respond adequately to what is put in front of me, to what is demand and expected. This fear I feel leads me to be meticulous and always make sure, always, that I don't run risks or put others at risk (EP17).

Fear of being infected and, especially, of being a means through which the disease can spread, to infect my colleagues, the diseased and my family (NP8).

The fear takes hold of most of the unending hours of my shift and even after it, but we hold on to the small victories day in, day out, to face each day, one at a time (NP12).

The feeling that's left is fear, and anxiety really, because we are the first people the user meets when he arrives at the unit. We do this triage (NB3).

I believe a consensus of the team is that the worse is yet to come, and that's when fear comes, if today it's already this bad. I think that, everyone there in the ICU thinks the worse is yet to come, that it's still to come (NB24).

As much as we were trained to do this, we feel very afraid of catching the disease, because we don't know what's after that. We feel very exposed, almost all the time, and since I was working directly with COVID-19, it was even riskier (NB28).

DISCUSSION

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), better known as COVID-19, surfaced unexpectedly. As a new nosological entity, it represents one of the greatest challenges the world is facing8Miranda FMDA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impact on the health of the nursing profissionals in the context of Covid-19. Cogitare Enferm. 2020;25:e72702. doi: http://doi.org/10.5380/ce.v25i0.72702.
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, requiring a coordinated and responsible response. Health systems, governments, and many instances of society need to agree on the ways to face the crisis being guided by an essential value: the defense of life.

The context imposed by the COVID-19 pandemic has revealed a new side of health care, especially because, more than ever, prevention is the only "medicine" found until the moment. Cutting-edge technology, especially material technology, has been used to maintain and save lives. However, simple techniques and attitudes (washing hands, using a mask, cleaning materials, and staying home) are the real responsible for reducing the dissemination of the new coronavirus, avoiding the overload of health institutions and deaths.

This is a collective health problem that cannot be treated only with technologies from a biomedicine perspective. The knowledge of the health professions need to be articulated, considering especially that of nurses which involves the complexity and multiple dimensions of human care, as well as the knowledge accumulated by epidemiology, anthropology of health, mathematics, economics, and sociology. The concepts of health determination of the health-disease process, interdisciplinarity, interprofessionality, and intersectorality have been, more than ever, shown to be essential to confront the pandemic11Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Salud Pública. 2013 [cited 2020 Aug 10];31(Supl 1):S13-S27. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-386X2013000400002&lng=en .
http://www.scielo.org.co/scielo.php?scri...
.

The experience around the globe warned us about the need to control the speed of the progression of the epidemic curve12Rafael RMR, Neto M, Carvalho MMB, David HMSL, Acioli S, Faria MGA. Epidemiology, public policies and Covid-19 pandemics in Brazil: what can we expect? Rev Enferm UERJ. 2020;28:e49570. doi: https://doi.org/10.12957/reuerj.2020.49570.
https://doi.org/10.12957/reuerj.2020.495...
. Among the most effective measures, as many countries have shown, physical social isolation stands out. However, while the population was asked to keep this isolation, staying home, health professionals, especially nursing ones, continue in the frontlines of the fight against COVID-19.

In this setting, this research focused on the "voice of those who care". To do so, it aimed to identify what the nurses have been saying to society through the press. The results have shown the relevance and the nature of the professional work of nurses, the importance of the working conditions, and the implications of this work for those who carry it out.

The word "home" was the most common in the interviews with the nurses and was found to be a multivocal term. It expresses that these workers base their practice on the available scientific knowledge as they advocate for the population to "stay home", to protect themselves and save lives. This is also expressed as a professional responsibility, as they recognize the importance of being present in the health services to care and alleviate the suffering of people. However, this does not let them "stay home", limiting their self care. The nursing workers are afraid to go back to their homes and, sometimes, stop coexisting with their family to guarantee their safety.

Interviews published in the press showed many appeals nursing workers made for people to stay home. This was also identified in another study13Forte ECN, Pires DEP. Nursing appeals on social media in times of coronavirus. Rev Bras Enferm. 2020;73(Supl 2):e20200225. doi: https://doi.org/10.1590/0034-7167-2020-0225.
https://doi.org/10.1590/0034-7167-2020-0...
. Physical isolation makes it possible to control the epidemic curve and to diminish the number of cases of infection and of hospitalized diseased persons, also reducing the likelihood of infections among nursing workers. This, consequently, reduces their anxiety and their fear of being infected and contaminating their relatives14Bezerra ACV, Silva CEM, Soares FRG, Silva JAM. Factors associated with people’s behavior in social isolation during the COVID-19 pandemic. Ciênc Saúde Coletiva. 2020;25(Supl 1):2411-21. doi: https://doi.org/10.1590/1413-81232020256.1.10792020.
https://doi.org/10.1590/1413-81232020256...
.

In the same interpretive vein, excerpts from the interviews related to the object of work of nursing stand out, articulating the words "home", "patients/diseased", and "care". Nurses, when they talk about the profession and their actions, always highlight their preoccupation with those they care for, the patients/diseased/people who need the care of nursing professionals, considering their individuality, family relations, and cultural standards15Moreira DA, Ferraz CMLC, Costa IP, Amaral JM, Lima TT, Brito MJM. Professional practice of nurses and influences on moral sensitivity. Rev Gaúcha Enferm. 2020;41:e20190080. doi: https://doi.org/10.1590/1983-1447.2019.20190080.
https://doi.org/10.1590/1983-1447.2019.2...
. They recognize the severity of the disease and show to be sensible and empathetic in regard with the suffering of hospitalized people and the vulnerability of the population concerning the harm caused from coronavirus. Since the pandemic started, predicting the possibility of an increase in the number of cases and loss of capacity from the health systems4Direção-Geral da Saúde (PT). Plano nacional de preparação e resposta à doença por novo coronavírus (COVID-19). Lisboa: DGS; 2020 [cited 2020 Jul 06]. Available from: https://www.dgs.pt/documentos-e-publicacoes/plano-nacional-de-preparacao-e-resposta-para-a-doenca-por-novo-coronavirus-covid-19-pdf.aspx .
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, health workers, specifically, those in the field of nursing, were tireless in the dissemination of preventive measures, which was perceivable in the findings from the interviews.

In third place, it could be noted that, in parts of the interviews, which were articulated in the words "nurse", "patient/diseased", "care", and also in the words "protection" and "mask", two aspects stood out. First, the relevance and need for social valorization of this profession, which is essential for human life. Second, that even in different institutional and political settings, adequate and safe environments for the practice of the profession are paramount to protect the workers and those who receive care from nurses.

During the critical stage of the COVID-19 pandemic, civil society has shown recognition from the work provided by nursing workers. However, the profession fears that this is a temporary valorization, due to the dramatic situation the world is going through right now, instead of being based on the true value of the profession.

Professional nursing work needs qualified workers, specifically educated for this purpose, in addition to the permanent production of knowledge that serves as a base for the practice in constantly changing settings, not to mention adequate working conditions, laws to protect the workers and ethical norms to guide the decision making process8Miranda FMDA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impact on the health of the nursing profissionals in the context of Covid-19. Cogitare Enferm. 2020;25:e72702. doi: http://doi.org/10.5380/ce.v25i0.72702.
http://doi.org/10.5380/ce.v25i0.72702...
,10Pires D. A enfermagem enquanto disciplina, profissão e trabalho [ensaio]. Rev Bras Enferm. 2009;62(5):739-44. doi: https://doi.org/10.1590/S0034-71672009000500015.
https://doi.org/10.1590/S0034-7167200900...
,15Moreira DA, Ferraz CMLC, Costa IP, Amaral JM, Lima TT, Brito MJM. Professional practice of nurses and influences on moral sensitivity. Rev Gaúcha Enferm. 2020;41:e20190080. doi: https://doi.org/10.1590/1983-1447.2019.20190080.
https://doi.org/10.1590/1983-1447.2019.2...
). To value nursing work means to invest in the profession.

As they go through unprecedented situations, the nursing professionals show the world that knowledge and vocation are the guides of their professional action. Competence, resilience, and the spirit of a mission have been determining factors in the fight against the new coronavirus.

This result reiterates that which is widely registered in literature, that in health, the workforce is fundamental, with emphasis on nursing professionals. They are relevant due to its numerical contingent, its presence in the services, and the centrality of their work, dedicated to human care10Pires D. A enfermagem enquanto disciplina, profissão e trabalho [ensaio]. Rev Bras Enferm. 2009;62(5):739-44. doi: https://doi.org/10.1590/S0034-71672009000500015.
https://doi.org/10.1590/S0034-7167200900...
. This means that, even in a dramatic situation, such as the COVID-19 pandemic, in a world moved by technological development, especially 4.0 technology, which allows for the interconnection of data, both to monitor the advance of the pandemic and to push forward the work of scientists in many locations in the planet searching for a vaccine and of medication, care is essential. In practice, bedside care, relatives care and health education actions are paramount for prevention, damage control, and the preservation of life.

In the scope of the United Nations (UN) and the World Health Organization (WHO), the importance of health as a universal right is discussed, including questions about how and what to do to achieve universal access. In this setting, the fundamental value of nursing work has been recognized. The campaign "Nursing Now", formulated by the International Council of Nurses (ICN) in partnership with the English parliament and the WHO, stands out in this regard 16Cassiani SHB, Lira Neto JCG. Nursing perspectives and the “nursing now” campaign. Rev Bras Enferm. 2018;71(5):2351-2. doi: https://doi.org/10.1590/0034-7167.2018710501.
https://doi.org/10.1590/0034-7167.201871...
. The WHO 17International Council of Nurses [Internet]. WHO and partners call for urgent investment in nurses. Geneva: ICN; 2020 [cited 2020 Jul 25]. Available from: https://www.icn.ch/news/who-and-partners-call-urgent-investment-nurses?fbclid=IwAR2gRxgs6OMnMoqHZAF7IkrT6xZOsfsd5HPgpgOwbK3wFksYZBzY7PFRjeo .
https://www.icn.ch/news/who-and-partners...
warns the governments of several countries about the need to invest in nursing, since, if they do not, they may see a worsening of current health problems. The "Nursing Now" campaign (2018-2020) recognized the importance of nursing for the health of the population, which was tragically and exemplarily confirmed in this pandemic.

Despite these international recommendations for investing in nursing to qualify health services, the interviews show how much has to be done for this to be operationalized in regard to health policies. Nursing workers are 59% of the work force in the health sector18World Health Organization (WHO). State of the world's nursing 2020: investing in education, jobs and leadership [Internet]. Geneva: WHO; 2020 [cited 2020 Jul 25]. Available from: https://apps.who.int/iris/bitstream/handle/10665/331677/9789240003279-eng.pdf?sequence=1&isAllowed=y .
https://apps.who.int/iris/bitstream/hand...
and are in the frontlines of the fight against the pandemic. However, the profession still needs to fight hard to guarantee dignified working conditions.

Although the media often shows the efforts of health institutions in providing adequate human and material resources for the struggle against the pandemic, the context nursing workers deal with are still far from ideal. These professionals are aware of the long work hours, interpersonal conflicts, the feelings of fear and impotence, and the low remuneration8Miranda FMDA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impact on the health of the nursing profissionals in the context of Covid-19. Cogitare Enferm. 2020;25:e72702. doi: http://doi.org/10.5380/ce.v25i0.72702.
http://doi.org/10.5380/ce.v25i0.72702...
,13Forte ECN, Pires DEP. Nursing appeals on social media in times of coronavirus. Rev Bras Enferm. 2020;73(Supl 2):e20200225. doi: https://doi.org/10.1590/0034-7167-2020-0225.
https://doi.org/10.1590/0034-7167-2020-0...
. They also have to deal with the lack of personal protective equipment in adequate numbers and of adequate qualities, which could endanger them even more.

In Brazil, the Federal Council of Nursing created a channel to give support to the nursing workers in the frontlines. The feelings that were declared during the attention provided were: anxiety, related to the lack of PPE; pressure from immediate superiors; and news from the media. The stress was associated with the high number of people who arrive at the health service and of deaths from COVID-19, and to the fear of being infected and infecting their families19Humerez DC, Ohl RIB, Silva MCN. Mental health of Brazilian nursing professionals in the context of the covid-19 pandemic: action of the Nursing Federal Council. Cogitare Enferm. 2020;25:e74115. doi: http://doi.org/10.5380/ce.v25i0.74115.
http://doi.org/10.5380/ce.v25i0.74115...
.

The lack of PPE shows the lack of working conditions nurses from all over the world have dealt with when fighting against the pandemic. For the pandemic to be confronted, the safety of the workers must be guaranteed, and predicting and providing for it adequately is the first step towards this goal13Forte ECN, Pires DEP. Nursing appeals on social media in times of coronavirus. Rev Bras Enferm. 2020;73(Supl 2):e20200225. doi: https://doi.org/10.1590/0034-7167-2020-0225.
https://doi.org/10.1590/0034-7167-2020-0...
.

In fourth, also focusing on the workforce, the relationship between professional and personal life was highlighted, including the importance and difficulty of caring for oneself and one's relatives, and the fear of infection and death, which were identified in the texts in the articulation of the words "home", "family", "fear", and "protection".

Nursing workers and those who are their work object have the same human nature. Therefore, the transformative action of their work involves relations and exchanges between them. This is important for an effective result, be it in the care for hospitalized patients or in the many scopes of the practices of care, which has been mentioned in a previous study10Pires D. A enfermagem enquanto disciplina, profissão e trabalho [ensaio]. Rev Bras Enferm. 2009;62(5):739-44. doi: https://doi.org/10.1590/S0034-71672009000500015.
https://doi.org/10.1590/S0034-7167200900...
.

The difficulties in putting to effect protective measures show that the health-disease process has multiple and complex determinations11Breilh J. La determinación social de la salud como herramienta de transformación hacia una nueva salud pública (salud colectiva). Rev Fac Nac Salud Pública. 2013 [cited 2020 Aug 10];31(Supl 1):S13-S27. Available from: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=S0120-386X2013000400002&lng=en .
http://www.scielo.org.co/scielo.php?scri...
. The issue of respecting social isolation is a very apt illustration of the complexity of the phenomenon. Nurses and health authorities appeal daily towards this goal, but putting it into effect is difficult. In the Brazilian reality, one of the factors that contributes with this difficulty seems to be related to the high number of fake news surrounding the topic. A study14Bezerra ACV, Silva CEM, Soares FRG, Silva JAM. Factors associated with people’s behavior in social isolation during the COVID-19 pandemic. Ciênc Saúde Coletiva. 2020;25(Supl 1):2411-21. doi: https://doi.org/10.1590/1413-81232020256.1.10792020.
https://doi.org/10.1590/1413-81232020256...
about social isolation shows that, despite the abundant information about the importance of isolation, 7.88% of people still doubt the strategy. The decision to adhere to isolation, on the other hand, is related to the fear of becoming infected and suffering even greater financial and health damage. The quarantine of contact and the social isolation measures (with a reduction of 60% of social contacts) has shown its effectiveness in the reduction of the transmission of the disease.

This reality led nurses to acquire, on their own, personal protective equipment, to adopt highly specific hygiene procedures in their homes8Miranda FMDA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impact on the health of the nursing profissionals in the context of Covid-19. Cogitare Enferm. 2020;25:e72702. doi: http://doi.org/10.5380/ce.v25i0.72702.
http://doi.org/10.5380/ce.v25i0.72702...
,13Forte ECN, Pires DEP. Nursing appeals on social media in times of coronavirus. Rev Bras Enferm. 2020;73(Supl 2):e20200225. doi: https://doi.org/10.1590/0034-7167-2020-0225.
https://doi.org/10.1590/0034-7167-2020-0...
and to make hard decisions, becoming more distant from their families and living near the hospitals, often in hotels, lodgings, or accommodations made available by the government and/or by civil society.

The workers experience, daily, the ambivalence of being applauded on one side, receiving recognition in regard to the social importance of their work, and being discriminated on the other side, as potential agents that can transmit the COVID-19. In addition, the lack of institutional valorization, the depression associated with the loneliness and with the death of co-workers, as well as the emotional exhaustion associated with the amount of work has also led the workers to seek emotional support17International Council of Nurses [Internet]. WHO and partners call for urgent investment in nurses. Geneva: ICN; 2020 [cited 2020 Jul 25]. Available from: https://www.icn.ch/news/who-and-partners-call-urgent-investment-nurses?fbclid=IwAR2gRxgs6OMnMoqHZAF7IkrT6xZOsfsd5HPgpgOwbK3wFksYZBzY7PFRjeo .
https://www.icn.ch/news/who-and-partners...
.

Unfortunately, around the world, there already are a significant number of cases indicating the disease and death of nursing workers due to COVID-19. According to news from the ICN, in June 3, 2020, following the issuing of official data from a limited number of countries, it has been confirmed that at least 230,000 nurses were infected by the disease, and more than 600 died due to the coronavirus. Aware that this data is far from the reality, the ICN have asked the several countries not only to record the number of infections and deaths of nursing professionals, but also to take the necessary measures to protect these workers who, working towards the recovery of the diseased and the wellbeing the population, have been significantly exposed to the risk of falling ill or even dying20International Council Nurses [Internet]. More than 600 nurses die from covid-19 worldwide. Geneva: ICN; 2020 [cited 2020 Jul 29]. Available from: https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide .
https://www.icn.ch/news/more-600-nurses-...
.

In Portugal, although no deaths from nursing professionals fighting against COVID-19 were recorded, the number of infected workers is worrying and requires monitoring. In Brazil (August, 2020), however, the situation is substantially more serious, and stands out due to the growing number of deaths among nursing workers. From the more than 32 thousand cases reported, 15,112 cases were confirmed, 3,145 were not, and 13,861 remained suspected. The lethality rate in Brazilian nurses is 1.96%9Conselho Federal de Enfermagem (BR) [Internet]. Observatório da enfermagem. 2020 [cited 2020 Aug 10]. Available from: http://observatoriodaenfermagem.cofen.gov.br/ .
http://observatoriodaenfermagem.cofen.go...
.

This data shows that the political settings, the institutional practices, and the work conditions are distinct in these countries. In Portugal, there was an immediate recognition of the seriousness of the situation, which was confronting the world, and, particularly, the European countries. The Portuguese government, the organization of the health institutions, and the reasonable actions of the people determined the trajectory of the disease in Portugal, as well as the mortality of nursing professionals. On the other hand, in Brazil, there has been a discrepancy between the measures adopted by the federal, state, and city governments, leading to uncontrolled contamination indices, with consequences for both the general population and those who are in the frontlines of care. Brazil has a universal public health system, the Single Health System (SUS), which has been the protector of the population. However, its chronic underfunding, in association with the disastrous government management of the pandemic3COVID-19 in Brazil: "so what?" [editorial]. Lancet. 2020;395(10235):1461. doi: https://doi.org/10.1016/S0140-6736(20)31095-3.
https://doi.org/10.1016/S0140-6736(20)31...
led to more than 100 thousand deaths in a period of 5 months.

Nurses are protagonists in this story, both for their tireless and constant work in all levels of health services, and for the fact that they are victims, and suffer with a high number of disease and death. The experience of nurses in the pandemic, in Portugal and in Brazil, has shown that they are identified in regard with the nature of their work and with their preoccupations, but disease and death numbers are completely different between them.

The limitations of this study are associated with how difficult it is to access the complete content of certain news pieces that could be part of the corpus analyzed, but were not, due to the fact that the newspapers that had them required paid subscriptions.

FINAL CONSIDERATIONS

Listening to the voice of those who provide care, to their appeals, guidance, and to their fear when confronted with the pandemic, shows the social importance of nursing to guarantee the health of population. As a result, the most common word was "home", present in appeals to raise the awareness of the population and showing the difficulties they are going through themselves. It also exposes the challenges that still need to be dealt with, regarding the guarantee of better work conditions.

In the context of the pandemic crisis, in the scope of the reorganization and restructuring of health services, the involvement of the professionals is essential, highlighting, especially, nursing workers, who represent more than half the workforce in the field of health.

The pandemic has shown the world how necessary it is to adapt to a new reality, or, as it has been called, a new "normal". The new normal imposes sanitary precautions, social isolation, public investment in health, and shows the hidden side of social inequality. The guarantee of social rights was never so necessary, showing the relevance of the State in the protection of the population.

In 2020, the "Nursing Now" campaign has been repeated beyond its slogan, that cries for the valorization of nursing. "Nursing Now", in times of pandemic, also shows the relevance of this profession and the commitment nurses have to life.

REFERENCES

Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Data availability

Data citations

Ministério da Saúde (BR) [Internet]. COVID-19 no Brasil. 2020 [cited 2020 Jul 27]. Available from: https://qsprod.saude.gov.br/extensions/covid-19_html/covid-19_html.html

Publication Dates

  • Publication in this collection
    12 Nov 2021
  • Date of issue
    2021

History

  • Received
    26 Aug 2020
  • Accepted
    09 July 2021
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