Abstract

The mental health of health professionals who worked directly in services during the COVID-19 pandemic to care for patients affected by the disease became a fundamental issue to be considered, given the several consequences of this activity for these professionals. This article aimed to understand the challenges and demands of health professionals concerning support to address the emotional and physical exhaustion of working on the so-called frontline during the COVID-19 pandemic. The qualitative methodological approach was based on semi-structured interviews conducted online with these professionals after the first months of the pandemic. The hero’s place in which they were set, even if only in media discourses, soon gave way to their weaknesses and fragile work relationships to emerge: stress, fear, and the listening and reception desire. Marcel Mauss’ gift theory was brought up considering that new ways of reading and interpreting health work relationships contribute to necessary and urgent reformulations of their current context, targeting mental health and, more broadly, the comprehensive health of healthcare professionals.

Key words:
COVID-19; Mental health; Health professionals

Introduction

This article contextualizes the healthcare professional’s role in caring for patients affected by COVID-19 in the first year of the pandemic. More than two years into the onset of the health emergency¹1 Lipsitch M, Swerdlow DL, Finelli L. Defining the epidemiology of COVID-19 - studies needed. N Engl J Med 2020; 382(13):1194-1196., this work presents statements from health professionals who worked in person during the first months of the pandemic in Rio de Janeiro state public and private institutions.

The global flexible work paradigm, which defines the free worker as starting from their ability to be open and prepared for changes, produces new power and control²2 Sennett R. A corrosão do caráter: as consequencias pessoais do trabalho no novo capitalismo. Rio de Janeiro: Record; 2008. structures instead of creating better conditions. The pandemic emerges in this setting of devaluation, demanding more from workers without ensuring the necessary rights and support. Besides the harsh epidemiological context, the pandemic revealed what years of substandard work resulted in the lack of public policies, fragile labor rights, and health sector underfunding³3 Helioterio MC, Lopes FQRS, Sousa CC, Souza FO, Pinho PS, Sousa FNF, Araújo TM. COVID-19: por que a proteção da saúde dos trabalhadores e trabalhadoras da saúde é prioritária no combate à pandemia? Trab Educ Saude 2020; 18(3):e00289121..

The first Brazilian case of the disease was recorded on February 25, 2020⁴4 Lancet The. COVID-19 in Brazil: "So what?". Lancet 2020; 395(10235):1461.. In the subsequent months, registered cases and deaths increased dramatically, and the demand grew exponentially for these professionals. Besides exposure to physical conditions, which generated a large number of infections and even deaths of healthcare workers⁵5 Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, Ng CH. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020; 7(3):228-229., according to the World Health Organization (WHO), professionals were at an even greater risk of developing mental health issues⁶6 Loss JC, Boechat L, Silva L, Dias V. The mental health of health professionals on the front lines against COVID-19. Rev Transform 2020; 14(4):54-75. during this period. Even so, actions aimed at caring for professionals were not always put into practice or seen as a priority by public or private services.

We are in 2022, and the health emergency persists, resulting in several meaningful and lasting developments⁷7 Diniz D. O legado da Zika. Correio Braziliense 2017; 19 nov.. Thus, addressing how workers’ mental health has been affected in recent months is vital, considering their precarious context in the pre-pandemic period.

The present study seeks to understand the needs and demands highlighted by health professionals regarding support to address emotional and physical exhaustion and the challenges faced by those who worked on the so-called frontline during the COVID-19 pandemic. Given the multiplicity and characteristics of health work, the present study opted to listen to health professionals providing direct and continuous care to patients infected by COVID-19.

Methodological path

Based on the interest and need to know more about health professionals and their work in the COVID-19 pandemic, a group of researchers from the Fernandes Figueira National Institute of Women, Child, and Adolescent Health - Fiocruz (IFF/Fiocruz) developed the research project “Clinical-epidemiological and psychosocial profile of health professionals in the face of the COVID-19 epidemic in the state of Rio de Janeiro (COVIDPRO)”. This project is registered on Plataforma Brasil under CAEE 31997320.5.0000.5269 and was approved by the IFF/Fiocruz Research Ethics Committee under Opinion N° 4.102.925.

A questionnaire was prepared with 30 closed-ended questions and one open-ended question⁸8 Camacho KG, Gomes Junior SCS, Reis AT, Junqueira-Marinho MdF, França LCM, Abramov DM, Azevedo ZMA, Moreira MEL, Vasconcelos ZFM, Salú MS, Silva ML, Castro BSM, Rodrigues JM, Pereira CD, Werner Junior J, Bastos Junior RM, Caixeta DML, Moore DCBC. Repercussions of the COVID-19 pandemic on health professionals in the state of Rio de Janeiro/Brazil. PLoS ONE 2022; 17(1):e0261814. searching for data on demographic and work characteristics and their interface with mental health. This document was shared with participants in an electronic form developed on the Google Forms platform and sent with a link for access through social networks.

This form was answered by 1,190 participants, who accepted the Informed Consent Form before starting the questionnaire. Five hundred fifty-four responded to the open-ended question: “We would like to leave this space open for you to write how you feel during this pandemic or contribute with suggestions for issues not covered in this study”.

After completing the questionnaire, it was possible to signal interest in participating in the interview that integrates the qualitative part of the study, which this article presents. One hundred twenty-six of these 554 people who responded to the open-ended question volunteered to participate in the interview. An email was sent to those providing direct and continuous care to COVID-19 patients, inviting them to the next step. In the end, ten interviews were held virtually via the Zoom platform.

Methods: the qualitative stage

Semi-structured interviews⁹9 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2012. were performed from a previously prepared roadmap. Each interview lasted an average of 40 minutes, totaling more than seven hours of recording. The roadmap aimed to grasp what health professionals’ most significant challenges were and how they addressed these issues in the first months of the pandemic: their work routine, how they felt in this environment, and how this was reflected in their personal lives. We also aimed to understand what support each professional received or would like to have received as a healthcare worker in such a challenging time. The ten respondents were from different professional categories, age groups, and work profiles, and all were Rio de Janeiro state residents (Chart 1).

The interviews were subjected to meaning interpretation method principles. Under this method, the context, reasons, and logic undertaken that evoke actions and interactions between groups and institutions¹⁰10 Caillé. O dom entre interesse e desinteressamento. In: Martins PH, Campos RB, organizadores. A polifonia do dom. Recife: Ed. Universitária; 2006. p. 25-65. matter. The gift theory, whose main systematizer is Marcel Mauss¹¹11 Mauss M. "Ensaio sobre a dádiva: forma e razão da troca nas sociedades arcaicas" em sociologia e antropologia. São Paulo: Cosac Naif; 2003., supported the analysis structure of the interviews. The extracted participants’ statements revealed the central ideas and their underlying meanings, ultimately providing the organization of interpretative cores. The discussion on mental health and work relationships was articulated considering the interpersonal exchange system’s effect.

Lacerda and Martins¹²12 Lacerda A, Martins PH. A dádiva no trabalho dos agentes comunitários de saúde. Realis 2013; 3(1):194-213. discuss the importance of collective health studies, adding the gift theory to their health services analyses. This allows an expanded understanding of how social relationships and social networks are established in the daily routine of health services. The authors point out that the gift circulation in health is still little explored in Brazil. However, ongoing discussions elucidate that relationships in health services are also established from this paradigm at the most diverse care levels and intertwine with the state and commercial rationales.

Results and discussion

Social relationships can be analyzed from different categories, but we cannot downsize them to just one. The power relationships that arise and the importance of the economic interest that guides many interactions are fundamental. However, they cannot expose exchanges that cannot be described or explained within utilitarian thinking. The option to discuss the results of this study based on the concept of gift aligns with the perspective that social relationships in health and work must be interpreted by subverting market logic¹³13 Antunes R. Coronavírus: o trabalho sob fogo cruzado. São Paulo: Boitempo; 2020.

Understanding the gift as a bare exchange system of social life allows us to break with this utilitarian and dichotomous thinking in which society would only be the result of the actions of the State and the market¹⁴14 Martins PH. A sociologia de Marcel Mauss; dádiva, simbolismo e associação. In: Martins PH, Campos RB, organizadores. A polifonia do dom. Recife: Ed. Universitária; 2006. p. 89-116.. Unlike the two-party system of the market, which works through the give-pay equivalence, in the gift (give-receive-return), the returned goods never have the same value as that initially received; the value that matters is qualitative: what grounds the return is not the equivalence, but rather asymmetry.

To mark the distinction of the gift against the economy, Caillé¹⁰10 Caillé. O dom entre interesse e desinteressamento. In: Martins PH, Campos RB, organizadores. A polifonia do dom. Recife: Ed. Universitária; 2006. p. 25-65. proposes a definition in which the gift can be qualified as any service or good provided without the guarantee of return to create, feed, or recreate the social bond between people. This definition brings to the fore a dimension ignored or even denied by economists and shows that goods and services can also be valuable based on their capacity to create and reproduce social relationships, thus having a value not only for exchange or use but as a bond, which is worth more than the goods.

As a result, we can understand that a gift is not an economic model but a person-to-person social system that continues to this day and is, therefore, dear to analyzing current situations and contexts¹⁵15 Godbout J. O espírito da dádiva. Rio de Janeiro: Ed. FGV; 1999.. Very little was known about COVID-19 during the first months of the pandemic, its transmissibility and severity, and health professionals were allocated on the frontline in this setting full of uncertainty. Those who, even without knowing what awaited them, often without resources, needed to be the “heroes” or “warriors”. The narrative created about this experience was closely linked to these signs, even before topics such as scarcity of resources, increased workload, and rights that were not being fulfilled were questioned.

The asymmetry, a fundamental point for discussing the gift, was soon exposed. It was not for the salary that people stood up and supported themselves or thought they would sustain their position before the advancing pandemic. This hero status has always been very fragile. So, what else was at stake? What else can we say about these exchanges in which what is offered is much more than what is received in return if we could put it objectively?

A vital characteristic to consider is that symmetry in the gift circulation is not always possible nor desirable, such as when differences are exacerbated, such as adults and children, or care for people in health or socially vulnerable situations. A new term, benevolence, should be added to discuss this asymmetry. Someone needs to be benevolent.

The highlighted excerpts make us wonder what this desire would be, what would be at stake for health professionals to make themselves available to work in a very uncertain and, as we will see, often precarious setting. It is not the money, in the respondent’s words. However, something that she cannot name but still made her “go” makes us bring the gift theory to discuss work relationships and the symbolic exchanges of these professionals during the most challenging moments of the pandemic, which cannot be merely narrowed down to an economic relationship.

Considering the gift’s symbolic cycle, what moves us is the desire to be recognized as generous donors. However, this recognition is intertwined with several social aspects. Therefore, recognizing that not all gifts bring honor and prestige is an essential improvement in the gift theory¹⁶16 Caillé. Dádiva, care e saúde. Sociologias 2014; 16(36):42-59..

Once again, the asymmetry, typical of gift exchanges, surfaces. Although most professionals genuinely desired to be on this frontline, occupying this position took work. The complex setting that the pandemic created brought several consequences for those who worked directly in patient care. The new care demands generated physical and mental exhaustion among professionals, influenced by decision-making in extremely delicate situations and suffering from losing patients and co-workers. All of this contributed to the emotional overload of these professionals, affecting their mental health¹⁷17 Fermandes MA, Ribeiro AAA. Salud mental y estrés ocupacional en trabajadores de la salud a la primera línea de la pandemia de COVID-19. Rev Cuidarte 2020; 11(2):e1222..

Even though the care demands, which these professionals are accustomed to address, are linked to the physical health of their patients, during the pandemic, the issue of mental health care, of embracing pain and suffering, became even more evident as something that cannot be dissociated from biological aspects and disease care, reinforcing the meaning of comprehensive health¹⁸18 Camargo Junior KR. Um ensaio sobre a (in)definição de integralidade. In: Pinheiro R, Mattos RA. Construção da integralidade: cotidiano, saberes e práticas em saúde. Rio de Janeiro: IMS Abrasco; 2003. p. 35-43.. However, dealing with suffering so openly and amid so much uncertainty created even more overload on professionals, who also needed a receptive place for their suffering.

The respondent’s statement is blunt. At some point, she realizes that the silence has a meaning. It was fear, the fear of dying, that patients faced seeing so many others dying every day. This fear was also put on the professionals, affecting their mental health.

The respondent’s statement points to the question about gift and mental health. The hero’s role implied an emotional availability that is often hard to sustain. Permanent fear certainly generated high stress and affected professionals’ daily lives. “Not talking” appeared as a fragile but possible psychic defense to address suffering and the desire to remain working on the frontline. There was a lack of strategies to make professionals feel safer to face the pandemic and all its consequences. The idea of the group as a team supporting each other and working together was certainly crucial to providing a psychological contour to professionals, but insufficient to avoid stress-related outcomes¹⁹19 Krystal JH. Responding to the hidden pandemic for healthcare workers: stress. Nat Med 2020; 26(5):639..

Having a space to address these new feelings linked to work and emotional overload was necessary; listening to these professionals was fundamental to rethinking the place of mental health in a unique moment, which exacerbated and complicated pre-existing challenges in health work²⁰20 Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020 323(21):2133-2134.. Several demands were identified when people started listening to these professionals. Some measures were crucial²⁰20 Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020 323(21):2133-2134.

21 Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singap 2020; 49(3):155-160.

22 Greenberg N, Brooks SK, Wessely S, Tracy DK. How might the NHS protect the mental health of health-care workers after the COVID-19 crisis? Lancet Psychiatry 2020; 7(9):733-734.^-2323 Wu PE, Styra R, Gold WL. Mitigating the psychological effects of COVID-19 on health care workers. CMAJ 2020; 192(17):E459-E460.: from actions to implement strategies to provide more safety to professionals, such as training in the correct use of PPEs and availability of this equipment, better flow and screening of these patients (so that professionals are not so exposed to undiagnosed patients), testing, workload reduction and, finally, psychological support for these professionals.

The role of someone who could serve as a reference for professionals within their services often needed to be completed. Typically, heads of sectors and managers could not be close to their teams because of uncertainty and almost daily changes in information and protocols. However, professionals who occupy these leadership positions must understand the sources of employee concerns and work together to reduce them. Concrete answers are expected in order to reduce these concerns, not even solutions to problems, but that questions raised are listened to and acted upon to have them addressed, showing that their perspectives were heard and considered relevant²⁰20 Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020 323(21):2133-2134..

These measures start from listening and reclaiming the subject’s place by circulating the gift: giving, receiving, and reciprocating. Nothing works if professionals and managers do not permanently help each other with technical advice, emotional support, and information of all sorts, thus recreating the social bond. Even if asymmetrical, the gift implies a circulation in which everyone recognizes themselves as subjects participating in the same social and historical moment, committed to the fabric of the health work process.

Health practices are complex and diverse. So, in some services, social relationships are more centered on the gift paradigm, and the market paradigm is more prominent in others. Services whose care is based on the bond and appreciation of individuals tend to present more gift-based social actions¹²12 Lacerda A, Martins PH. A dádiva no trabalho dos agentes comunitários de saúde. Realis 2013; 3(1):194-213.. Again, strengthening social ties at work is a process in which the worker’s physical and mental health are pillars for better health care.

Final considerations

Health work is increasingly involved in market logic, and the gift theory brings us the interpretation of relationships built beyond this logic, reinforcing the importance of interpersonal exchanges in health services.

For these professionals, being seen, embraced, and recognizing their fears and challenges in their work environment is urgent. As much as the importance of support is recognized, such as support from family and friends, exercise, hobbies, and even the space for individual psychotherapy, being able to expose own weaknesses in one’s work environment and have them recognized as real challenges is crucial in the statements of these professionals.

It is impossible to generalize how each health professional addressed the issues over time. There are multiple experiences, professional categories, work environments, and how each person can deal with work-related issues daily. However, if, on the one hand, we cannot respond for everyone, we also cannot individualize the effects of these relationships at work to think about the support these people need. We should move forward and understand these effects on the spaces and relationships built at work.

Protocols aimed at health care for workers are welcome and hold their place of relevance. However, we should consider strengthening workers’ personal and internal motivation and their respective contexts. Although the gift circulation is asymmetrical, it encompasses personal and contextual aspects so that giving-receiving-returning cannot be separated from the health work process.

In this sense, the work context of professionals, which involves everything from salaries to interpersonal relationships and working conditions, assumes a critical role. These issues come to light in a health emergency such as COVID-19, revealing the need for support and care for healthcare workers’ physical and mental health. Health services should be organized to meet the workers’ demands, exercising daily what could become more delicate in a possible new health emergency.

References

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