Emotional repercussions manifested by nurses in the care of COVID-19 patients

Repercussões emocionais manifestadas por enfermeiros(as) diante do cuidado a pacientes com COVID-19

Abstract

This study aimed to understand the emotional repercussions manifested by nurses in a field hospital in the care of COVID-19 patients. It was a descriptive and qualitative exploratory research with 16 nursing professionals from a field hospital specializing in COVID-19 in the Central region of Brazil. For data collection, a professional profile questionnaire and online interviews were used and later subjected to thematic content analysis. Regarding the results, the category "Emotional repercussions of nurses in the care of COVID-19 patients" emerged, showing that professionals expressed feelings of powerlessness, uncertainty, insecurity, fear, sadness, consternation, irritation, longing, rejection, apathy, satisfaction, and happiness through the experience of contributing, altruism, devotion, empathy, and gratitude. This study revealed the ambivalence of emotions arising from the actions of nurses in caring for COVID-19 patients, demonstrating that even after vaccination, there is a need for mental health promotion actions for nursing professionals.

Keywords: COVID-19. Nursing care. Nurses. Manifested emotions. Nursing professionals.

INTRODUCTION

COVID-19 pandemic brought significant challenges to global healthcare systems, requiring complex strategies and public policies for prevention, containment, diagnosis, and treatment¹. These challenges disrupted the routine of healthcare services and imposed an urgent need for professionals to adapt to the new scenario, resulting in increased physical and psychological workloads with implications for the health of workers, due to exposure to the virus, illness, and death².

In this scenario, it is important to broaden the focus on the emotional issues of healthcare professionals assisting people with COVID-19, especially of the nursing staff, which is the category that remains with the patient for the longest time; besides being caregivers, they also need mental health care².

Therefore, understanding the experiences of nurses related to the repercussions of the COVID-19 pandemic is essential for developing health promotion strategies for this group, contributing to patient safety³. It is necessary to comprehend the relational skills of nursing professionals in facing the pandemic, involving the establishment of interpersonal relationships guided by empathy for patients, their families, and other members of the healthcare team, essential for the realization of emotional intelligence and the minimization of stress⁴.

It is worth noting that emotion can be understood as an immediate and short?duration reaction to a given stimulus, not involving thought or rationalization; it guides the individual in their actions and allows them to grasp reality⁵. On the other hand, feeling involves the cognitive component of perception and evaluation of something; it is perceptible only to the individual and is more enduring than emotions⁶.

Despite being a new disease, the negative effects of COVID-19 on the mental health of healthcare professionals have already been observed, with nursing having a higher susceptibility to psychological illness. This is due to the longer time spent and interaction with patients; pressure to perform their activities with quality; and dealing with the process of death and dying, as they are trained and qualified professionals to heal^7-8.

Thus, the high workload, the feeling of inadequate support, a high rate of COVID-19 infection among workers, fear of contaminating family members, and cases of deaths within the healthcare team are the main factors contributing to serious mental health problems, an increase in cases of Burnout syndrome, as well as an increase in anxiety, depression, stress, and panic disorder^9-10. This hinders the development of nurses' self?care, making it essential to promote an appropriate environment for these professionals; otherwise, pre-existing problems and occupational exposure will contribute to increased physical and psychological suffering¹¹.

Furthermore, an investigation aiming to describe the impacts of the COVID-19 pandemic on the health of nurses revealed that the fear of the unknown and transmitting the virus to their families, as well as the experience of grief and the need to develop coping strategies at both a personal and professional level, are factors that interfere with the health and quality of care provided by nurses¹².

In this context, another study conducted in Guayaquil, Ecuador, in order to explore the feelings, stress factors, and adaptation strategies of nurses during the COVID-19 pandemic, pointed out that the humanistic feeling, the fear of virus contamination and work-related stress are present in the daily work of nurses. This indicates that the COVID-19 pandemic brings emotional harm to nursing professionals, which can lead to exhaustion if actions are not taken to minimize this situation¹³.

Therefore, this study was important, given the vulnerability and occupational complexity of nursing professionals, as well as the need to develop mental health promotion actions by healthcare service management to assist in the development of emotional intelligence of nurses. The objective was to understand the emotional repercussions manifested by nurses in a field hospital caring for patients with COVID-19.

METHODOLOGY

This was a descriptive exploratory research with a qualitative approach, conducted following the Consolidated Criteria for Reporting Qualitative Studies (COREQ). The research setting was a field hospital for COVID-19 (HCAMP) in a municipality in the state of Goiás, designed to attend to contaminated patients undergoing treatment for COVID-19.

To contact the study participants, a preliminary meeting was held with the nursing management of the hospital to present the project and request that actively working nurses be invited. During the meeting, due to the risk of contamination posed by the ongoing COVID-19 pandemic and the nature of their work processes, the management suggested remote data collection.

An email invitation was sent to the hospital's administration, which was then forwarded to the nurses. Along with an explanation of the research, the researcher's contact information was provided in the invitation email to the 44 nurses directly involved in the care of COVID-19 patients. Out of these, 16 accepted to participate in the study. Inclusion criteria encompassed nurses in active professional practice who worked directly in the care of COVID-19 patients. Nurses with less than 30 days of employment in the unit were excluded.

Upon accepting the invitation, nurses received a link to conduct online interviews through a video conferencing application (Google Meet). Upon entering the meeting room, they were instructed on completing the Informed Consent Form (ICF) and the research objectives.

Data collection took place individually during November 2021, involving the 16 nurses after conducting two pilot tests, online, with audio and video recordings that were later transcribed for data analysis. A nurse and a research assistant conducted the interviews, both previously trained to ensure agreement in data collection.

They collected the data through semi-structured interviews covering professional profiles and the guiding question: "What feelings have you experienced in attending to patients diagnosed with COVID-19, and how did you deal with these feelings?" The average duration of the interviews was 30 minutes.

Transcribed interviews were analyzed using Content Analysis, following Bardin's methodology, in three stages: pre-analysis, exploration of the material, and treatment of results: inference and interpretation¹⁴. In the pre-analysis, the material to be analyzed was organized, followed by a floating reading of the data to formulate initial hypotheses, objectives, and indicators through the analysis of text excerpts in the documents¹⁴.

In the exploration of the material, coding systems were operationalized by identifying the recording and context units, guided by hypotheses and theoretical references to support classification and categorization. Finally, in the results treatment phase, the information from the analytical process was condensed through inferential interpretations, resulting in categories¹⁴.

The project followed the recommendations of resolution no. 466/2012¹⁵. The research was approved by the Research Ethics Committee (CEP), protocol Nº 4.530.689, and CAAE 39567920.1.0000.5078. To ensure confidentiality, participants were coded with the letter "E" followed by the interview execution identification number.

RESULTS

The average age of the interviewees was 36 years, with 50% of participants having between one to two years of professional experience, and 68.8% were female. Regarding the number of employment contracts, 62.5% of them had more than one employment contract, and 100% worked on a cooperative basis.

From the content analysis process, the category "Emotional repercussions of nurses in the care of COVID-19 patients" emerged, highlighting the manifestation of subjective aspects of nurses throughout their caregiving practice during the COVID-19 pandemic, as illustrated in the code tree (Figure 1).

A sense of powerlessness emerged in the nurses' testimonies because, even though they were providing assistance, the clinical condition of the patients worsened rapidly, leading to deaths. They also witnessed pleas for help from the assisted individuals who feared death:

“(...) we saw patients who progressed very quickly (...) to reach death, in a matter of days, you know?! Like, I admit the patient today, and the day after tomorrow, I come back for my shift, and I know that he had a complication in the morning and ended up passing away.” (E1)

“I had male patients, bearded, 30, 40 years old, who arrived at the hospital, you'd talk to this patient, he'd start crying and say 'for God's sake, I don't want to die.' It really messes with our minds a lot.” (E4)

One of the participants mentioned the uncertainty facing a new epidemiological scenario and a disease for which there were no consolidated clinical procedures for effective care:

“We went in there, and no one knew how to deal with that or how to approach the patients. There are diseases that we monitor, we already know what to do to give better comfort, to help the patient, but this one, we knew nothing.” (E4)

In this direction, another participant mentioned feeling insecure because it was his first job associated with the pandemic situation:

“Being the first job, in the first shifts you already start insecure, and even more in such a scary pandemic situation, so the situation was very turbulent.” (E12)

Fear was mentioned in some reports, both related to the new and unknown and to the contamination by the new disease:

“I think we are on edge because we deal with human life, right, so any mistake you make can be fatal for someone. I think the biggest obstacle I had was this, a bit of fear (...)” (E6)

“It was a new environment because we entered with a lot of fear. The disease was new, right?! The fear of contamination, of bringing it home, all of that counted.” (E8)

Sadness was mentioned by a participant when reporting the severity of the clinical condition of the assisted patients and the rapid progression to the terminal phase:

“Because we were very close to patients who progressed to the terminal phase very quickly, we were shaken by that (...) In the beginning, I was quite shaken, the head wasn't good, it's not good anyway?! Then it got worse.” (E1)

In addition, the consternation caused by witnessing the loss of many patients due to COVID-19 was also expressed in the testimony of one of the nurses:

“Sometimes I would get home and wonder 'why such a young person, but wow, they got there in that way, why did this happen?' But in terms of suffering, it didn't destabilize me, it didn't reach that point.” (E3)

Irritation was mentioned by a participant as a result of working night shifts, and this feeling extended beyond the work environment:

“I was very irritated, losing patience with everyone, from the time I started doing night shifts… so much so that when I left, it felt like I took a 100kg weight off my back.” (E6)

Longing close family members due to the risk of COVID-19 contamination was an emotion verbalized by one of the nurses:

“And longing, right? Because I've always been very attached to my son, I had never been away from my son for three months (...) What really hurt me was longing, I wanted to be close, you know?” (E12)

Nurses also mentioned rejection regarding approaches that constantly underwent changes and the feeling of stigma from the general population, who showed fear and apprehension toward healthcare professionals. This feeling was expressed in the following testimony:

“(...) we also had the issue of prejudice. I think that was harder because 'Wow, you work there in the disease hospital, wow,' you know?” (E4)

The statement of a participant evidenced apathy, mentioning feeling indifferent to the situation experienced:

“I even questioned myself a lot: 'wow, did I take that part of the profession, as many people say, you end up becoming cold and all' (...) Because I didn't have that moment of suffering or not wanting to go to work there.” (E3)

Satisfaction with the experience of being able to practice their profession and start their careers was mentioned in many reports:

“It was an opportunity to gain experience in terms of assistance because I didn't have any.” (E8)

“I thought 'how good that someone gave me an opportunity.' Because it's very difficult to graduate and distribute resumes, no one gives you a chance because you don't have experience.” (E9)

“So, in addition to gaining experience, right, because it's a new disease, you're working on the front line.” (E2)

Altruism and the purpose of healthcare professionals emerged in the nurses' statements, as illustrated below:

“But when I saw that this place was indeed a reference, and it was a greater burden (…) then we feel as if we have more purpose, especially regarding the pandemic. It's like we are really at the forefront. Then I felt more at ease to continue.” (E16)

Empathy for the families who lost a loved one emerged in the testimony of one professional:

“It's very distressing, especially when they die. I worked day shifts, so there were visits, we saw the families suffering, we followed along, it was very, very sad to see the suffering. I've cried a lot, held back too because, whether we want it or not, we create a bond.” (E11)

Devotion was reported by a participant in the study as an aspect that guided their actions to do their best for the patients:

“We started to value more (...) we started to have a different kind of vision, trying to do the maximum for that patient who came in, we really gave our all.” (E1)

Furthermore, the participants also expressed gratitude for the lessons learned from the experience:

“Thanks to God a lot, especially us who went through all this and can have this conversation today, so it's just gratitude, it's learning that was a lot, a lot.” (E4)

DISCUSSION

The results indicate different emotions and feelings experienced by nurses, both negatively and positively. The feeling of powerlessness in the face of the pandemic's unfolding was evident in the nurses' reports as a recurrent aspect in their professional daily lives, a situation not limited solely to the care scenario. A study aiming to identify the effects of the COVID-19 pandemic on the mental health of the academic community of a federal university revealed that 93.5% of participants expressed a sense of powerlessness¹⁶.

Uncertainties in the face of the new scenario imposed by the pandemic were another feeling that emerged in the context of nursing care for patients. A qualitative study involving 719 nursing professionals pointed out that uncertainties related to the future, whether it would return to normal or not, were one of the meanings attributed by participants to their experiences in the context of the COVID-19 pandemic¹⁷.

The feeling of insecurity was another finding of the study, evidenced by nurses in the context of their professional practice, aligning with another investigation describing the experience of nurses in connection with community health agents facing the local impact of the COVID-19 pandemic. This study indicated that community health agents carried out their activities in the territory with fear and insecurity¹⁸.

A study on working conditions and perceptions of nursing professionals working in the fight against COVID-19 in Brazil reported that 83% of respondents pointed to fear as a sensation experienced in various situations, in the family context, in the workplace, in relation to management, and when thinking about the future. Approximately 45% reported fear as a feeling experienced during the pandemic, acting as a driver for self-care and a factor leading to stress¹⁹.

Irritation was another emotion expressed by one participant during night shifts, leading to physical and emotional exhaustion. A study evaluating the emotional impact, types of concerns, and needs related to the social confinement imposed by the COVID-19 pandemic showed that 57.5% of participants expressed concern about health and, after six weeks of confinement, experienced significant differences related to irritation²⁰.

Furthermore, another professional emphasized missing his child due to the need to isolation while treating COVID-19 patients. A qualitative study, based on 45 interviews given by nurses to widely circulated newspapers in Brazil and Portugal, indicated that one nurse's strategy to minimize missing his child was to maintain conversations through social media²¹.

Due to their frontline work, participants expressed the feeling of rejection, amplified by the community’s fear and prejudice. An investigation aimed at understanding the repercussions of the COVID-19 pandemic on the daily lives of family members of health professionals working in emergency units revealed that prejudice also occurs among the family members of health professionals²².

Apathy is also present during nursing care for COVID-19 patients. An integrative literature review seeking to identify the impact of Burnout syndrome faced by healthcare professionals in the context of the COVID-19 pandemic pointed out the lack of professional?related perspectives because of the new reality experienced by professionals²³. This can trigger apathy not only towards employment but also in other areas of life.

Despite the pandemic context, the nurses expressed feelings of satisfaction and happiness in being able to contribute to the care of people during the pandemic. A study conducted with nursing professionals working in a COVID-19 unit of a university hospital in the Southern region of Brazil indicated that job satisfaction and satisfaction with the work shift showed a statistically significant association with depression²⁴. This suggests that the professional's satisfaction with their work can be a protective factor contributing to their mental health.

Altruism was another emotion expressed by nurses during their professional practice in the context of the pandemic. This aligns with nurses working on the frontline who participated in activities of an extension project called "Life in Quarantine: Mental Health in Focus", aiming to promote the mental health of professionals²⁵.

Another feeling highlighted by one of the participants was devotion in giving their best during nursing care for COVID-19 patients. Devotion, along with zeal and compassion, are aspects recommended in nursing care by Florence Nightingale since the early days of the profession²⁶. During the pandemic, these characteristics gained even more relevance, emphasizing the greatness of nursing professionals who, despite risking their own physical and mental well-being, strive to care for others.

In this regard, some participants in the study shared expressions of gratitude for contributing in this challenging time and for the lessons learned. This reality is echoed in another study indicating that the feeling of gratitude is part of the daily life of nursing professionals providing care to suspected or confirmed cases of COVID-19²⁷.

Empathy was one of the findings of the study that permeates the experiences of nurses during patient care and with their families experiencing the loss of a loved one. An investigation aiming to describe nursing students' knowledge of the concept of empathy in facing COVID-19 revealed that 92% of participants were familiar with the concept of empathy, although they may not always practice it in their work²⁸.

Given the above, therapeutic groups can be a tool to promote mental health during pandemic periods. These groups work on emotional issues and stimulate interactions among participants, even in virtual formats, as demonstrated in an experience with university students²⁹. This approach could also be extended to nurses.

Additionally, floral therapy is another resource that can be used for the care of individuals affected by the mental health repercussions of social isolation caused by the COVID-19 pandemic, especially addressing issues such as anxiety, fear, insecurity, and insomnia³⁰.

A limitation of the study is the exclusive focus on interviews with nurses. Including other healthcare professionals, such as nursing technicians and assistants, as well as other frontline healthcare team members, would enrich the discussions and reflections, suggesting the need for future research.

  CONCLUSION

Through the expression of the nurses who participated in the study, there was a revelation of ambivalence in emotions arising from their work in providing care to COVID-19 patients, such as powerlessness, uncertainty, insecurity, fear, sadness, consternation, irritation, longing, rejection, apathy, satisfaction, and happiness for the experience of contributing in this pandemic moment, altruism, devotion, empathy, and gratitude. This provided an understanding of the internal and subjective world of nursing professionals, revealing conflicting feelings.

The study contributes to nursing practice by highlighting that even after the availability of vaccines, there is a need for actions to promote mental health directed towards nursing professionals before and during their placement in health units that assist individuals with suspected and/or confirmed COVID-19. This should be undertaken by health service management to develop the emotional intelligence of teams and minimize psychological harm, as the manifestation of fear and insecurity among nurses still persists.