Experiences and feelings of nurses who work on the COVID-19 frontline: a documental study Vivências e sentimentos de enfermeiros(as) que trabalham na linha de frente do COVID-19: um estudo documental

OBJECTIVE


Introduction
Since the discovery of the new coronavirus, SARS-CoV-2, in Wuhan, Hubei province, China, in 2019, the virus has spread throughout the world. In Brazil, from the beginning of the pandemic in 2020 until May 3, 2023, 37,449,8418 cases and a total of 701,494 deaths were recorded. 1 COVID-19 is an infectious disease caused by the novel coronavirus (SARS-CoV-2) and people with infection may have symptoms ranging from mild to severe, with a large part of the population being asymptomatic carriers. The most commonly reported symptoms include fever, tiredness, cough and shortness of breath, nasal congestion, headache, conjunctivitis, sore throat, diarrhea, loss of taste or smell, skin rash or discoloration of the fingers or toes. One in six people infected with COVID-19 becomes seriously ill, develops difficulty breathing and needs to be hospitalized. 2,3 Although the main target of coronavirus infection is the lung, cardiovascular, gastrointestinal, renal, hepatic, central nervous system and ocular damage occur, which should be closely monitored. 2 According to the authors, patients who have acute respiratory distress syndrome can quickly worsen and die from multiple organ failure.
As with other respiratory viruses, the transmission of SARS-CoV-2 occurs with high potential of infectivity, mainly by the respiratory route, and transmission by droplets is the main recognized form, although aerosols may represent another important route. The presence of the virus was detected on inanimate surfaces such as door handles and the surface of mobile phones in residential locations of patients with confirmed COVID-19. Thus, individuals who have come into contact with contaminated surfaces can be infected if they touch their eyes, mouth or nose, if there is no hand hygiene. 3 Health professionals, nurses, nursing technicians, doctors, physiotherapists, who provide clinical care to patients with COVID-19 consequently have a higher risk of in-fection. 4 Considering that most of the nurses' work involves direct contact with patients, these professionals have great vulnerability to infection, especially in ventilatory care. 5 According to the Ministério da Saúde (Ministry of Health), until November 2021, 152,147 cases of COVID-19 were confirmed in health professionals, with higher records in technical-co-nursing auxiliaries, followed by nurses and doctors. 1 It should be noted that this scenario is worrisome, considering that currently, nursing professionals constitute more than half of the health workforce, with the largest number of workers in a hospital, being considered the backbone of health care. 6 In addition to the ability of infectivity of the virus, factors related to the work of health professionals, such as high workload, large number of severe cases, few hours of sleep, insufficiency and inadequacy of personal protective equipment and infrastructure, intensified by the pandemic, increase the risk of infection and generate physical and mental exhaustion. 7 Exposure to illness by the work of health professionals who work on the front line in the care of patients with COVID-19 is not limited to contact with the agent, but also to other risk factors, such as those of a psychosocial nature, such as the presence of fatigue, anxiety, fear of illness and death and fear of family contamination. 7 Although publications on the impact of the disease resulting from field research, mainly with a qualitative approach, articles of reflections and experience reporting have increased in the main nursing journals, studies that address what nurses said to the media are still few. Thus, it is thought that the data found in this study may reveal situations experienced by nurses who can serve as a reference for further reflections on the subject, interventions that offer greater support to nursing professionals in situations similar to the COVID-19 pandemic.
Given the above, the interest in knowing what nurses have been reporting to the digital media, such as newspapers, magazines and blogs, as has been their experiences in providing care to patients infected with COVID-19. Thus, this study aimed to analyze reports of experiences and feelings of nurses who work in the frontline of COVID-19 disclosed by the media.

Method
Documental, descriptive, exploratory study of qualitative approach. The study used secondary data taken from online media, such as interviews and testimonials published in newspapers and magazines, blogs and websites during the period of COVID-19. The time frame for searching the studies was from March 2019 to November 2021. The search was defined through the association between the Health Sciences Descriptors (DeCs) "COVID-19"; "nursing"; "mental health"; "coronavirus"; "pandemic"; "health professionals".
The research sample was composed of nurses, who through reports, narrated to some means of online communication, their experiences and feelings in coping with COVID-19. The inclusion criteria were: reports of nurses who work in the front line; and exclusion were reports of nurses who do not address the object of study.
The saturation criterion was used to define the sample size. When there is no need to insert any new element that allows increasing the number of information in the research, it does not alter the understanding of the studied phenomenon. 8 The data collected in the published interviews were treated using content analysis 9 , following the steps of pre-analysis, material exploration, results treatment and interpretation. In the pre-analysis, it was given the choice of documents to be submitted to analysis and floating reading of them. In the second stage, a detailed reading was carried out to identify the units of record and context for the confirmation of the categories chosen a priori and identify a posteriori subcategories. Finally, the results were interpreted based on articles already published on the subject.
The research will not require approval from the Research Ethics Committee, as the data were in the public domain.

Results
Among the 20 interviews published and selected for this study, seventeen were from female nurses and only three from male nurses. Regarding age, thirteen nurses were more than 30 years and twelve had more than 10 years of training. In six interviews age and training time were not available.
The textual corpus consisted of 20 texts, separated into two broad categories and five subcategories defined based on the objective: Category 1 -experience expressed by nurses working on the frontline of COVID-19 having as subcategories (facing challenges and changes in professional life, changing the routine in personal life and having to acquire new knowledge and training in the work process) and Category 2feelings revealed by nurses who work on the frontline of COVID-19, being the subcategories (feelings related to the other and feelings related to oneself).

Category 1. Experience expressed by nurses who work on the frontline of COVID-19
This category and its three subcategories portrayed that working in the line of Covid-19 conditioned them to face changes in professional life and personal life, often having to adapt and acquire new knowledge in a short time.
Facing challenges and changes in professional life -in this first subcategory are described changes in the work routine of nurses during the pandemic. Among the changes mentioned was evidenced the discomfort caused by the mandatory use of personal protective equipment during the period of duty, increased working hours, the need to work even sick, increased work overload and intensification due to increased number of patients and reduced number of professionals, among others: "The emergency room turned crazy, with patients even accommodated in the exam room. We are working at a fast pace again, even more than we were at the beginning of the pandemic. Sometimes it seems to me that this will never end" N19 Having to acquire new knowledge and training in the work process -in this second subcategory it is evident that it was necessary to study and prepare nursing workers to deal with an unknown disease. "There were situations of nurses hostilized on public transport or even in condominiums where they lived" N3

Category 2. Feelings revealed by nurses who work on the frontline of COVID-19
This category deals with the states and reactions expressed by nurses in the face of the different situations they experienced. In this category emerged two subcategories: feelings related to others and feelings related to oneself.
Feelings related to the other -this subcategory reveals the feelings of nurses who work in the front line of COVID-19 in relation to the other, whether this other patient, family and even the environment.
Among the feelings towards others arises empathy and solidarity with hospitalized patients as revealed in the following statements: It is noteworthy that emotion and anguish were present in the face of suffering and increased chances of death of patients as represented in the speeches: "It is distressing, even more so because we know that more than 70% of patients who enter the ICU die, and this was not the usual mortality here in the Hospital's ICU" N2 "I have always worked in intensive care, but this disease is very different. Patients are already aware of the possible gravity. They arrive anxious and afraid to die. They are left without a companion, without a visit and without family support. Many times, we are the support.
The patient's plea that she not be intubated. At that moment, I thanked for wearing a mask and face shield (face shield). That way, no one could see the tears that flowed. I had to leave and walk the halls aimlessly, take a breath and come back" N5 Regarding family members, the concern of nurses was generally related to the fear of their contamination: It can be seen that the feeling of concern extends to co-workers, not only because of the risk of contamination, but also because of the strenuous work they have to perform, as evidenced in the excerpts: "When we have a coworker admitted to the ICU, tension takes over our hearts. Two of our nurses have already been hospitalized" N2 "This is our biggest concern: the large number of infected health professionals. It is a great personal fear, a great anguish, and it greatly reduces our workforce in nursing" N4 Although most feelings were negative, some participants reported positive feelings, highlighting the feeling of protection, gratification and overcoming fear:

"I was calmer, less paranoid, I was able to hug my children again, after all I had not contracted anything. And I also feel protected in the work environment" N1
"I remember the first patient, he was a gentleman. I remember that when I had to go into the room, I had that feeling: it was time to assist him. At that moment, despite everything that goes through people's minds, the sovereign is caring for people. We know we are entering a risk zone, an infected environment, but when you look at it, fear overcomes" N6 "On the other hand, there were stories with happy endings. One occurred last week, when an elderly, diabetic, hypertensive and obese patient who spent 32 days intubated returned to the hospital to thank the team that had been with her throughout the recovery process.

She brought souvenirs, (she was) without any symptoms.
That's the rewarding part of all our effort" N20

Discussion
The result of this study shows the experience and suffering of nurses who work on the frontline of COVID-19. In the interviews analyzed, nurses highlight the challenges faced to care for patients with severe COVID-19, and abrupt changes in work routine and personal life classifying them as challenging and suffering experiences.
The most recurrent words and phrases were constituted by the discomfort resulting from the use of personal protective equipment throughout the day, increased working hours and accelerated pace of work, large number of patients in inadequate spaces, insufficient number of professionals and precarious working conditions. Virtually all of these complaints have been highlighted in other publications. [10][11][12] It should be noted that in the care of patients with COVID-19, being more exposed to the risk of contamination, having to perform functions of new or unknown clinical procedures, expanded workloads, having to use PPE compulsorily, Coping with the adverse effects of the use of PPE and facing the scarcity of equipment represent risk factors for the mental and physical health of health professionals, including nurses. [10][11][12] Although the use of PPE represents adequate protection for health professionals, reducing the risk of disease transmission, for health professionals and among other patients, there are problems related to the lack of these PPE, as well as adverse effects of their use. 13 The use of face masks (especially N95 masks) and goggles for long periods, in addition to discomfort, cause a high prevalence of skin lesions on the nasal bridge, cheek and forehead, in all health professionals, with a higher frequency among nursing professionals. 14 According to these authors, the intensification of hand hygiene was associated with a higher incidence of dermatitis.
Depression, physical exhaustion, stress, anxiety, sadness and compromised social interaction were the main risk factors in relation to the development of psychological diseases acquired by health professionals during pandemic. 12,15 For the prevention of diseases and emotional problems, it is essential that health authorities follow up groups of health professionals affected by pandemic. 7 These considerations point out that in the midst of a pandemic situation, similar to that of COVID-19, with rapid spread of the virus, all health professionals, especially those who work on the front line, need to be physically and mentally healthy to avoid contamination, not to spread the disease and also to safely care for those who are hospitalized.
The participants' statements express that several distinct feelings, caused by a lack of material, professionals and work structure, such as insecurity, fatigue, exhaustion, anguish, impotence and pain due to work overload. Studies show that the scarcity of PPE, which occurred at the national level, put professionals at serious risk of contamination and potentiate mental suffering, having a negative impact on the physical and mental health of these workers. 7,12,16 Aware that in epidemic situations, health professionals are more likely to have their mental health affected, with increased symptoms of anxiety, depression, loss of sleep quality, psychosomatic symptoms and fear of infection, recommendations were developed to protect the team against chronic stress and mental health problems to be performed by managers. 4,17 Recommendations include monitoring team wellbeing, sharing knowledge and updates about the disease, training on proper use of PPE and ensuring good quality communication, the alternation of workers between high and low voltage activities, the guarantee of regular rest, the guarantee of adequate spaces for rest, food and drinking water. 4,13 In the context of health care during the COVID-19 pandemic, nurses were considered protagonists 6 , as their work goes beyond direct patient care. In the managerial function, the nurse is responsible for the organization of the services, for the provision of necessary inputs and materials, as well as for the training of other health professionals for the handling of the months. 18 It is considered that the pandemic has imposed challenges related to the reorganization of the physical structure and new work demands in health services for all other health professionals, especially for nurses 4,16,17 , which has led to even more stress.
Parallel to the increase in the visibility of nursing professionals, during pandemics6, the importance of the moment to discuss the working conditions of these professionals in the Brazilian scenario, and remember the claims of safe working conditions, decent wages, norms on working hours and nature of employment links. 18 We can infer that being considered "heroes" does not meet the old and current claims of the category with regard to decent and fair working conditions.
It is worth mentioning the dual characteristic of the nurse's work process (assistance-management). 18 According to the author, this professional has become more required to work in a unit of care for patients with COVID-19, not for the appreciation of his work itself, but because these professionals in their daily lives accept to perform these two functions in precarious working conditions, even with low wages.
Phrases like, "I thought I was in a war, with many people in the corridors, in the exit wing, in all spaces, had people hospitalized in chairs" and "the emergency room became crazy, with patients accommodated even in the examination room" describes well some environments in which nurses had to work, and these conditions impact decision making and consequently contribute to the establishment of fear of error and lack of assistance due to physical incapacity to meet all demands.
The challenge related to having to dedicate more time to study about the disease, treatment, new protocols and staff training is evidenced in some speeches of the nurses interviewed. Even in the context of the COVID-19 pandemic, some professionals sought to base care practice on scientific evidences. 19 The absence of well-established care protocols, delimited and shared with professionals who worked in the "front line" may represent an aggravating factor of their physical and psychological exhaustion, since these protocols would facilitate the work to be performed. 19 It is worth mentioning that with COVID-19, nurses had to deal with an even greater amount of medication administration, new routine of positioning the patient in bed, orotracheal intubation procedure, especially in ambulances, where there is not enough physical space, increasing the risk of contamination due to aerosol dispersion. 20,21 Such considerations indicate that continuing education, intense training and the establishment of a schedule of work shifts for nurses are essential for the continuity of work and health of these professions. 10 Statements related to family withdrawal and changes in their homes to protect their families reported in this study were also found in other studies included in integrative reviews. 17,22 Knowing that the family is safe and having their work valued by friends and society is essential for health professionals to perform their tasks with courage and hope. 11 Still in relation to this situation, it is worth mentioning that the possibility of mental illness of nursing workers due to social isolation that distance them from family members and loved ones, may increase vulnerability to the emergence of new suffering or aggravations of already existent disorders. 15,17 Regarding the changes considered negative in the daily lives of professionals during the pandemic regarding the cancellation of planned annual holidays, It should be noted that this change can aggravate the wear and stress of nurses who worked on the frontline of COVID-19.
Another determinant for the psychological suffering of nurses interviewed was living with a high number of deaths of patients under their care, experience the process of illness and death of co-workers as a result of contamination.
Although the process of dying is part of the reality of health professionals, the experience with high numbers of deaths along with the pressure of organizations and society are considered exposure factors for the development of anxiety disorders, and consequently use of self-medication in professionals who are at the forefront of COVID-19. 23 Another point to be evidenced is that, together with the recognition of part of society of the value of nurses' work 6 , situations of prejudice, discrimination and hostility in various environments, including public transport and condominium, was also found in other studies. 17,24,25 In the study by Queiroz and collaborations 25 , participants pointed out that they experienced situations of violence, discrimination, stigma and disrespect for the population, and that these situations hinder professional practice.
Thus, it can be said that nursing professionals during the pandemic experienced, sometimes ambivalent situations, if on the one hand they were seen as heroes of the nation, on the other hand they were stigmatized by the risk and contamination bias, even by family members. These situations left them vulnerable with negative repercussions on their work routines, resulting in an even more critical experience in a pandemic text.
The second category of this study analyzes the feelings revealed by nurses who work on the frontline of COVID-19. Most of these feelings are classified as negative and are common in situations of facing the unknown and crisis, which breaks an established order and creates tensions and conflicts. The fear of 'exposure', resulting from the lack of training to deal with the unpublished, may involve feelings of fear due to ignorance of the disease and because they are not instrumentalized for care. 23 It is perceived by the interviewees' speeches and the literature 17,26 that, in the pandemic context, these feelings emerged in profusion, being a source of stress and psychic suffering for these workers. For the prevention of diseases and emotional problems, it is essential that health authorities and managers follow up the groups of health professionals affected by pandemics. 7 It is noteworthy that interventions in addition to collective actions to increase safety at work, must include individual actions respecting the particularities of each one.
As seen in some testimonials, various feelings such as anxiety, impotence, fear, anguish and other negative emotions manifested. Similar feelings were described in another study that justify exposure to the virus, exposure of the family, lack of support for personal needs, inability to provide competent care, all of which generate confused and conflicting feelings in these professions. 16,26 The fear of participants for contamina-tion acquired in the workplace, in addition to the risk of illness, can generate stress and lowering of mood, a worrying fact for those who need to work vigilantly to avoid errors and iatrogenics.
It is interesting to note that some positive feelings were identified in the present study, such as sense of protection, gratification and overcoming of fear.
One of the emotions experienced by nurses when realizing that a serious patient needed care and that he (she) as a professional could dispense the necessary assistance in the best way possible, which would result in an improvement of the patient, gave way to a feeling of satisfaction, well-being and a sense of duty. These findings are in line with a study conducted with 719 nursing professionals from five geographic regions of Brazil in the context of the COVID-19 pandemic, which verified the existence of positive feelings such as satisfaction, hope and faith. 27 It should be added that although most of the nurses interviewed have reported experiences that brought suffering, it should be considered that each individual is a unique being, and that each one gives meaning to their experiences according to their previous experiences, with different degrees of intensity and consequences, thus requiring individualized attention.
Based on the entire context presented, it can be said that the nurses, especially those who worked on the frontline in the pandemic, faced additional challenges in all dimensions, including physical, emotional, economic, labor, social and psychological. Thus, it is reflected that, in other similar situations, interventions related to the development of labor activities, the well-equipped and healthy work environment, and the implementation of strategic psychosocial care services as early as possible, play an extremely important role in minimizing the damage to these health workers.
As limitations of the study, there stands out the fact that the documentary sources used in the study do not provide important information about the interviewees, such as age, training time, wage, working conditions and previous experience, allowing understanding the study population, and thus being able to make some inferences. Or limiting factor refers to the documents used, because they do not constitute a representative sample of the object studied, since they were not prepared for the purpose of providing data for an investigation.

Final thoughts
The findings allow concluding that the nurses who worked on the frontline of COVID-19 went through the experience that had repercussions on their personal and professional lives. Among the negative experience can be listed the discomfort of the use of PPE, the changes and/or introduction of new care protocols, the long and exhaustive working hours, the insufficient number of professionals, inadequate spaces to meet the high demand and the high number of deaths of patients under their care. Isolation and changes in personal life were also considered a suffering experience.
The main concerns of the nurses referred to the possibility of themselves or some co-worker becoming infected or carrying the infection to their families, and also to provide quality care in the face of such adverse conditions. The feelings reported by the nurses were fear, anguish, insecurity, anxiety and impotence. Thus, it can be said that acting on the frontline in the pandemic generated psychic suffering for these professionals. It was also observed the existence of ambivalent feelings, such as fear and courage, insecurity and the feeling of protection.
Finally, it can be thought that the pandemic allowed revealing the importance of the nurses' work in health services, and at the same time the often precarious and adverse conditions with which they have to live. Thus, it is understood as fundamental the need for emotional health care strategies and appreciation of this professional category by health organizations and society in general.