NURSING CARE PROVIDED TO PEOPLE WITH COVID-19: CHALLENGES IN THE PERFORMANCE OF THE COFEN/CORENS SYSTEM

ENFERMERÍA EN ATENCIÓN A PERSONAS CON COVID-19: DESAFÍOS EN EL DESEMPEÑO DEL SISTEMA COFEN/CORENS

ABSTRACT

Objective:

to analyze the challenges of the Federal and Regional Nursing Councils regarding the performance of nursing in providing care to people with COVID-19.

Method:

a documentary study carried out on the websites of the Federal Nursing Council and respective Regional Councils of São Paulo, Rio de Janeiro, Ceará, Amazonas and Pernambuco. Data collection took place in May, encompassing bulletins published from March to April 2020. A total of 149 bulletin items were analyzed through Content Analysis.

Results:

most of the bulletins published by the Federal Nursing Council cited support for professionals, and health service inspection and task force creation stand out for the Regional Nursing Councils among the included units. The findings were organized into four categories: The nursing professional during the pandemic: the fight against the invisible enemy; Working conditions in providing care to people with COVID-19: barriers and challenges; Professional devaluation x technical responsibility: frontline scenario; Mental health of nursing professionals: living with fear and uncertainty.

Conclusion:

the challenges of the Federal Nursing Council and the Regional Nursing Councils regarding nursing performance in providing care to people with COVID-19 are directly linked to the supervision and support to the category in the daily exercise of the profession as evidenced by structural difficulties of the working conditions, professional devaluation due to their technical responsibility, inadequate dimensioning of the workforce, overload and problems related to mental health.

DESCRIPTORS:
Coronavirus; Pandemic; Job; Nursing care; Health regulation and inspection

RESUMEN

Objetivo:

analizar los desafíos de los Consejos Federales y Regionales de Enfermería en cuanto al desempeño de la enfermería en el cuidado de personas con COVID-19.

Método:

investigación documental realizada en los sitios web del Consejo Federal de Enfermería y los respectivos Consejos Regionales de São Paulo, Río de Janeiro, Ceará, Amazonas y Pernambuco. La recopilación de datos tuvo lugar en mayo, abarcando noticias publicadas de marzo a abril de 2020. Se analizaron 149 noticias a través de Análisis de contenido.

Resultados:

la mayoría de las noticias publicadas por el Consejo Federal de Enfermería citaron apoyo y apoyo a los profesionales y, por los Consejos Regionales de Enfermería entre las unidades incluidas, destacan la inspección de servicios de salud y la creación de equipos de trabajo. Los hallazgos se organizaron en cuatro categorías: El profesional de enfermería en la pandemia: la lucha contra el enemigo invisible; Condiciones laborales en el cuidado de personas con COVID-19: barreras y desafíos; Devaluación profesional x responsabilidad técnica: escenario de primera línea; Salud mental de los profesionales de enfermería: vivir con miedo e incertidumbre.

Conclusión:

los desafíos de lo Consejo Federale de Enfermería y los Consejos Regionales de Enfermería en cuanto al desempeño de la enfermería en el cuidado de personas con COVID-19 están directamente vinculados a la supervisión y apoyo a la categoría en el ejercicio diario de la profesión, evidenciada por dificultades estructurales de la condición laboral, devaluación profesional por su responsabilidad técnica, inadecuado dimensionamiento de la plantilla, sobrecarga y problemas relacionados con la salud mental.

DESCRIPTORES:
Coronavirus; Pandemia; Trabajo; Cuidado de enfermera; Regulación e inspección en salud

RESUMO

Objetivo:

analisar os desafios dos Conselhos Federal e Regionais de Enfermagem perante a atuação da enfermagem na atenção às pessoas com COVID-19.

Método:

pesquisa documental realizada nos sítios eletrônicos do Conselho Federal de Enfermagem e respectivos Conselhos Regionais de São Paulo, Rio de Janeiro, Ceará, Amazonas e Pernambuco. A coleta de dados ocorreu no mês de maio, englobando notícias publicadas no período de março a abril de 2020. Analisaram-se 149 notícias por meio da Análise de Conteúdo.

Resultados:

a maioria das notícias veiculadas pelo Conselho Federal de Enfermagem citava o suporte e apoio aos profissionais, e, pelos Conselhos Regionais de Enfermagem entre as unidades incluídas, destacam-se a fiscalização de serviços de saúde e criação de força tarefa. Os achados foram organizados em quatro categorias: O profissional de enfermagem na pandemia: a luta contra o inimigo invisível; Condições de trabalho no cuidado a pessoas com COVID-19: entraves e desafios; Desvalorização profissional x responsabilidade técnica: cenário da linha de frente; Saúde mental do profissional de enfermagem: convivendo com o medo e a incerteza.

Conclusão:

os desafios dos Conselhos Federal de Enfermagem e Regionais de Enfermagem perante a atuação da enfermagem na atenção às pessoas com COVID-19 estão diretamente ligados à fiscalização e suporte à categoria no exercício cotidiano da profissão, evidenciados por dificuldades estruturais da condição de trabalho, desvalorização profissional perante a sua responsabilidade técnica, inadequação de dimensionamento da força de trabalho, sobrecarga e problemas ligados à saúde mental.

DESCRITORES:
Coronavírus; Pandemia; Trabalho; Assistência de enfermagem; Regulação e fiscalização em saúde

INTRODUCTION

The new SARS-CoV-2 virus (from the acronym Severe Acute Syndrome Coronavirus-2), identified in China in late 2019, has caused a respiratory disease known as COVID-19 (of the acronym COronaVIrus Disease), with a high potential for contagion and growing incidence, becoming the largest worldwide pandemic of the last decades.1^-3 As it is a disease with a broad clinical spectrum, more serious cases and higher mortality are observed among older adults and in people with pre-existing diseases such as hypertension, diabetes mellitus , chronic lung disease, and cancer, among others.2^,4

The number of cases and deaths due to COVID-19 significantly increased in Brazil between the months of March and April 2020, requiring the government, official health agencies, researchers and the scientific community in general to search for alternatives to confront the disease in order to minimize the impacts of the pandemic.5^-6 On the one hand the challenges relate to the response capacity in this scenario, which reflects the capillary action of its health system and adopting measures in favor of monitoring the epidemic curve of the virus.3^,7 On the other hand, the work of teams of professionals from different areas in the scope of health services in providing care to cases and in preventing and controlling infection stands out.8^-10

Nursing has been recognized among the health professions as essential and nuclear in the front line in the fight against COVID-19, acting in the public, philanthropic and private sectors. In the opposite direction, the pandemic macro-context circumscribes the invisibility of work processes, meaning that nursing professionals are confronted with a reality marked by the lack of working conditions, low wages, long hours, and experience suffering and death, among other problems.11^-13

Brazilian Nursing as a professional category is organized into three categories, namely: Nurses, Nursing Technicians and Nursing Assistants; the professional practice of these are standardized and supervised by the Federal Nursing Council (Cofen) and respective Regional Councils (Corens), also known as the Cofen/Corens system.14 This system is responsible for ensuring the quality of the services provided, being in compliance with the Law15 which defines the rights and duties of professionals, and above all to guarantee professional protection.

The complexity in the current health and epidemiological scenario of COVID-19 which involves the various nursing work processes is understood, especially in preventing and treating affected people, with repercussions in the illness process or even in the deaths of these professionals. Thus, the present study aimed to analyze the challenges of the Federal and Regional Nursing Councils regarding the performance of nursing in providing care to people with COVID-19.

METHOD

An exploratory study was carried out through documentary research seeking to capture the events, values ​​and discourses of a certain social group in a historical period, thereby unveiling the social relations which are established at a given moment.¹⁶

The research scenario circumscribes two aspects: the national scope and the locoregional ones as defined by the selected States. The eligibility criterion was defined as having the highest number of victims of illness and death in the population during the studied period: São Paulo, Rio de Janeiro, Ceará, Amazonas and Pernambuco. The option for these States is also justified by the disparity in the coverage of nurses and nursing technicians, especially between the States of the Southeast Region with the highest number of professionals, and the North Region with the lowest number.¹⁷

Access to the data was done by searching both the Coren and Cofen websites. Pairs of independent researchers were established to collect the published documents (bulletins). Data collection took place between March and April 2020.

The selection of documents was preceded by a preliminary analysis about authenticity (primary and those made available by the author), representativeness (containing the necessary information for the study object) and meaning (understanding of the actors involved in the context).¹⁶

As inclusion criteria, we considered the bulletins regarding the performance of the Cofen/Corens system before the nursing demands of COVID-19. Bulletins which identified nursing professionals was excluded. In total, 247 bulletin items were analyzed and 149 documents subsequently remained after applying the exclusion criterion and removing duplicates, which constituted the corpus of analysis.

Next, once the research corpus was constituted, the analysis step was performed by following the analysis technique proposed by Bardin¹⁸ in its different phases: pre-analysis; exploration of the material or coding; processing results; inference and interpretation. For this purpose, excerpts of the most relevant bulletins related to the topic at issue were extracted, giving rise to four central categories: Nursing professionals in the pandemic: the fight against the invisible enemy; Working conditions in providing care to people with COVID-19: barriers and challenges; Professional devaluation x technical responsibility: frontline scenario; Mental health of the nursing professional: living with fear and uncertainty.

As these data are electronically available and freely accessible, and do not directly involve human beings, analysis by the Research Ethics Committee was unnecessary; however, the precepts of Resolution 510/2016 were respected. The regional and national councils were randomly ordered in order to safeguard their identity for further codification: Council I, Council II ... until Council VI.

RESULTS

Altogether, 149 nationally transmitted bulletins were analyzed about the actions of the Cofen/Corens System regarding Nursing performance in providing care to people with COVID-19, encompassing four general aspects: inspection of health services and creation of task force; complaints and judicial requests; support for professionals; and qualification initiatives (Chart 1).

Chart 1 -
Distribution of the occurrences of bulletins published on the Cofen and Corens System portal in the states of São Paulo, Rio de Janeiro, Ceará, Amazonas and Pernambuco. Brazil, 2020.

BULLETIN	FU - CORENs					COFEN
	SP	RJ	CE	AM	PE
Inspection of health services and creation of task force	12	07	01	13	18	05
Complaints and judicial requests	02	06	02	02	03	4
Support for professionals (donation of PPE, remote psychological support, extension of deadlines for payment of fees, among others)	07	01	05	04	09	20
Qualification initiatives (courses, guidelines and recommendations, podcast, live, booklet, among others)	09	07	01	-	01	10
TOTAL	30	21	09	19	31	39

• FU: Federal unit; CORENs: Regional Nursing Councils; COFEN: Federal Nursing Council; SP: São Paulo; RJ: Rio de Janeiro; CE: Ceará; AM: Amazonas; PE: Pernambuco.

It is observed that most of the bulletins published by the Federal Nursing Council cited support for professionals (n = 20); while health service inspection actions and task force creation stood out for the Regional Nursing Councils in the different federal units (n = 51).

The categories elaborated in the study through the qualitative aspects evidenced in the selected bulletins are presented below.

Category 1 - Nursing professionals in the pandemic: the fight against the invisible enemy

Nursing exponentially plays a relevant role in the context of the pandemic given its wide insertion in the fields which involve healthcare, from the management and management of services to the direct care of individuals and families, especially those of their exclusivity. The fact that it is a new viral disease, still without a vaccine or effective drugs for treatment, has generated feelings of doubts and uncertainties among nursing professionals and their representative bodies in the face of an invisible enemy:

The COVID-19 pandemic took the world by surprise, with an enormous speed of propagation, causing a great deal of confusion regarding the best ways to combat and diagnose the disease caused by the New Coronavirus (Council I).

These are difficult times, of great uncertainty. But,we know something: at this moment, it is necessary to channel the efforts of the Nursing Councils to protect professionals and the population (Council VI).

The beginning of the pandemic in Brazil redefines a scenario in constant changes in the daily work of professionals, especially those at the front line in providing care to people with COVID-19:

Nursing has a fundamental role in combating the pandemic, not only because of its technical capacity, but also because it is the largest professional category in Health, and the only one that is beside the patients 24 hours a day [...]. Professionals are making a heroic effort to provide care. Our focus is to minimize the risk of contagion and to seek alternatives to expand care, meeting the needs of the population in a context of crisis (Council VI).

The Council itself defines its role in this pandemic moment:

The initiative of the Cofen/Corens system aims to maintain uninterrupted service to those who are at the forefront of combating the COVID-19 pandemic and need to have their feelings welcomed, and in a way need to be helped to understand weaknesses and potentialities in facing their fears and anxiety, or to clarify doubts about situations experienced during care (Council VI).

Category 2 - Working conditions in providing care to people with COVID-19: barriers and challenges

In the analyzed documents, we highlight the installation of a “task force” implemented by Cofen with support from the Corens to do “on-the-spot” inspections of the working conditions of nursing teams between public and private services in Brazilian states and municipalities:

The inspection continues to be active in the face of the COVID-19 pandemic scenario, inspecting health institutions to check the availability of PPE for nursing professionals and also the adaptation of work and care flows (Council I).

The Council carried out an inspection at the Hospital this morning (04/04) to investigate complaints which indicate the use of tissue masks by the technical nursing professionals of the Hospital (Council III).

Inspection actions are a routine of the councils, which was expanded in this pandemic moment:

The municipality has received many complaints from service professionals who point out the precariousness and even the absence of Personal Protective Equipment (PPE), especially in public hospitals (Council II).

It is urgent to provide adequate personal protective equipment to reduce the risks of contamination of nursing professionals who are at the forefront combating the pandemic. These professionals are with patients 24 hours a day and receive a high virus load, being more vulnerable to developing severe forms of the disease (Council V).

The complexity of the work process developed in the Nursing area in the hospital environment, associated with the lack of infrastructure and minimum conditions of recommended precautions given the scarcity of personal protective equipment (PPE) and human resources due to the great demand from users and maximized work overload, among other challenges which directly reflect on the care provided stands out as found in the bulletin reports in the materials:

We have been experiencing this chaos in health for years, these problems are not new today. We need to find the best way to alleviate the suffering of our professionals and the population [...]. Inspection actions were triggered simultaneously since March 23, 2020, in which irregularities were found in several health establishments under State administration with the practice of “rationing” PPE in an inappropriate manner and outside the guidelines established by the National Health Surveillance Agency, in addition to the severe deficit and absence of professionals in the Emergency Services. The State was also requested in the action to ensure guarantee of voluntary removal or respective relocation of professionals from the risk group who are currently providing direct care to patients with COVID-19 (Council IV).

The inspection also checked for specific flows and protocols for action in the pandemic. In addition to the inspection, the inspectors guided the nursing professionals on safe practices and also on how they should protect themselves in their professional practice, such as formalizing and registering all orientations transmitted to the teams (Council I).

The pandemic reveals the precariousness of the work processes of nursing professionals, instability in work relationships, an increase in the degree of work intensity that is expressed in the extension of work hours, in the increase in the pace and speed of activities and in the accumulation of functions.

Provisional Measure 927 issued by the Federal Government during the COVID-19 pandemic generated repudiation among class entities, especially the Cofen/Corens System, for introducing the possibility of expanding the hours of health professionals for up to 24 hours and reducing the rest time to 12 hours, in addition to not considering cases of contamination by the new coronavirus as an occupational disease, as expressed by the Council:

The measure issued by the [Presidency of the Republic] increases the burden of nurses, technicians and nursing assistants, a reality experienced even before the public health emergency. These professionals are at the forefront of combating the disease (Council IV).

Category 3 - Professional devaluation x technical responsibility: frontline scenario

Recognizing the performance of nursing professionals in this moment of crisis caused by the pandemic of COVID-19 was a globalized event and never before seen in the social and historical construction of the profession. However, there is a clear devaluation with regard to the salary issue imposed by government officials and employers to hire health professionals in order to work in field hospitals for COVID-19 according to representatives of the Council:

[...] It is introduced, through this Note, to repudiate the table released by the Department of Health with the values destined to the payment of the shifts of cooperative professionals interested in working with COVID-19 patients. The values represent a total disrespect for Nursing technicians and nurses, a class which will be with the patients throughout their hospital journey (Council III).

The need to guarantee minimum working conditions led the Councils in several states to judicialize these issues:

The Council sues the Federal Court against the State for illegal rationing of PPE, work overload and to guarantee the voluntary removal of professionals from risk groups (Council IV).

Category 4 - Mental health of nursing professionals: living with fear and uncertainty

Nursing care for patients with COVID-19 has repercussions on mental health problems in professionals who start to live with anxiogenic, stressful and depressive emotions and feelings resulting from working conditions, touched by the distance from the family and affective bond, caused by anguish, fear and uncertainty, whether from dealing with a little-known disease, the risk of becoming infected, and in some cases the removal of the family and even deaths of colleagues in severe cases, as reported in the following note:

Work overload and fear of contagion by COVID-19 have contributed to an increase in professional disorders related to stress and anxiety among nursing professionals. A channel created by Cofen to offer emotional help to professionals during the pandemic performs an average of 130 calls per day. The team is made up of volunteer nurses specialized in mental healthcare who aim to collaborate with the thousands of professionals who have worked tirelessly in the country’s health units (Council V).

In other notes, there is support from the Class Entity:

In the midst of the COVID-19 pandemic and its consequences, which has directly affected health professionals, the Council’s National Commission on Mental Health Nursing has provided an emotional support tool through a chat with nursing professionals working in facing this public health crisis that is ongoing in the country (Council VI).

Other initiatives were disclosed, as follows:

The Council has created a support network to care for nursing professionals in the pandemic with the proposal of articulating help and offering free, distance, psychological listening and guidance for integrative and complementary health practices that help workers to reduce stress and overcome the multiple challenges that have caused physical, mental and emotional suffering (Council IV).

DISCUSSION

The pandemic of the new coronavirus, COVID-19, is the most discussed subject since the beginning of 2020, whether in the popular imagination, in the media, in the pages of scientific literature, as well as among class entities. A reality arising from fear, uncertainty and mainly ignorance about the disease behavior.9^-10 The World Health Organization (WHO) warned of the severity of the disease due to the high transmissibility and mortality rate.3

Paradoxically, much information is based on early evidence, analysis of case series and reports, as well as data from previous coronavirus infections such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), which even the moment are not completely understood.1^,4 Given the uncertainties and lack of detailed epidemiological information, it is recommended to pay attention to minimizing the risks related to the relatively high proportion of lethality, and silent infections in reaching professionals who are on the front line, such as the nursing team.2^,19

Another particularity which draws attention from the data presented referring to a universal access health system is the obstacles and challenges faced by nursing in face of the working conditions in providing care to people with COVID-19.5^-6^,20

Although it represents a contingent of more than 1.8 million workers throughout the Brazilian territory, as well as a decisive influence of their work on the quality of health actions, the dimensions of the precariousness of nursing work point out omissions by the State regarding the maintenance of health services and legal protection of their profession with adequate working hours regulated by law,21 among other rights.12^,22

The dimensions of the precariousness analyzed affect nursing professionals and also clinical practice in healthcare, since they prevent or limit the care provided to the user as some minimum working conditions are not guaranteed.20^,23

In a previous study13 carried out in an Emergency Unit of a hospital service in the Northeast of Brazil with nurses and nursing technicians, among the factors which hindered satisfactorily executing their activities were the lack of material and human resources, an excess of daily activities, patient demands, in addition to the inadequate physical conditions of the hospital.

A fact which deserves mentioning refers to the need to adapt the nursing staff dimensioning based on the care complexity,14 especially in a complex care unit for critically ill and life-threatening patients, such as in an ICU.12 However, if a safe limit is not established for the time of the workday due to the variety of conditions involved, it is noticed that the high loads not only affect the health of professionals, but also the care quality.23^-25

The contingency in health services with regard to the insufficient number of nurses per shift creates an overload of physical and mental work, combined with the professional devaluation of nursing regarding the salary issue, proving to be significant and expressed by the feelings of indignation and injustice.11^,23 The devaluation attributed to the profession refers to the low wages expressed in comparison to the other professional categories in the health area and offered in Public Notices for hiring Nursing professionals. This fact in itself is considered a factor which characterizes the devaluation of nursing, imposing the need for a double workday onto workers and thereby motivating absenteeism due to health problems.20^,22^,26

The evidence can be corroborated with the facts found in a literature review study in which insufficient personnel, lack of security, low financial valuation, lack of resources for adequate care, long working hours and a great demand for work were found.24 The feeling of frustration and discontent compared to the responsibility and professional practice of nursing workers generates physical, psychological and social disorders which can harm the health of these workers, in addition to intervening in the performance of their functional activities.23^-24^,27

The productive aspect of the conflict is reinforced for these workers herein, since the motivation characterized by idealized feelings of the profession conflicts with the reality determined by the capitalist market, in which exhaustive and uninterrupted shifts are observed, task overload, in addition to living with the pain and suffering of others, thereby making these professionals more prone to work-related illnesses.28

The historical devaluation and lack of recognition of nurses’ work can directly interfere with their efforts, their self-esteem, and consequently the professional’s relationship with their work and with themselves. Workers may cease to engage in performing their function because they do not feel valued.20^,27

In a critical perspective, it is stated that work, regardless of the name it receives, such as trades, vocations or professions, is not reduced to the economic exchange of an energy expenditure for a salary, but has a symbolic dimension in terms of carrying out the work itself and social recognition, characterized as a transformation process required by human needs which, in the ​​Nursing area, are also related to the legitimation of knowledge in the process of constructing professional identity.29

Other evidence pointed out in publications deals with the mental health of the nursing professional in the face of COVID-19. According to published reports, the fear of being infected by a potentially fatal virus of rapid dissemination, whose origins, nature and course are still little known, ends up affecting the psychological well-being of these professionals.30

The reviewed problem refers to the scarcity of materials and the inadequacy of human resources associated with the increase in the work pace contributes to the psycho-emotional exhaustion of workers, negatively affecting the work process and the health of these professionals.20^,24 This fact was observed in a study carried out with nursing workers at a psychiatric hospitalization unit in Rio de Janeiro which identified (in addition to the psychological burdens inherent to professional work in mental health) further burdens related to inadequate working conditions, such as the absence of material resources, structural inadequacies in terms of physical space, qualitative and quantitatively insufficient equipment and reduced number of professionals.19

Nursing professionals are circumstantially exposed to stress/tension, psychological distress, emotional exhaustion and feelings of dissatisfaction, which ultimately determines mental illness, as evidenced in a study10 conducted with health professionals during the COVID-19 outbreak in China, in which signs of psychological distress, increased irritability and refusal to take moments of rest were observed among professionals who worked on the front lines.

This documentary study has some limitations since the use of documents only reveals one side of the problem, and it is interesting to look in loco for other data sources to triangulate with the research results, although the possibility of capturing facts from the past is highlighted in this case as still being in progress to make inferences to the future and to contribute in the reconstruction of the lived experiences.

It is suggested to develop new investigations with methodological designs capable of revealing the real impacts of this pandemic on the professional category as a whole and respecting the locoregional characteristics.

CONCLUSION

The challenges of the Federal and Regional Nursing Councils regarding the performance of nursing in providing care to people with COVID-19 are directly linked to the supervision and support to the category in the daily exercise of the profession as evidenced by structural difficulties of the working conditions, professional devaluation in the face of technical responsibility, inadequate dimensioning of the workforce and overload.

Considering that nursing is present on the front line, it is worth highlighting the implications of this scenario for the mental health of these professionals due to their daily and intense coexistence with fear and uncertainty.

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Publication Dates

• Publication in this collection
  21 Dec 2020
• Date of issue
  2020

History

• Received
  09 June 2020
• Accepted
  13 Aug 2020