Ethical-emotional support for Nursing professionals facing the COVID-19 pandemic: An experience report

Abstract

Objective

To describe the experience of planning, implementing and evaluating an ethical-emotional support service for Nursing professionals facing the COVID-19 pandemic.

Method

An experience report in the scope of the Ethical-Emotional Support Commission of the Regional Council of Minas Gerais, Brazil, developed between April and December 2020 and operationalized through phone calls and messages via a communication application.

Results

A total of 241 professionals were assisted. Feelings, emotions, experiences and problems arising from the daily Nursing work in the pandemic context were revealed and stated. Such problems reinforce the prominence, urgency and value that the support service had for the life, work and health of the professionals assisted, configuring itself as a health and intervention strategy, indispensable for mental health promotion, prevention, safety and protection in the face of the pandemic. The consultations culminated in the reduction of negative feelings; in increased perception (identification of potential threats and “trigger” contexts); in personal appreciation; and in self-knowledge and self-care.

Final considerations and implications for the practice

The support service was innovative for the Health and Nursing areas by constituting a multidisciplinary strategy that promotes, counsels, and facilitates care in times of COVID-19. We encourage the maintenance of this strategy after the pandemic.

Keywords:
COVID-19; Mental Health; Nursing; Nursing Professionals; Telemedicine

Resumo

Objetivo

Descrever a experiência de planejamento, execução e avaliação de um serviço de suporte ético-emocional para profissionais de enfermagem frente à pandemia de COVID-19.

Método

Relato de experiência no âmbito da Comissão de Suporte Ético-Emocional do Conselho Regional de Minas Gerais, Brasil, desenvolvido entre os meses de abril e dezembro de 2020 e operacionalizado através de ligações telefônicas e mensagens via aplicativo de comunicação.

Resultados

Foram atendidos 241 profissionais. Foram revelados e declarados sentimentos, emoções, vivências e problemas oriundos do cotidiano de trabalho da enfermagem diante do contexto pandêmico. Tais problemas reforçam a eminência, a urgência e o valor que o suporte teve para a vida, trabalho e saúde dos profissionais atendidos, configurando-se como uma estratégia de saúde e de intervenção indispensável à promoção, prevenção, segurança e proteção da saúde mental frente à pandemia. Os atendimentos culminaram na redução de sentimentos negativos; na percepção aumentada (identificação de potenciais ameaças e contextos de “gatilhos”); na valorização pessoal; no autoconhecimento e autocuidado.

Considerações finais e implicações para a prática

O suporte fez-se inovador para área da saúde e da enfermagem ao constituir-se como uma estratégia multidisciplinar promotora, aconselhadora e facilitadora do cuidado em tempos de COVID-19. Encoraja-se a manutenção desta estratégia após a pandemia.

Palavras-chave:
COVID-19; Enfermagem; Profissionais de Enfermagem; Saúde Mental; Telemedicina

Resumen

Objetivo

Describir la experiencia de planificación, implementación y evaluación de un servicio de soporte ético-emocional para los profesionales de enfermería ante la pandemia de COVID-19.

Método

Relato de experiencia en el ámbito de la Comisión de Soporte Ético-Emocional del Consejo Regional de Minas Gerais, Brasil, desarrollado entre los meses de abril y diciembre de 2020 y operacionalizado a través de enlaces telefónicos y mensajes vía la aplicación de comunicación.

Resultados

Se atendió a 241 profesionales. Se revelaron y declararon los sentimientos, las emociones, las experiencias y los problemas derivados del trabajo diario de las enfermeras ante el contexto de la pandemia. Estos problemas refuerzan la eminencia, la urgencia y el valor que el soporte tiene para la vida, el trabajo y la salud de los profesionales atendidos, configurándose como una estrategia de salud y de intervención indispensable para la promoción, prevención, seguridad y protección de la salud mental frente a la pandemia. Las consultas culminaron en la reducción de los sentimientos negativos; en el aumento de la percepción (identificación de posibles amenazas y contextos “desencadenantes”); en la valoración personal; en el autoconocimiento y el autocuidado.

Consideraciones finales e implicaciones para la práctica

El soporte fue innovador en el ámbito de la salud y la enfermería como estrategia multidisciplinaria para promover, asesorar y facilitar la asistencia en tiempos de COVID-19. Se fomenta el mantenimiento de esta estrategia después de la pandemia.

Palabras claves:
COVID-19; Enfermería; Profesionales de Enfermería; Salud Mental; Telemedicina

INTRODUCTION

Health professionals' well-being, safety and protection must represent and sculpt the primal scope of health actions, incentives and policies¹. Thus, regardless of the social-global context, safeguarding health professionals in order to offer them guidelines, assistance and support is one of the essential measures for the maintenance, promotion and protection of physical and mental health, especially in the context of the COVID-19 pandemic².

Thus, in view of the pandemic situation, the Minas Gerais Regional Nursing Council (Conselho Regional de Enfermagem de Minas Gerais, COREn-MG), regulatory body for the professional Nursing practice, established the Ethical-Emotional Support Commission (Comissão de Suporte Ético-Emocional, CSEE) articulated to the respective Crisis Management Committee of the aforementioned council, through ordinance No. 166, of March 30^th, 2020³. Above all, the CSEE aimed at welcoming these people in view of the repercussions of COVID-19 on the Nursing professionals' lives, work and health. The idea of this intervention implied objective and concrete actions, based on the reality of the professionals from Minas Gerais, which in this case was primarily care for ethical-emotional distress³.

In this context, the importance of providing ethical-emotional support in the maintenance, prevention, promotion and protection of Nursing workers' health during the pandemic scenario is highlighted. Also noteworthy is the relevance of this support when conducted by nurses specialized in mental health and/or individualized care for the entire Nursing category. After all, in addition to offering continuous and specialized care, Nursing works with a view to therapeutic action built from human subjectivities and complexities. During COVID-19, Nursing listens and welcomes with sensitivity and scientificity, especially to the emotional dimension of the human being⁴.

From this scenario, the following question arose: Who will take care of those who take care? Therefore, this report aims at describing the experience of planning, executing and evaluating an ethical-emotional support service for Nursing professionals in the face of the COVID-19 pandemic. The text summarizes some interventions and strategies that favored and sensitized mental health promotion and protection among Nursing professionals, providing them with safe and qualified care, involving ethical-emotional support and assistance, as well as identifying their demands and satisfaction with the support provided.

DESCRIPTION OF THE EXPERIENCE

Experience reports narrate and describe life experiences, articulating them to the scientific-theoretical-practical routine⁵. Thus, this report derives from an experience within the COREn-MG CSEE, headquartered in Belo Horizonte, Minas Gerais, Brazil, developed between April and December 2020. Given the situation of social isolation and distancing necessary to prevent contagion by COVID-19, this support was operationalized through phone calls and messages via the communication application (with an official number for this purpose) and also had a team of nurses qualified in mental health care and trained in order to carry out the organization of the service and of the care processes.

The support service started from previous scheduling by the enrollees, via the COREn-MG communication channels (webpage and institutional number of a communication application). The offer of services was defined based on some criteria: 1) being a Nursing professional (nurse, technician, assistant and midwives); 2) being enrolled in COREn-MG; 3) possibility of being: on vacation, away from work, unemployed or working in the public or private sector during the COVID-19 pandemic; and 4) having an up-to-date telephone number. Thus, when meeting these criteria, the Nursing professional (identified as “enrolled” by the CSEE) could seek an appointment for support. For scheduling, it was necessary to inform the following: a) full name or pseudonym; b) professional category; c) contact telephone number; d) preferred day and time for the appointment. The enrollees who opted for scheduling via the communication application were given the option of support via phone call or via the application's message chat, using a contact number devoted to support scheduling. It is noteworthy that, throughout its development, the CSSE has adopted and considered the ethical precepts involving human beings. Thus, information such as full name, professional category and telephone number was maintained only for the control and matrix support of the commission itself. In addition, the enrollees who opted for scheduling via the communication application immediately received an appointment confirmation message with the day, time and full name of the professional nurse who would assist them. For the scheduling option via the website, this message was sent 24 hours before the day scheduled for the appointment.

It is noteworthy that the CSSE had available times from Monday to Friday from 8 am to 9 pm, when there were at least two professionals available for assistance. As this is an online service targeted at emotional issues throughout work, criteria were developed for a remote risk classification based on: a) the content of the enrollee's conversation; b) their vocal performance (voice trembling, crying, panting, etc.), observed by the connection and/or audios of the communication application; c) the enrollee's profile image in the application; d) the phrase used in their application status (since some enrollees adopted phrases with words of warning, pain, sadness and suffering); e) on the perception of clinical parameters in mental health and risk analysis (inconsolable crying; speeches of suicidal ideation or self-mutilation; speeches suggestive of self-medication or substance abuse such as alcohol; self-neglect; intense anxiety, panic and impulsivity with risk for themselves and/or third parties; insomnia; aggressiveness, etc.); thus, when these signs were immediately identified, the enrollee was assisted.

Subsequently, the enrollee(s) received a phone call from the professional nurse designated to assist them on the scheduled day and time. The content of the calls lasted for certain time (between 15 and 120 minutes) and themes were defined and conducted by the enrollee who was assisted, and the nurse responsible for the service was in charge of receiving complaints, reports, distresses and needs presented by the enrollee(s), providing them with listening, safety, confidentiality, professionalism and support in aspects of life, health, work and coping with the COVID-19 pandemic. Minimum and maximum numbers of appointments were not established; thus, at the end of each appointment, the enrollees were given a new schedule, as needed (weekly, fortnightly or monthly).

During that period, some enrollees were seen twice a week; others were assisted only through messages (communication application) and there were other enrollees who only wanted a single appointment. It is noted that: 1) no enrollee was deprived of welcoming and guidance (even if their initial demand was destined to other COREn-MG sectors (such as the financial sector and complaints, among others); 2) if the enrollees did not feel comfortable with the professional who assisted them, they were allowed to experience care by another professional; 3) those enrolled with more than two appointments were kept on the same day and time (respecting their professional routine) and were assisted (if they wished so) by the same professional); and 4) if the call was not answered on the day and time scheduled, the professional responsible for the appointment made three attempts to call, with 30-minute intervals and if, even so, the enrollee did not answer for some reason, a new contact was made and a new appointment was scheduled. It is noted that the report on the work overload experienced by many professionals was an impediment to many appointments because, even with a scheduled day and time, they were unable to receive support, sometimes because they were called at the last minute to cover some colleague on duty, and others because they ended their workday much longer than their pre-established hours.

The CSEE team members, known as collaborators, consisted of 3 nurses and 16 nurses, trained to develop the various activities of the CSEE, such as formulation of strategies to publicize the service to the professionals in the state of Minas Gerais; care organization and management; evaluation, case discussion and referrals, when necessary; management of the communication and scheduling application; and evaluation of the appointments by conducting a satisfaction survey. In addition to professional listening, at the end of the appointment, the enrollee was invited to participate in a survey on working, life and health conditions carried out by this commission, with approval from the National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa, CONEP).

The satisfaction survey was carried out the week after the appointments, via phone calls (up to three attempts), using the Net Promoter Score (NPS)⁶, which measures client's/patient's satisfaction in relation to a service/product. The clients/patients are asked to provide a score (0-10 points) about their satisfaction, stratifying them into three categories: a) promoters (9-10 points): they liked the service, were satisfied and encouraged other individuals to participate in the support provided; b) neutral (7 to 8 points): they did not help or hinder dissemination of the support service; c) detractors (0 to 6 points): dissatisfied, they did not have a good relationship and even harmed the image of the support provided. At the end, the NPS is calculated by subtracting the percentage obtained between the promoters and detractors (% promoters - % detractors) and classifies satisfaction as follows: excellence zone (from 75% to 100%); quality zone (from 50% to 74%); improvement zone (from 49% to 0%) and critical zone (from -100% to -1%).

For developing the work, the collaborators attended monthly training sessions and meetings, spaces for communication about the work process, discussion and supervision of cases. It is noteworthy that, in a unique way, agreed upon between collaborators and enrollees, there were conversations and referrals to the mental health network services in the municipality of reference of the professional assisted, in order to provide greater monitoring for cases with worse evolutions. This fact was possible given the previous insertion of the collaborators in the mental health network of the capital and metropolitan region or a survey carried out with a list pre-distributed to the collaborators about services available in the regions of the state, enabling connections between those assisted and referral services. In addition, it is noteworthy that a large part of the enrolled patients reported a history of monitoring in mental health. However, in addition to their therapeutic plans, they opted for ethical-emotional support, considering professional identification and empathy, given that it was a service offered by nurses for Nursing professionals, in which they could also talk about problems experienced in the work environment with greater fluidity of communication.

To assess the clinical-emotional pattern presented by the patient, the collaborators had a mental health risk classification protocol⁷, in addition to international tests validated in the Brazilian context, such as the AUDIT-C⁸ and DASS-21⁹, which dialog about the pattern of alcohol consumption and symptoms of depression, anxiety and stress, respectively. In addition to the use of the aforementioned criteria, the clinical-emotional pattern was assessed in each call through verbal reports, expression of emotions, as well as tone of voice, since it was a remote welcoming instance, a fact that precluded broader assessments.

It is noteworthy that the appointments and ethical-emotional support provided by nurses have as their legal basis Law No. 7498/86 (which regulates Nursing performance)¹⁰; COFEN resolution No. 599/2018 (which establishes the parameters for ethical, safe and humanized performance in Mental Health)¹¹; and COFEN resolution No. 564/2017 (which outlines and explains the Code of Ethics for Nursing Professionals)¹². Thus, at all times, the ethical-legal aspects that permeate Nursing consultations in Mental Health were respected, based on the aforementioned regulations. In addition, this experience report was approved by the National Research Ethics Commission under Opinion No. 4,169,027 and CAAE 32019320.4.0000.0008.

RESULTS OF THE EXPERIENCE

Mental health promotion in the face of the COVID-19 pandemic: Experiences of the enrollees assisted by the CSEE

A total of 241 Nursing professionals were assisted by the support service, among them, technical level professionals and women constituted the majority of those enrolled who sought the service. It is noteworthy that, given the confidential nature of the appointments and in order to ensure the anonymity and protection of those enrolled, they were guaranteed the use of pseudonyms, as well as their non-identification. Therefore, it was not possible to detail other elements about the characterization of the professionals assisted. It is noteworthy that COREn-MG is headquartered in Belo Horizonte and has nine subsections in several municipalities of the state, in addition to 19 representatives, in the process of expanding their in-person representation in the 853 municipalities of Minas Gerais; as well as it has 219,175 professionals enrolled, the majority being technicians (n=133,389; 60.9%), followed by nurses (n=55,442; 25.3%), assistants (n=19,750; 9%), and attendants (n=10,594; 4.8%)¹³.

During the appointments, emotions, feelings, experiences and problems arising from the new pandemic context were revealed and described. The problems reported were frequent during the CSEE appointments and reinforce the prominence, urgency and value that ethical-emotional support had during the pandemic for the Nursing professionals' life, work and health since, for many of them, the support provided was companionship, rescue, protection and an “exhaust valve”. In addition to that, the problems experienced and reported were strongly influenced by seasonality and by the specificities of COVID-19 prevention and control adopted in each municipality of Minas Gerais. It was observed, for example, that opening of trade imposed significant feelings of anxiety, fear and insecurity on the health professionals, since such expansion of circulation also represented a greater risk of infection, which consequently resulted in overcrowding of the health services and in physical and emotional overload at work (Figure 1).

Figure 1
Situations experienced by the Nursing professionals in the face os the face of the COVID-19 pandemic. Minas Gerais, Brazil, 2020.

The themes addressed during the appointments followed the theoretical foundations of the mental health field¹⁴, using the concepts and practice of a person-centered approach and sharing decisions. Therefore, these included: a) identification and immediate course of action in emergency and priority situations; b) recognition and attention to the subjectivities of the professionals assisted; c) creation and establishment of a therapeutic plan with the enrollee with coping tools and precautionary strategies to avoid recurrence of anxiety and stress crises at work; d) guidelines for seeking information, prevention and control of COVID-19 on the COREn-MG website; e) guidelines and instructions for the proper and healthy use of information about COVID-19 (this strategy was essential for stability and emotional control, avoiding “triggers”); f) suggestion to use relaxation techniques or integrative and complementary practices (acupuncture, meditation, reflexology, reiki, etc.) for the purposes of prevention, control, management and coping with anxiety, fears, psychosomatic symptoms, concerns and other symptoms that emerged or were attenuated during the COVID-19 pandemic.

The indispensability and importance of ethical-emotional support were portrayed and asserted through the NPS results, in which 84% of the people who answered the satisfaction survey declared themselves satisfied and would recommend the service to colleagues (promoters); followed by 11% who maintained neutrality in relation to satisfaction and disclosure of the support provided (neutral); and only 5% who were dissatisfied or did not have a good relationship with the support provided (detractors). This result places the ethical-emotional support service in the zone of excellence, obtaining an NPS score of 79%, and can be exemplified by the statements collected below:

[...] The person who assisted me was an angel who called me at the time, which I so badly needed. I was about to take a quick test, I was very insecure, my heart was racing because I have children and I was afraid of being ill. I liked it so much that I requested a new appointment with her. She helped me a lot, rescued the professional that I am, and raised my self-esteem. I really enjoyed her appointment, it made me safe, it took my fear away. I can't even explain how useful this support was to me. Thank you! [...] (Enrollee 1).

[...] For the first time, the council provided a service that the Nursing class needs, as we're professionals who have many imbalances due to the wear out inherent to our profession. We have many difficulties in coping, especially now in this crisis, seeing our colleagues dying. For the first time I saw the board interacting with us beyond bureaucratic demands such as a professional card. We really needed it and, for the first time, I felt really welcomed! I liked it so much that I booked again [...] (Enrollee 2).

[...] The girl helped me a lot, we talked about things about my life besides the pandemic, I felt much more confident! I'm going to tell you that I've been in the Nursing field for over twelve years and I've never seen a program as wonderful as this one! Thank you immensely and when I need it again I will send you a WhatsApp [communication app]! You should spread more on social media! [...] (Enrollee 3).

[...] Because it's good for us to talk to someone who understands us, talking to family members or friends when we're lost is sometimes difficult, they don't understand. When you're a Nursing professional, who is prepared for this type of listening and who does it with professionalism, we feel more secure. The service was very good [...] (Enrollee 4).

In this way, the ethical-emotional support developed by the CSEE was configured as an indispensable health and intervention strategy for the promotion, prevention, safety and protection of the Nursing professionals' mental health in the daily routine imposed by COVID-19.

The nurses' work in mental health in the face of the COVID-19 pandemic: Performance of the CSEE collaborators

Faced with the emergency context, the CSEE worked using multifaceted approach strategies and parameters for an ethical, safe and humanized performance in mental health, which resulted in a concrete action based on the reality(ies) and subjectivity(ies)/need(s) of the professionals enrolled. It is noteworthy that, for the execution and excellence of the work provided, the selection of a qualified team was essential.

During the CSEE's period of activity, construction of bonds and trust was observed between the professional nurse (collaborator) and the registered professional assisted. It is noted that the appointments were based on qualified listening; humanization; exercise of shared empathy and of non-violent communication, respecting the singularities, diversities and potential of human beings and complying with the secrecy and anonymity of the professionals assisted, which ended up in the reduction of negative feelings; in heightened awareness (for identifying potential threats and “trigger” contexts); in personal enhancement; and in self-knowledge and self-care.

As particularities of ethical-emotional support, it is observed, for example, the non-continuity of a subsequent appointment, since some enrollees no longer wanted support for that moment, as the first appointment brought the perception of feeling good and welcomed in their needs, obtaining the expected resolvability for their demand, thus respecting their autonomy and desire, keeping the support always available.

Furthermore, during the appointments, the professional nurse (collaborator) used the Systematization of Nursing Care and its tools, such as the Nursing note, to monitor the evolution, progress and individual interventions of the enrolled patients, as well as the use of scales and instruments associated with mental health (scales on the pattern of alcohol consumption and symptoms of depression, anxiety and stress).

Finally, the service model proposed by the CSEE was based on: weekly matrix support for the cases assisted; in the supervision and training of the team; in the elaboration of monthly service reports, as well as in the daily exchange of experiences and feedback among employees, in periodic meetings and in a communication group by application.

REFLECTIONS OF THE EXPERIENCE

It stands out that working with Mental Health promotion and protection in the days of COVID-19 was an enormous challenge, although it turned out to be rewarding in the end.

It is noted that the free nature of this service has become welcoming, mainly due to the socioeconomic repercussions caused by coronavirus infections and, consequently, by COVID-19. The fact that the CSEE is operationalized by appointments via phone calls and a communication application and because it has extensive service hours (Monday to Friday from 8 am to 9 pm) has given it a flexible character in the Nursing professionals' search.

As a strength and innovative character of this report, it is highlighted that the CSEE offered a remote risk classification and allowed the identification of risks to mental health through speech, listening, silence and reports through messages, audio or via telephone calls. The communication application was very useful along this path, as it established itself as a facilitating instrument for the CSEE, mainly because it allowed useful communications and scheduling, which were able to avoid failures, inaccuracies and distress among the enrollees and the entire CSEE team. Despite the large geographic extension of Minas Gerais and the institutional character (COREn-MG) of the support service, it is noteworthy that the implementation of Telehealth services, such as those operated by the CSEE, has the potential to be developed in various social contexts, provided that it has qualified professionals for its management. These actions can be applied and offered to different professional categories (not only to health professionals) and to the general population, as such intervention is characterized by empathic, non-violent, non-pharmacological and low-cost welcoming and communication techniques, and have potential for individual and collective use, making them indispensable in the face of emotional harms and coping with the COVID-19 pandemic.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR THE PRACTICE

This report reinforces the premise: “where there is life, there is Nursing!” This is because, regardless of the social context experienced, the space (in-person or online), the population to be cared for and the care activity to be performed (consultation, management, assistance, education or research), Nursing is extraordinarily multiscient and enabled.

Thus, the support service explained in this report was innovative for the Health and Nursing areas by constituting a multidisciplinary strategy that promotes, advises and facilitates care in times of COVID-19. Maintenance of this strategy after the pandemic is encouraged.

In addition, disclosing this experience in the current times fosters new reflections, discussions and information capable of directing and benefiting mental health promotion actions among health workers.

Due to the isolation context of the enrollee and of the professional nurse (collaborator), there was lack of enrollees' data and medical history and it was not possible to carry out an in-person observation of the language and body expressions used. However, such implications did not constitute significant limitations since, even at a distance, the therapeutic potential was reached, mainly due to interpersonal involvement, developed through listening and through the weekly, fortnightly or monthly permanence of the professional nurse in the enrollees' lives.

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• ¹⁴
  Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde mental [Internet]. Brasília: MS; 2013. (Cadernos de Atenção Básica; no. 34) [citado 13 mar 2021]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/cadernos_atencao_basica_34_saude_mental.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/cadernos_atencao_basica_34_saude_mental.pdf

Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  27 Oct 2021
• Date of issue
  2022

History

• Received
  07 June 2021
• Accepted
  07 Sept 2021