INTRODUCTION

The new coronavirus, SARS-CoV-2, or Coronavirus Disease 2019 (COVID-19) emerged in China and was one of the official causes of the pandemic declared by the World Health Organization (WHO), in March 2020 ^(1,2.

The SARS-CoV-2 provokes a respiratory disease that, in its early or viral-response stage, can be asymptomatic or have influenza-like symptoms (ILS). Later, in its inflammatory or pulmonary stage, it can reach a hyper-inflammatory or systemic phase, with complications such as the Severe Acute Respiratory Syndrome (SARS) and/or multiple organ failure, which can be fatal^1,3.

The virus is transmitted through unprotected contact or by mouth or nose droplets from coughs or sneezes from up to 1.5 meters. This can take place via direct contact with the eyes, nose, or mouth, directly or indirectly, after touching contaminated objects. ^1,4

One sixth of patients develop difficulties breathing and, as a result, require more health care, hospitalizations, and may require intensive care, in which case the likelihood of death is high ^1)(2)(5.

Most deaths involve patients from the risk groups: elders with severe or untreated diseases (cardiopathies, pneumopathies, immunodepression, chronic kidney diseases in an advanced stage, diabetes mellitus, chromosome diseases in an immunologic fragility stage), smokers, overweight, pregnant women, and women in their puerperium⁶.

Therefore, hospitals from the whole world are overloaded, with shortage of Personal Protection Equipment (PPE) for the health team, in addition to structural problems. This is another challenge for public health systems, such as the Single Health System (SUS) in Brazil ^1)(2)(5.

In the absence of a vaccine and of a specific treatment, the main measure to contain the pandemic and minimize the overload of health services are alternative mitigation strategies (the combined isolation of cases, home quarantine, and social distancing of the population) ^(2,7).

Medication such as oseltamivir and chloroquine, associated or not to azithromycin, are prescribed by physicians, in addition to measures to support the prevention of complications/health issues. However, in the international context, the efficacy or safety of these treatments have not been scientifically proven. Other treatments under study are also not yet proven ⁸.

The golden-standard diagnostic exam to confirm the clinical diagnosis of SARS-CoV-2 is the real time RT-PCR (qRT-PCR), which uses a sample from the upper respiratory tract in the first week of signs or symptoms of ILS. Other exams include immunological tests to identify the IgM and IgG antibodies produced against SARS-CoV-2. Among these, is the rapid test ^6,8.

Furthermore, the identification of diseased people, medical care, monitoring of contacts, in addition to the preparation of health institutions to manage an outbreak and train health professionals, are actions aimed at diminishing the predicted health totals in more than half, reducing the peak demands for health care in 66% ^2,7).

From this perspective, health units must be prepared to attend to the demands from SARS-CoV-2 and to protect their health teams, which are essential in the response to the current situation. As a result, compromising the composition and the number of health teams can have a noTable socioeconomic impact in the country ^7).

The pressure that, as a result, is generated over health workers, increase the risks of contamination, as well as physical and emotional stress. Therefore, since nursing workers are a fundamental part of the multiprofessional health team, this study uses current scientific evidence to analyze, describe, and make explicit the impact of this pandemic in the role of these workers.

METHOD

A narrative review of literature was carried out from May to September 2020, searching the databases Pubmed, BDENF, Scielo, and Google Scholar, which are sources of gray literature. The references in the articles found were also searched, and official health websites were also used as references.

The articles selected are related to the practice of nursing and to the pandemic of the new coronavirus (COVID-19), from the perspective of our guiding question: what is the impact of the pandemic on the role of nurses? The studies were chosen by combining the following keywords: COVID-19 and Nursing and Pandemic.

The inclusion criteria were being related to the role of nurses in pandemic times; focusing on the new coronavirus; and being thematically in line with the objective of this research. As a result, the studies excluded were those whose text was not available in full and whose themes were not in accordance with the objectives of this work.

RESULTS

Since this is a recent theme, only four studies were available after the keywords were used. Therefore, the descriptor COVID-19 was the most used to manually select adequate articles from the 13,354 ones related to the new coronavirus that have been published up to the moment this study started.

The study included 44 relevant studies which were, mostly, published in 2020. There were 13 original articles, including systematic and editorial reviews and experience reports, in addition to 31 official publications from government bodies, especially from the Brazilian National Nursing Council. The analysis, review, and selection of publications, started with a reading of their titles and/or abstracts.

To better understand and discuss the results, they were organized in thematic units: Changes in assistance; Prevention related to occupational exposure; PPE-related skin injuries; Mental health care; Infections by COVID-19 among nursing workers.

It stands out that new studies are being produced at a fast pace, and the information contained in this article is subject to change as evidence is produced.

DISCUSSION

Health workers are in direct contact with patients with suspected and/or confirmed cases of the new coronavirus. They advise the other citizens to stay home and comply with social distancing, although they themselves have to remain in the front lines of the pandemic, putting their lives and those of their loved ones at risk ^2,5) .

Workers who deal directly with these patients are naturally going to become anxious, due to the uncertainty and the need for rationing PPEs, the careful and adequate training for personal protection, and for the protection of their patients and relatives ^2,5.

In spite of these challenges, nursing workers in all categories have to adapt to the new directives, providing the adequate care to the patients who are suspected or confirmed to have COVID-19 ⁹.

Changes in assistance

It is extremely important for the nursing team to receive constant updates regarding new directives, resolutions, and technical norms from the Ministry of Health (MH), from the nursing councils, and from the National Agency of Sanitary Surveillance.

The Brazilian Federal Nursing Council (COFEN) assumes that the actions of nursing workers in the pandemic can be affected by high levels of infection, which leads to their being on leave from their roles. Therefore, Regional Nursing Councils (COREN) received the authorization to accept in their ranks the alumni from nursing courses who had not yet gone through graduation ceremonies, to complement the number of nursing workers in the country ¹⁰.

The MH implanted, via Decree No. 467, from March 20, 2020, the distance attention, which includes pre-clinical attention, assistance support, consultation, monitoring, and diagnostic. The attention is provided by chat in the MH website, using the application "Coronavírus - SUS", or through free phone calls to the number 136, in the scope of SUS ⁶.

As a result, the COFEN authorized and normalized, via Resolution No. 634/2020, nursing teleconsultations during the pandemic. The council considers that this service makes it possible for the health systems to better answer to the demands, making it easier for people to access trustworthy information. This contributes to diminish the levels of transmission of the disease as well as the overload in the health units, while also aiding in the organization of the flow of people in the Health Care Network (HCN). Furthermore, it makes possible for workers from risk groups to work remotely ^11-13.

Due to the importance of nursing workers in the struggle against the new coronavirus, COFEN put into effect Resolution No. 636/2020 to standardize the register of nursing workers through the system "Brasil Conta Comigo - Profissionais de Saúde" (“Brazil Can Count on Me - Health Professionals”). This provides a non-mandatory civil service action to Decree 639/2020 from the Ministry of Health, including on-line training for all clinical protocols to deal with the pandemic ¹⁴.

In Resolution COFEN No. 639/2020, the responsibilities of the nurse were established when caring for patients undergoing mechanical ventilation (MV) in the extra- and intra-hospital environments. This aimed to give them legal support and clarify what their attributions are in this public health emergency ¹⁵.

Furthermore, COFEN established the Standardized Opinion No. 002/2020, regarding the ideal minimal parameters of the nursing professionals for the attention of COVID-19 patients who are hospitalized in general hospitals, field hospitals, and ICUs, exclusively during the pandemic ¹⁶.

The councils united in the hotsite "Juntos Contra Coronavírus" (Together Against Coronavirus), whose moto is "To protect nursing is to protect health in Brazil". It provides general recommendations to organize health services and prepare nursing teams, in addition to recommendations to protect them, with campaigns and measures to reduce crossed infections between patients and health professionals ¹²⁾ .

Furthermore, as part of the role of nursing workers, health education should disseminate correct information about educational preventive measures, contention of the new coronavirus pandemic, and for the struggles against the fake news about the disease, since these encourage the population to take risky behavior, consequently increasing further the burden on hospitals and their workers ¹².

These nurses advise about respiratory etiquette; correct hand hygiene using water, soap, and alcohol gel; the correct hygiene for environments/objects; how to search for attention at the first symptoms via teleconsultation (TeleSUS), to monitor symptoms while reducing the risk of complications; and to seek the health service only in cases of shortness of breath ^4,12.

Furthermore, there are instructions to isolate the symptomatic patients for up to 14 days, with social distancing, regardless of symptoms, including the provision of prescriptions with more distant expiration dates, so the patient does not need to go back to the unit ^4,12.

Primary Health Care (PHC) units are the gateway into SUS, and must be strengthened and structured as the main responses from the health sector to the pandemic. There, professionals fill in identification forms that will make it possible to follow up the patients with ILS through teleattention ^6,17.

The nursing technicians from the PHC register patients’ personal data, ask them about relevant symptoms, and classify them as suspected or not for ILS. Then, the patient suspected to have the disease is referred to a separated and ventilated waiting room, always wearing a mask, while they wait for a nursing or medical consultation ⁽⁶.

The nurse reevaluates the situation via telephone, monitoring patients with the symptoms every 48 hours, or every 24 hours, in the case of patients from the risk group. This is done until the symptoms reach 14 days. Then, they decide how the case will be monitored: by telephone, through an in-person evaluation, or if it is necessary to refer the patient to an emergency service ¹⁴.

The nursing technician/administrator responsible for the health institution must fill in a form, notifying the COFEN about suspected or confirmed cases of infection and of death. This is done to monitor the situation of the pandemic and search for solutions that reduce the risk of contamination of these professionals¹⁸.

Prevention related to occupational exposure

Hand hygiene and antisepsis, in addition to the adequate use of PPE, is essential for prevention in cases of occupational exposure, especially during pandemics, since, once contaminated, the worker must be removed from their function, causing a social and economic impact, while also facilitating and increasing crossed infections ¹⁹.

The efficacy of PPEs depends directly on the quality and availability of the equipment and of its correct and continuous use. The scarcity of PPEs, due to the demand, became a challenge for the health systems of many countries. As a result, managers must encourage rational use ^13,19.

The PPEs must be selected according to the biological risk to which the nursing workers and other health workers are exposed. Recommendations state that PPEs must be worn in the following order: hand hygiene, apron or cloak, surgical mask, gown, goggles or face shield, hand hygiene, and gloves ^(13,19.

In the case of procedures that generate aerosols - tracheal intubation or aspiration, non-invasive ventilation, cardiopulmonary resuscitation, manual ventilation before intubation, sputum induction, collection of nasotracheal and bronchoscopy samples -, the surgical mask must be replaced by a respiratory protection mask (N95, N99, N100, PFF2, or PFF3), and a cap or gown is added before the gloves^13,19.

The equipment must be removed following the order: gloves, hand hygiene, apron or cloak, hand hygiene, gown or cap, goggles or face shield, surgical mask or respiratory protection mask, and hand hygiene. The mask cannot be removed before leaving the room of the patient ¹⁹.

Respiratory protection masks must be replaced when they are saturated, dirty, or humid. When a mask needs to be reused (respecting the criteria of change), the conditions of storage and safety of the equipment must be taken into account (these will be defined by the service/sector, considering the adequate protection) ¹⁹.

The Brazilian National Sanitary Surveillance Agency (ANVISA) determined measures for the protection of health professionals exposed to prevent and control the transmission of SARS-CoV-2 in the health services. Among the following, all are possible: passive surveillance, in which the professional is responsible for their self-evaluation regarding the possibility of contracting COVID-19; active in-person strategies, in which professionals present themselves for evaluation before starting their work shifts; active remote strategies, where each professional report, directly and remotely, the presence or absence or symptoms. The nurses in leadership positions must encourage this care in the team, to protect them ¹³.

Professionals with ILS with closed or confirmed domiciliary contact which were confirmed of having COVID-19 must be immediately removed from work for up to 14 days from the start of the symptoms, or until a laboratory exam shows a negative result or a medical evaluation guarantees that they can resume work ⁽¹⁹,

As they resume their activities, the workers must use surgical masks even in areas with no patients, and if they need to remove the mask, they need to guarantee that they are distant from others, especially newborns and immunocompromised people. However, they must not use masks with exhalation valves as a source of control, since these masks release the air breathed by the person wearing them, which can be contaminated ¹³.

PPE-related skin injuries

Medical device related pressure injuries (MDRPI) are caused by the constant use of PPEs, especially respiratory masks and protective goggles ^(20,21.

The MDRPI can be painful, cause discomfort, and be a gateway for infections, while also impacting on the quality of assistance of patients and on the quality of life and self-esteem of the professionals ^20,21.

Furthermore, the constant need to carry out hand hygiene and antisepsis increases the likelihood of dermatosis and dermatitis, which can cause erythema, dryness, desquamation, fissures, pruritus, secondary infections, and the worsening of previous skin conditions ²⁰.

As a result, some measures to minimize the development of these ulcers are recommended. These include hand and face skin hydration and reducing the pressure in the places where the PPEs are fixed with a prophylactic coverage, that is, an interface between the skin and the device. These can include polyurethane foam, silicon, and thin or extra-thin hydrocolloid film, which do not affect the safety of the equipment ^20,21).

Stoma therapists also recommend the following: relieving the pressure at least every two hours, undressing adequately to avoid contamination; inspecting, cleaning, treating, protecting, and avoiding the use of equipment over skin injuries, eczema, or hyperemia ²⁰.

Mental health care

Caring for the mental health of the multiprofessional teams of health institutions is to treat them integrally. The patient must be cared for, and it is essential for both the safety of workers and that of patients, and for the better performance and efficacy of the work being provided ^19)(22)(23.

Anxiety, depression, insomnia, and psychosomatic symptoms become common, as does an increased consumption of legal and illegal drugs. The sources of these reactions are, especially, the concern about the access to adequate PPEs, the probability of MDRPI, the exposure to the new coronavirus at work, and the possibility of transmitting the infection to relatives ^{7,19,20,22-24}.

Furthermore, these workers fear they will lose their livelihood, have a greater workload due to the increase in the work hours and in the number of patients, suffer with the lack of consistent knowledge about the virus and the need to stay updated with the best and most current practices, are uncertain about the trajectory of the pandemic and the general level of anxiety in the community. These factors are burdens to the health systems and to the workers who are part of it ^7,19.

Studies show that nursing workers are mentally more affected than other professions, since they are more directly related to the patients, and susceptible to higher levels of stress, emotional exhaustion and depersonalization, symptoms of the Burnout Syndrome. This is not a simple psychic impairment caused by excessive work; it has high costs, as it decreases the quality of attention and increases the risk of mistakes^7,24.

Health professionals generally consider themselves to be self-sufficient, and many of them do not ask for help. Therefore, the leaders must consider the potential professional insecurities of the team as a form of valuing their biopsychosocial health, in addition to encouraging them to ask for help when needed and to trust one another^22,23.

In accordance with this line of thought, all sites from the Nursing Councils and the hotsite "Together Against Coronavirus" made available an attention line for emotional support, called "Solidary Nursing". This is a chat with voluntary nurses who specialize in mental health, active 24 hours a day, to give exclusive support to nursing workers during the COVID-19 pandemic ²⁵.

This line has attended nearly 130 professionals every day, especially during the nights. Most of the callers are women and nursing technicians, the majority of whom live in São Paulo or Rio de Janeiro. Their main issues are related to the scarcity of PPEs, work overload, fear of infecting relatives, solitude, moral harassment, and social discrimination ²⁵.

Infections by COVID-19 among nursing professionals

In many countries, health professionals are called heroes in a coat. However, they are not immune to the disease, neither to the neglect of health organs. As a result, the COFEN and the COREN from many regions have been reporting problems that preceded the pandemic and were intensified ^(26,27.

This include: the illegal rationing and distribution of PPEs that do not correspond to ANVISA standards; the lack of preparation of the team to put on and remove the PPEs during the provision of clinical support to patients with suspected/confirmed coronavirus cases; infrastructure problems (lack of sinks, soap, alcohol); professionals from the risk group who continue working; disorganization in work routines; work overload; deficit of human resources; and insufficient resources to test health workers for the infection ^26,27

At the moment, the tests available in the public network are recommended to test workers from health services or public safety who present symptoms and are working and people with ILS who work in the same house as health or safety professionals who are active. They are also directed at testing the population from the risk group and for the economically active population (those from 15 to 59 years old). Although health professionals are a priority, there are shortcomings in the care with the team ⁸.

In this context, the COREN from the state of Rondônia filed a lawsuit against the State to guarantee tests for the nursing workers who are exposed to the coronavirus. However, this type of lawsuit must be carried out all over the globe, since the contamination puts the lives of these workers at risk, presents risks of crossed infections to the patients and their relatives, and can bring health care into a collapse²⁷.

Many workers who are removed due to the disease are not replaced, which increases the burden of those who are still working, as well as the risk that they will be infected. According to the International Council of Nursing (ICN), up to May 2020, Brazil had lost 137 workers, the equivalent of 34% of the total losses in the world, while the United States, up to May 2020, had lost 91; Spain, 50; and Italy 39, from the total of 360 professionals lost in the pandemic ²⁶.

Up to the first week of November 2020, the Nursing Observatory notified 21,817 confirmed cases and 15,475 suspected cases reported to COFEN. There were also 426 confirmed deaths by COVID-19 and 34 suspected cases, among the 2,263,132 registered nursing workers in the country. Brazil, as such, has lost more professionals from this category than any other nation ^18,26).

May 12th is the International Day of Nursing, and 2020 was declared the Year of the Nurse, as an homage to the 200th year since the birth of Florence Nightingale, the founder of modern nursing, the first to realize that hygiene is the main way to prevent infections, knowledge which has been essential for combating the current pandemic²⁸.

In that day, nursing professionals met in front of the Republic Museum, in the capital of the country, Brasília, respecting preventive measures against the transmission of the disease, to pay homage to their colleagues who died in the front lines of the fight against coronavirus. They also sought to claim for better work conditions and more professional recognition, since these workers are under work overload and their salaries are not in accordance with their role, while also receiving unfair retirement pensions and having inhumane work hours ^3,29.

In the Day of Nursing, Bill No. 2564/2020 was also brought to the floor of the senate. It aims to change Law No. 7.498/1986, to establish the minimum salary for nursing professionals and a weekly 30-hour work journey. Other projects, waiting in the floor of the House of Representatives for more than 20 years, were also brought forth. Considering the current context, the increased visibility of nursing makes this an adequate moment to debate the new project ^29,30.

Low salaries mean that nursing workers need to work in more than one institution, increasing their workload and their permanence in different environments, all of which are extremely contaminated, and much more exposed to biological risks, in addition to physical and mental exhaustion. This directly interferes in the quality of life of the workers and, potentially, in the quality of the assistance they provide ^(29,30.

Senator Fabiano Contarato, author of the project, points out that the disparity in the salaries of physicians and nurses is clear, and that this health category, which is, at the moment, in the front lines of the health care of society, should not earn an such an undignified remuneration. Contarato also highlights that approving this project would be the best possible homage to nursing professionals, and indeed, it would ^29,30.

CONCLUSIONS

The impact of the pandemic in the role of nurses involves changes in the routine of assistance, an increased adherence and understanding of the importance of having adequate personal protection equipment available, as well as the intensification of other measures to prevent infections at work.

There is a concern about the psychosocial wellbeing of nursing workers and other health professionals, not only in the struggle against COVID-19, but regarding their work routines, since integral care with the health of workers also affects the quality of the work provided.

Furthermore, this moment called society's attention to the role of nurses and is an appropriate moment for the category to fight for the rights they have sought for so long.

In this situation, nursing can be recognized as the essential workforce in the response to the pandemic, being necessary in the front lines of this fight. In addition, it encourages nurse workers to face the challenges and adapt to new directives and conditions, to look at themselves and provide the necessary care to the population with dedication, respect, and courage.