Abstracts

Introduction

The first case of Covid-19 reported in Brazil was on February 26, 2020. According to data from the Ministry of Health¹1 Brasil. Ministério da Saúde. Painel Coronavírus [Internet]. Brasília: Ministério da Saúde; 2023 [citado 20 Abr 2023]. Disponível em: https://covid.saude.gov.br/
https://covid.saude.gov.br/... , the country had exceeded 700,000 deaths and more than 37 million confirmed cases of the disease by April 2023.

Pandemics such as Covid-19 have tested the organizational capacity of health systems around the world, including in Brazil, since their rapid transmission and the severity of the cases have exposed the urgent need for investments to strengthen public health. Another characteristic of the Covid-19 pandemic, especially in the first year of its occurrence, was the high number of cases among health professionals, driven by high exposure to patients and a shortage of personal protective equipment (PPE), which aggravated the situation in health services²2 Vedovato TG, Andrade CB, Santos DL, Bitencourt SM, Almeida LP, Sampaio JFS. Trabalhadores(as) da saúde e a Covid-19: condições de trabalho à deriva? Rev Bras Saude Ocup. 2021; 46:e1..

The impacts of the pandemic have been innumerable, including on the health training of resident professionals, such as surgical residency programs that had their activities relocated to deal exclusively with Covid-19 cases, indicating a perception of damage to training by residents³3 Zeni Neto C, Castro GRA, Pires PH, Souza TD, Postiglioni AV, Pereira IRPD. Análise do impacto da pandemia de Covid-19 no ensino em residências médicas de cirurgia geral. BioSCIENCE. 2022; 80(2):32-7..

Undergraduate teaching has also been affected, as in the case of nursing, marked by contradictions regarding the positive and negative repercussions of remote teaching, the absence or reduction of practical activities to test technical skills⁴4 Nascimento AAA, Ribeiro SEA, Marinho ACL, Azevedo VD, Moreira MEM, Azevedo IC. Repercussões da pandemia Covid-19 na formação em enfermagem: scoping review. Rev Latino-Am Enfermagem. 2023; 31:e3913., or even medical students who have suffered psychological and socio-cultural impacts, showing insecurity and uncertainty with their academic education⁵5 Souza ER, Tonholo C, Kajiyama FM, Leite MPC, Pio DAM, Bettini RV. Estudantes do curso de medicina na pandemia da Covid-19: experiências por meio de narrativas. Rev Bras Educ Med. 2023; 47(1):e022..

The Covid-19 pandemic has caused the loss of health professionals due to death or leave of absence caused by the virus infection, triggering difficulties in replacing human resources²2 Vedovato TG, Andrade CB, Santos DL, Bitencourt SM, Almeida LP, Sampaio JFS. Trabalhadores(as) da saúde e a Covid-19: condições de trabalho à deriva? Rev Bras Saude Ocup. 2021; 46:e1.. In this context, health residents - health professionals who have graduated and are training in health services - have played a leading role in frontline work and coping with the pandemic, but have suffered from the transformations imposed by the pandemic⁶6 Farias E. O processo formativo de um programa de residência multiprofissional em saúde da família na ótica de egressos [dissertação]. Cascavel: Universidade do Oeste do Paraná; 2023..

Residencies in health professions - medical and multiprofessional - demand a dedication to a weekly workload of 60 hours over a period of two years or more, divided between theoretical and theoretical-practical activities. These characteristics are enough to justify physical and emotional exhaustion, which has intensified with the consequences of the pandemic⁷7 Dantas ESO, Araújo Filho JD, Silva GWS, Silveira MYM, Dantas MNP, Meira KC. Fatores associados à ansiedade em residentes multiprofissionais em saúde durante a pandemia por Covid-19. Rev Bras Enferm. 2021; 74 Supl 1:e20200961..

Using this issue as a starting point, this article analyzed the impacts of the pandemic on the mental health of health residents, in the context of medical and multiprofessional residency, and the implications for their training processes, at the Botucatu School of Medicine (FMB) of the São Paulo State University (Unesp). The study was justified by the need to understand these impacts, contributing to the historical record of the role played by residents during the pandemic and planning actions that indicate coping strategies in similar situations.

This article focuses on the experiences of health residents during the first year of the pandemic and is part of the first author’s master’s degree study. The study also sought to identify the repercussions of information and recommendations from state authorities about the Covid-19 pandemic on the work of health professionals; to identify difficulties in the work process perceived by health residents during the Covid-19 pandemic; as well as to identify survival and solidarity strategies in relation to the team and the residents themselves.

Methodology

The study is characterized as a qualitative research, aimed at understanding the phenomena and processes that correspond to the most intimate aspects of human relationships, in other words, their motivations, beliefs, values and attitudes, all those elements that cannot be quantified or measured⁸8 Minayo MCS. Pesquisa social: teoria método e criatividade. 17a ed. Petrópolis: Vozes; 2002..

To build the data, we used semi-structured interviews with the help of a script, with the intention of recalling the experience of the beginning of the pandemic in the household, the perceived impacts and their relationship with the information during the pandemic period, as well as a narrative question about a remarkable situation experienced during the pandemic.

The semi-structured interview and the narrative are techniques that complement each other and can be used in qualitative research to deepen knowledge about the same object.

Narratives seek to gain a deeper understanding of the phenomenon being investigated, through the emergence of life stories or situations experienced in everyday life⁹9 Muylaert CJ, Sarubbi V Jr, Gallo PR, Rolim Neto ML, Reis AOA. Entrevistas narrativas: um importante recurso em pesquisa qualitativa. Rev Esc Enferm USP. 2014; 48(2 Spec No):193-9..

Larrosa¹⁰10 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; (19):20-8. instrumentalizes this investigation with the concept of experience, defined as “whatever touches us, whatever happens to us”, what affects us, what is significant to us, not just a simple passing through of everyday things. Experience cannot be defined as the simple act of being informed, since information alone does not make it possible to learn from an event, in other words, it is not enough to spend all your time trying to be well-informed, as there is no guarantee that the subject will be touched by the information.

Thus, the concepts of narrative and experience were the theoretical guide of the analysis of this research. The interviews were conducted via Skype and Google Meet, and all took place in a single meeting, lasting an average of 50 minutes, from June 2020 to February 2021.

Participants were selected through non-probabilistic snowball sampling, using reference chains based on key informants identified as seeds, who helped the researcher to leverage research contacts. The seeds indicate other people in their network who could take part and the sample is defined and increased¹¹11 Vinuto J. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Tematicas. 2014; 22(44):203-20..

The study’s seeds were participants nominated by teachers or workers in the health services where the residents did their internships during the pandemic.

There was an intentional selection of participants to ensure diversity, interviewing professionals training in health residencies, in areas that include Primary Health Care (PHC) as a mandatory training field, covering residencies in Family and Community Medicine, Pediatrics and multiprofessional programs in Family Health, Mental Health and Adult and Elderly Health. This was due to the fact that all participants had done their practicum in PHC in 2020 and had been involved in actions and activities aimed at individual and/or collective care related to the pandemic.

Participants were contacted by phone messaging app and invited to take part in the research. Five invitations to take part in the study were declined due to lack of time or interest, and some invitations were not returned. We used the saturation technique to stop data building, as the data obtained proved to be sufficient to answer the research objectives, and further information was not necessary¹²12 Nascimento LCN, Souza TV, Oliveira ICS, Moraes JRMM, Aguiar RCB, Silva LF. Saturação teórica em pesquisa qualitativa: relato de experiência na entrevista com escolares. Rev Bras Enferm. 2018; 71(1):228-33..

The collected data were transcribed manually and the analysis process followed the methodological procedures proposed by Gomes¹³13 Gomes R. Análise e Interpretação de dados em Pesquisa Qualitativa. In: Deslandes S, Gomes R, Minayo MCS. Pesquisa Social: teoria, método e criatividade. 31a ed. Petrópolis: Vozes; 2019. Cap. 4, p. 79-105. for Thematic Content Analysis.

The focus was on the themes present in the participants’ statements, which could be represented by a word, phrase or summary, understood as recording units¹³13 Gomes R. Análise e Interpretação de dados em Pesquisa Qualitativa. In: Deslandes S, Gomes R, Minayo MCS. Pesquisa Social: teoria, método e criatividade. 31a ed. Petrópolis: Vozes; 2019. Cap. 4, p. 79-105.. In this study, we opted to keep the records as complete as possible to guarantee the essence of the narratives and preserve the contextualization of the content, a process of analysis defined as context units¹³13 Gomes R. Análise e Interpretação de dados em Pesquisa Qualitativa. In: Deslandes S, Gomes R, Minayo MCS. Pesquisa Social: teoria, método e criatividade. 31a ed. Petrópolis: Vozes; 2019. Cap. 4, p. 79-105..

We began with an exhaustive reading in search of a general understanding, and then went on to soak up all the content. The material was then broken down into parts.

We then moved on to exploring and analyzing the material, a methodological path that helped define categories through the nuclei of meaning, understood as the process of schematizing and dialoguing the selected excerpts in order to understand the broader themes that will help in the elaboration of the analysis¹³13 Gomes R. Análise e Interpretação de dados em Pesquisa Qualitativa. In: Deslandes S, Gomes R, Minayo MCS. Pesquisa Social: teoria, método e criatividade. 31a ed. Petrópolis: Vozes; 2019. Cap. 4, p. 79-105..

In the last stage of analysis, a result was obtained through an interpretative synthesis, referring to the hypothesis raised in the research about the impact of the pandemic on the mental health of health residents and on the training process, dialogued with studies that supported our analysis¹³13 Gomes R. Análise e Interpretação de dados em Pesquisa Qualitativa. In: Deslandes S, Gomes R, Minayo MCS. Pesquisa Social: teoria, método e criatividade. 31a ed. Petrópolis: Vozes; 2019. Cap. 4, p. 79-105., authors such as Raquel Silva Freire, Felipe Ornell, Carmem Teixeira and collaborators. To ensure the confidentiality of the participants’ identities, their names have been changed. The letter R was used to refer to the resident, followed by the year they were in residence. The study was cleared by the Research Ethics Committee of the Botucatu Medical School, according to opinion no. 3.994.204.

Results and discussion

In order to analyze the impacts of the pandemic on the mental health of residents and the implications for the training process, the results are presented in three categories: fear of becoming ill; loneliness in social distancing; mental health during the pandemic.

Category 1. Fear of becoming ill

The residents experienced intertwining affections and emotions in moments of paralysis in the face of the fears caused by the pandemic. Fears of death and of becoming infected and transmitting it to other people were added to the anguish arising from the need and duty to be a health professional and work on the front line.

Fear refers either to a specific object or to no object at all, i.e. fear can be related to a state of readiness and preparedness in the face of real danger or subjective danger¹⁴14 Klein T, Herzog R. Inibição, sintoma e medo? Algumas notas sobre a Angst na psicanálise. Rev Latinoam Psicopat Fund. 2017; 20(4):686-704.. In the case of the pandemic, the danger was real and concrete, in the form of infection and the risk of death, and residents had intense insecurity and fear due to the possibility of transmitting the disease to family members and other people they lived with.

The arrival of the new coronavirus in Brazil coincided with the start of the new health residency classes, which take place every year in March. Therefore, the residents were taken by surprise and had to prepare themselves to deal with the seriousness and consequences of a pandemic.

As soon as the health residents joined the services, they were exposed to the risk of contamination with the SARS-COV-2 virus. They experienced different forms of fear, anguish and uncertainty throughout the pandemic, coming face to face with finitude and the fact of being a potential transmitter of the virus.

The residents’ hurdles in dealing with the risks at the start of the pandemic in mid-March 2020 were mixed with the difficulties of the coordinators of the residencies and the health services in organizing a routine in which they could work safely amid so much anguish that permeated them.

The following narrative shows that, despite maintaining care measures, such as using PPE and social distancing, the fear of becoming infected and transmitting was not under control, as they were constantly close to suspected cases, with the risk of contaminating family members who were not exposed to the virus.

In the lockdown caused by Covid-19, patients undergoing psychological treatment talked incessantly about fear, especially the fear of death, their own and that of loved ones. In the pandemic, the fear of infection by the virus, this enigmatic enemy of human life, appears almost indistinguishable from anguish, because there is the object that is feared, but where is it? The invisibility of the virus vanishes the object that is feared and at the same time makes it omnipresent, producing the suffocation characteristic of anguish. When fear and anguish become homogenized, lending themselves to an unprecedented affective confusion, subjects react in different ways: with perplexity, denial or astonishment¹⁵15 Jorge MA, Mello DM, Nunes MR. Medo, perplexidade, negacionismo, aturdimento e luto: afetos do sujeito da pandemia. Rev Latinoam Psicopat Fund. 2020; 23(3):583-96..

The fear of the risk of transmission was so intense that residents suffered psychic problems, such as panic attacks and generalized anxiety, due to the fear of developing a serious condition with Covid-19 and having a fatal outcome. Mental illnesses emerged, which in some cases required drug support.

The fear of death is justified by the high number of deaths in the world. In September 2021, the WHO released data indicating that around 180,000 health professionals had died from Covid-19 worldwide and estimated that in Brazil up to 13,600 health professionals may have died from Covid-19¹⁶16 World Health Organization. The impact of Covid-19 on health and care workers: a closer look at deaths. Geneva: Working Paper 1; 2021. .

Usually, health residents are placed into services and begin to experiment the obstacles and dynamics of the work process of other health professionals, which was no different during the pandemic. Reference hospitals for Covid-19 patients pointed out the overload of tasks, fear, stress and insecurity experienced in the workplace¹⁷17 Freire RMS, Batista GS, Carvalho TA, Silva DS, Faustino TN, Merces MC. Profissional residente no enfrentamento da Covid-19: relato de experiência no contexto da enfermagem intensiva. Enferm Bras. 2020; 19 Supl 4:S13-20.. They described the increase in the number of health professionals infected with the virus and, consequently, the high number of deaths, as well as the feelings of frustration and impotence at the daily loss of patients and the fear of helplessness in a possible case of infection¹⁷17 Freire RMS, Batista GS, Carvalho TA, Silva DS, Faustino TN, Merces MC. Profissional residente no enfrentamento da Covid-19: relato de experiência no contexto da enfermagem intensiva. Enferm Bras. 2020; 19 Supl 4:S13-20..

It was troubling to work in hospitals, especially in Intensive Care Units (ICUs), since the professionals were now responsible for patients with very serious conditions, and the beginning of residency training presupposes a certain inexperience, making their work more challenging in the pandemic context. They had to adapt quickly to the work process, seeking new knowledge to help with their practices and not succumb to the psychological pressures caused by the pandemic¹⁷17 Freire RMS, Batista GS, Carvalho TA, Silva DS, Faustino TN, Merces MC. Profissional residente no enfrentamento da Covid-19: relato de experiência no contexto da enfermagem intensiva. Enferm Bras. 2020; 19 Supl 4:S13-20..

Category 2. Loneliness and social distancing

Given the high risk of infection and the seriousness of the cases, the short supply of PPE, the lack of knowledge about the natural evolution of the disease and the absence of specific prevention measures, such as vaccines, strategies had to be adopted to contain the spread of the pandemic, mainly by distancing people from each other. This also happened in the workplace, forcing the reorganization of health services in an attempt to avoid crowding, by means of scales and rotation between local staff and residents.

Extended social distancing (ESD) is considered an effective method for reducing morbidity and mortality indicators. It was a strategy implemented by many countries, including Brazil, in an attempt to minimize transmission of the coronavirus and, consequently, avoid overloading services, which could lead to the collapse of the health system¹⁸18 Rocha DM, Silva JS, Abreu IM, Mendes PM, Leite HDCS, Ferreira MCS. Efeitos psicossociais do distanciamento social durante as infecções por coronavírus: revisão integrativa. Acta Paul Enferm. 2021; 34:eAPE01141..

The government’s ESD guidelines, coupled with the risk of transmission, led to residents being cut off from their families and loved ones, causing anguish and loneliness. The fact that they were unable to meet their families also meant that it was difficult to get information about the health conditions of family members infected with the virus, accentuating the fear that family members would die while they were away. However, these moments of difficulty also made it possible for colleagues to get closer, as they were going through similar situations.

This new organization caused not only a physical distancing, but also an emotional distancing, since each person started to work alone in a residency program, which presupposes interprofessional work. Some didn’t see each other, while others didn’t recognize each other during the health services, since the masks and PPE disfigured physical features, as well as the sorrows and joys of an encounter.

The residents’ routine became exclusively focused on work, and the need to avoid social interaction and physical contact led them to restrict their social circle to their work colleagues, who were also at constant risk from exposure to the virus. Those who lived alone reported having experienced a sense of loneliness, unlike those who shared their homes with other people and were able to share what they were experiencing in the health services.

Those who tried to follow the social distancing guidelines more strictly began to feel the impact on their own mental health, as they had to deal with the contradiction between preserving their lives and not complying with the ESD in order to meet up with friends, triggering reflections such as the following.

Thus, physical distancing also triggered a great deal of emotional distancing, including a very lonely perception of coping with the pandemic, in which everyone tried to do what they thought was best for themselves.

Category 3. Mental health during the pandemic

Health residencies have the characteristic of bringing together health professionals with a desire to learn, putting into practice what they studied in undergraduate courses and specializing in a particular area of activity. During the pandemic, these desires, motivations and expectations clashed with the possibility of contributing to coping with Covid-19, but these professionals also had to deal with constant losses and risks of becoming infected, triggering effects on their own mental health, making it difficult to cope with the adversities arising from the pandemic and in their work as resident health professionals.

Health professionals, including the residents, were required to maintain or expand their tasks in health care during the pandemic, and were susceptible to psychological distress and mental disorders. This condition was even more evident among frontline professionals, with high rates of mental illness¹⁹19 Ornell F, Schuch JB, Sordi AO, Kessler FHP. Pandemia de medo e Covid-19: impacto na saúde mental e possíveis estratégias. Debates Psiquiat. 2020; 10(2):12-6..

The social role of health professionals has been highlighted by the media, giving them great importance and responsibility when working to tackle the pandemic. However, it is necessary to recognize their singularities as human beings, workers, who also carry their anxieties, fears and concerns.

Faced with this, health professionals sought to meet a socially imposed expectation, reflecting an emotional and physical overload, and this indicated a difficulty in getting in touch with their own emotional suffering, denying their own fear and anguish.

The fact is that health professionals have been educated and trained to deal with the illness of others, and little has been said about their own illness and its fragilities, limitations and finitudes.

It should be considered that the psychic illness of health professionals was also due to the overload of caring for patients in critical condition as a result of complications from Covid-19. Patients arrived at the health services in a variety of conditions, and the evolution of the cases was also very variable, ranging from very early deaths to long-term hospitalizations, causing emotional and physical strain on the professionals.

In order to deal with a crisis situation, health professionals need to be able to take care of their mental health, as physical and mental exhaustion makes it difficult to care for another person and can lead to unsafe conditions for both themselves and those under their care²⁰20 Santos TC, Almendra FS, Ribeiro MI. Help line: relato de experiência sobre um dispositivo de acolhimento aos profissionais de saúde durante a pandemia covid-19. Rev aSEPHallus Orient Lacan. 2020; 15(30):26-40..

Due to the high number of COVID-19 cases among health professionals, there was a consequently higher number of sick leaves, triggering overload and long working hours for those who remained in their jobs, in addition to the shortage of PPE and the insecurity of working in precarious conditions of resources and infrastructure¹⁹19 Ornell F, Schuch JB, Sordi AO, Kessler FHP. Pandemia de medo e Covid-19: impacto na saúde mental e possíveis estratégias. Debates Psiquiat. 2020; 10(2):12-6..

Since the fear of infection and transmission of the disease directly affects residents, developing strategies aimed at taking care of their mental health early is important to help them in their work routines, through preventive measures that reduce the risk of infection among health professionals, providing sufficient PPE to protect themselves, control of working hours and professional training¹⁹19 Ornell F, Schuch JB, Sordi AO, Kessler FHP. Pandemia de medo e Covid-19: impacto na saúde mental e possíveis estratégias. Debates Psiquiat. 2020; 10(2):12-6..

Collective support and care are also important strategies in mental health care, as the following narrative indicates. Solidarity among some residents highlights the importance of being welcomed by other health team professionals, showing concern and responsibility for others, and emphasizes the importance of the bond and trust when being cared for in moments of fragility.

This statement is reinforced by the following narrative, in which the resident says that he kept an eye out for information about the emotional state of the health team when they were in the workplace, not only because of the pandemic, but also because of the risk of psychological illness among health professionals in an unhealthy working environment.

There is a need to expand this care network to minimize the impacts of dealing with the pandemic, with individual and collective actions. It is important to plan mental health promotion and protection actions, in order to minimize psychosocial damage in the short and medium term²¹21 Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cienc Saude Colet. 2020; 25(9):3465-74..

Mental health care for health professionals, especially during the pandemic, should be made possible in health services through strategies to promote and prevent illnesses, bringing together trained professionals in the area who can form mental health support teams, including the Psychosocial Care Network²¹21 Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cienc Saude Colet. 2020; 25(9):3465-74.. In this way, welcoming and crisis care actions are offered, as well as initial psychological care, either face-to-face or online, structuring a care network aimed at the health of health professionals²¹21 Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cienc Saude Colet. 2020; 25(9):3465-74..

Final considerations

The wear and tear caused by the pandemic brought with it a significant feeling of helplessness in the face of the challenges facing the residents, who, in the midst of so many changes, needed to find their place as health professionals. However, at many moments, they found their professional practices meaningless and, perplexed by fear, they wished they weren’t there, they needed to feel protected from danger.

But how could they effectively protect themselves from the virus if there was a shortage of PPE? The world was facing the devastating consequences of Covid-19, and everyone was trying to protect themselves. Those who could should stay at home, that was the motto. It was recommended that people work from home, avoid face-to-face meetings and crowds, cancel classes, close some shops and other services. It was declared that only services considered essential should operate, and all health services were called upon to deal with the pandemic.

And which was the place of residents in the face of these restrictions? They are enrolled in postgraduate programs, so are they students? Are they already trained health professionals, so they should be working on the front line to tackle the pandemic? These are some of the questions that arose at the beginning of the pandemic and which caused dissension among the residents themselves, with the health services and the coordination of the residency programs.

In hindsight, health services and residency programs could have organized themselves more safely in order to arouse residents’ interest in tackling the pandemic. Other support services for residents could have been created to minimize the impact on physical and mental health. Strategies would also have been needed to develop technical skills that would make up for the shortcomings in their training and at the same time enable them to care for patients. Perhaps at that time, PHC managers, as well as the coordinators and preceptors of the residencies, understood that the moment required measures to ensure the possible safety of everyone - patients, workers, residents and students - in the face of fear, the unknown and the need to welcome the population, even if this caused frustration for the residents.

Therefore, recognizing health residents as professionals who are in training and who require a different look from other professionals favors the recognition of their fears, anxieties and frustrations, allowing the construction of a training path for the qualified exercise of health care. Bringing back these narratives and experiences has allowed us to understand that “the narrator always draws from experience what he/she narrates; from his/her own experience or from that which he/she has been told. And, in turn, they turn their stories into an experience for those who listen”²³23 Benjamin W. O narrador. In: Benjamin W. Magia e técnica, arte e política. Ensaios sobre literatura e história da cultura. São Paulo: Brasiliense; 1985. p. 197-221. (Obras escolhidas; v. 1). (p. 201).

Acknowledgements

To the resident health professionals who contributed their experiences during the pandemic, making it possible to carry out this study.

Referências

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