Changes in hospital organization and dynamics in the pandemic.

In this section, we will address how the measures to face the pandemic produced changes in the organization of space and in the provision of services in the investigated health facilities. From the perspective of professionals, the interruption of elective care, the closing of beds, the creation of new areas aimed at assisting patients with Covid-19 and the establishment of new care rules marked a new institutional dynamic. The threat posed by the health emergency also led to changes in the use of work tools, such as personal protective equipment (PPE) and collective protection equipment (CPE), and in the relationships between professionals and users. Concern was also reported about the consequences of limiting access to patients without suspicion or diagnosis of COVID-19. The relationship between risks and rights was also the object of reflection by the health workers, as well as their assessments of the past moment.

“Everything changed! The physical areas have changed. Our service protocols, equipment, and clothing have changed.” (São Luís, male, doctor 8)

At the beginning of the pandemic, the hospital structures available in the maternity hospitals studied were deemed insufficient and inadequate by health workers for the healthcare and isolation of pregnant and parturient women with suspected or diagnosed COVID-19. In Pelotas and São Luís, specialties and elective procedures were suspended. Beds were closed to make entire wards available for the isolation of pregnant and postpartum women.

“Obstetrics was, in fact, the only service in the hospital that remained open, attending patients on free demand and with the emergency room opened”. (São Luís, male doctor, 5)

“All surgical beds were closed, and the residents were relocated to other rooms, which were eventually interdicted as well. We had 12 beds closed so that the COVID maternity unit could be opened.” (Pelotas, female nurse 4)

“We started the first phase [of covid-19], which was the phase when we had the most patients, with 11 beds, right? So, this had a huge impact, because there were 11 wards that closed and each one could only hold one patient.” (São Luís, male doctor 1)

In the three maternity hospitals, healthcare rooms were opened for patients identified as having flu-like symptoms. Spaces such as the lounge for health workers and the recreational space for the team have become inappropriate due to the new protocol recommendations for contagion mitigation. In Niterói, new wards were opened in a site that was deactivated for a previously planned renovation. A professional meeting room was adapted for another use, such as a patient waiting room. The reduction of spaces for socialization of health workers, increasing the isolation among them, was also noted. In terms of impact on the operation of services, the low-risk maternity had fewer changes compared to the others.

“It is a low-risk maternity. (…) We haven’t changed much, no, and people keep coming. We did not have to close the outpatient clinic, there were no services that we had to stop […] relocation of people from a larger area that was not COVID-19 to a COVID-19 area.” (Niterói, female doctor 1)

Due to the emergence of that moment, changes in the organizational dynamics of services and service spaces occurred quickly and with the imposition of new service rules. The reorganization of the hospital space imposed by the sanitary emergency produced new practices related to contamination control and protection of health workers and patients.

“At the beginning, we were still discussing: do we only put a mask [on] those who have symptoms or does everyone have to wear a mask? So, after we had all things very clear concerning PPE, everything was very calm.” (São Luís, male doctor 5)

Initially, the changes were accompanied by a lack of knowledge and uncertainties regarding the need for use and the type of equipment to be adopted in each situation. Once the initial period of lack of consensus among experts on procedures to avoid contamination had passed, the use of greater amounts of equipment began to be adopted in health institutions.

Changes in protocols. Changes in work processes, according to the statements, indicated the creation and application of protocols, with systematic training on the healthcare of patients suspected of COVID-19. The main trainings were on donning and doffing and routine environment cleaning after caring for a patient. The interval between appointments for pregnant women increased because a disinfection was mandatory before and after each procedure.

“We had to make a change in the routine [of the service] … give more time for patients. Instead of attending in a three-hour interval (…) we had to put a six-hour interval, to give them time to arrive, have an interval between one and the other, clean the place, all that. (…) The patients cannot sit next to each other at the reception (…). So a lot has changed!” (São Luís, female doctor 6)

However, according to health workers, the pregnant women and their companions complained about this delay and perceived it as neglect and lack of attention, and not as a careful measure to prevent the spread of the disease. Initially, the creation of an isolation space for patients with suspected virus infection was not accompanied by the increase in the number of health workers in the sector, making service difficult, as an adaptation to PPE use was required to care for the patients. In São Luís, this procedure was considered time-consuming and a delaying factor.

“Including the training, you had to go there and put on the gown, put on a mask, all very neat, the order in which the equipment is put on and taken off.” (São Luís, male doctor 8)

In general, there was availability and adequacy of personal (PPE) and collective (CPE) protective equipment, instructions for use, training, and implementation of protocols, aiming at the protection of health workers and service users.

“Here at the maternity ward, it was very good, there were no shortages of PPE, there was no shortage of respirators, it was very good in relation to these outfits.” (Niterói, female doctor 1)

“I joined the service and I have already been called for training on how to wear PPE: donning and doffing, why the hygiene or the mask”. (Pelotas, female doctor 2)

However, in Pelotas, there were differences in the adoption of training and in the acquisition of personal protective equipment. Initially, in one of the maternity hospitals, not considered a benchmark, there was insufficient PPE and training, forcing health workers to purchase their own safety equipment.

The protection measures, whose purpose was to function as barriers to the transmission of the virus, also caused adverse effects, hampering the daily healthcare routine by producing, in addition to physical distancing, difficulties in communication between health workers and patients. In São Luís, the health workers considered the availability of adequate PPE, but reported that the use of masks and face shields, in particular, made communication between health workers and users difficult. The equipment was considered uncomfortable and heavy, and its continuous use left sores on their faces, but above all, it rendered listening difficult.

“There was a significant communication difficulty, both when speaking or listening, because this [face shield] causes an echo and communication is bad, regardless of whether you are talking to a patient or a teammate. It’s uncomfortable, it hurts. I think that, from the point of view of the doctor-patient relationship, there was, indeed, a certain distancing from each other.” (São Luís, male doctor 5)

In Pelotas, they reported discomfort from the use of the equipment and the occurrence of caustic lesions and allergies on their faces, on some occasions. PPE use training was reported to be efficient.

Between risk and good health practices. In general, the threat of the risk of infection affected the relationships between health workers and patients, reducing their interaction. The teams were concerned with the reception of patients and the quality of the services offered, but also with their own safety and that of the patients.

Now, in the patient who is a suspect, everyone is always a little afraid to get close to her. So, we realize that they end up, unintentionally, but they feel… a little… isolated. Because there’s no contact, we don’t get near them all the time. So, they feel a little of this distancing between the professional and the patient”. (Niterói, female, nurse 4)

According to interviewees from the maternity hospitals studied, a distancing of health workers and patients suspected of infection, in particular, was noticed by the latter, who experienced greater isolation. In Niterói, difficulty in adherence to preventive measures by patients and their families was also mentioned.

The safety recommendations against COVID-19, at the beginning of the pandemic, contradicted the recommendations for the humanization of childbirth. Given the risk, some rights guaranteed by law, such as the presence of a companion of the woman’s free choice, including during childbirth, were suspended in São Luís. In Pelotas and Niterói, the permission of one single companion was adopted for pregnant women. Walking restrictions and mandatory use of a mask by the patient at the time of delivery were also among the measures taken by health workers in São Luís who realized how much the new practices contradicted the previous ones, causing suffering to parturients, their families and health workers who attended them. This situation was described as a contradiction in terms of good practices.

“So, creating isolation to protect mothers who were not symptomatic, isolating this symptomatic woman, isolating and explaining this isolation to this companion was very complicated…And we had to explain to her that she had to wear a mask all the time. We didn’t have a bathroom just for her. It was horrible, because we were in this duality, in this contradiction (…). The patient in labor, for example, one of the measures we took was to ask her to walk around. How was she going to walk?” (São Luís, female nurse 1)

At the beginning of the pandemic, tests for COVID-19 were not available to all women in São Luís, but all who were hospitalized were monitored as a suspected case of COVID-19. At the time, there were few tests available, and the result took days to be released. The Niterói maternity hospital offered testing for COVID-19 (rapid test and PCR).

“It’s a room only for those who were suspected cases, with main signs, an isolated service. The ward was also only for those who had signs and symptoms. We started doing tests, the rapid test, and the RT-PCR test, according to the onset time and the signs and symptoms according to the complaint”. (Niterói, female doctor,2)

In Pelotas, the availability of tests for COVID-19 was also insufficient in the two maternity hospitals studied, especially in the one that was not a benchmark for pregnant women suspected or diagnosed with COVID-19.

Health care: Changes and effects. A strategy adopted to relieve the reduced number of health workers on leave due to illness or comorbidities and the partial suspension of services was the implementation of telemedicine. The health workers in São Luís considered this practice inadequate and of low effectiveness, because, usually, the prenatal care of pregnant women requires face-to-face contact and physical examination.

“We were not sure about managing the patient only by telemedicine, without them coming to be evaluated here.” (São Luís, male doctor 1)

In addition, they feared that communication difficulties in the service at-a-distance model would be even greater than in face-to-face consultations. In Pelotas, this strategy was used to maintain the continuity of outpatient care and monitoring of pregnant women, especially those with COVID-19.

In two cities, São Luís and Pelotas, there was a perception of an increase in the demand for prenatal care in maternity hospitals. According to interviewees, this fact was related to the decrease in the offer of consultations in the public primary healthcare network. As a result, there was an increase in the number of pregnant women with few prenatal consultations in maternity hospitals. The difficulty in maintaining continuity of healthcare for women was related to changes in the healthcare provided by primary healthcare units.

“Goodness! it’s nine months generating a being without any exam, without any consultation, without any laboratory, without any ultrasound image. Nothing nothing nothing.. So, no vaccine.”

[…] “[the pregnant woman] didn’t come because she didn’t want to come. She was afraid. And she didn’t come because she even wanted to, but there was no service for her anywhere. Everything was COVID, COVID, COVID”. (São Luís, female nurse 9)

In the first months of the health emergency, in São Luís, the public primary care facilities were divided into COVID-19 units and non-COVID-19 units, with the relocation of users from one healthcare facility to another. This change did not generate good results, because the information was not well publicized and also because, according to the health workers interviewed, women avoided leaving their homes. In Pelotas, care at public primary care facilities took place in separate shifts, but even so, there was a low capacity of solving problems, because one single healthcare shift was not enough to meet the needs of users.

In the emergency service of the high-complexity hospital in São Luís, in addition to this increase in demand, the occurrence of complaints commonly resolved in routine prenatal consultations was also identified. In Pelotas, an increase in the flow of pregnant women was reported in maternity hospitals that were not a benchmark for COVID-19, and this increase was explained by the women’s fear of getting contaminated in these maternity hospitals. The same happened in Niterói.

[…] “what actually changed was the demand. We had a demand equivalent to 60–70 deliveries per month, and this number of deliveries changed a lot, we reached 120–130 deliveries per month.” (Niterói, female nurse 4)

The maternity hospital studied absorbed the impact of the demand from other maternity hospitals. In all municipalities, difficulties were reported for women in accessing routine vaccination and necessary tests.

Hospitalization in the COVID-19 ward was described as one of many delicate situations. In São Luís, pregnant women resisted being isolated, claiming that the place caused them anxiety, and their companions were reluctant to leave them alone. To minimize the suffering caused to women hospitalized by the restrictions imposed, there was a greater offer of psychological care. Professionals from São Luís reported that the initial period of the pandemic was marked by an increase in preterm births, perinatal mortality and fetal losses, and difficulties in scheduling a puerperal consultation.

“We also had more complications. I don’t know how many…, but occasionally a patient with PPD [probable date of delivery] would come, more severe cases were coming because the patients stayed at home.” (São Luís, female doctor 4)

Retrospectively, health workers from all the maternity hospitals studied considered the adjustments to be positive for meeting the needs of coping with the pandemic, even though the reduction of beds and interruption of healthcare in other clinical and surgical sectors were mentioned. The suspension of activities that took place in the most critical period of the pandemic, from March to July 2020, created a pent-up demand for services in other specialties in Pelotas and São Luís. In Pelotas, the health workers interviewed expressed concern about the pent-up demand for services, such as gynecological surgical procedures and outpatient care. In São Luís, consultations and surgeries were resumed in August, on a reduced basis to ensure a presumedly safe resumption of services. At the time of the interview, in December, a manager who worked in healthcare stated: “There are still a lot of people in the line”. According to him, patients were also returning at a slow pace because of a decline in economic conditions during the pandemic, an impoverishment caused mainly by the loss of jobs.

“We were not able to clear all the lines, for us to get back to normal. There are still a lot of people in line. And coming to the hospital, in the capital, implies a cost, right?” (São Luís, male doctor 1)

This research was carried out at a time when there were still no vaccines, but there was already greater knowledge accumulated about the disease and somehow health workers believed that the pandemic was starting to recede. Elective services, pent up due to the temporary suspension, were being resumed, and the pace of transmission was falling, as well as the number of deaths. These health workers spoke as if the most difficult phase of the pandemic was already in the past.

Illness and suffering of health workers.

In this section, we will address how the statements of the health workers about their experience in the first year of the pandemic were marked by the intense psychological suffering caused by the changes that have occurred, both in the context of hospital care and in the context of social life. Professional insecurity to deal with an unknown disease, the risk of illness and absence from work, contamination of family members, fear, and loss of loved ones, in addition to patients, all these elements and even more the social transformations resulted in feelings of sadness, pain, indignation and isolation.

At the beginning of the pandemic, changes in the work process and safety protocols generated anguish and insecurity even in health workers accustomed to working in maternity hospitals. The requirement of physical distancing, due to the elevated risk of contamination, and the lack of knowledge about the new disease caused ambiguous situations that mixed fear, conflict and cooperation.

Work overload, lack of workers and their effects. Many interviewees, especially physicians, worked in both the public and private sectors. At the beginning of the pandemic, the interruption of activities in private healthcare clinics and medical offices resulted in greater availability of health workers for assistance in the public sector, in São Luís. In a brief time, however, this situation was reversed to a lack of health workers. In Niterói, the accumulation of jobs in public services caused work overload and a greater risk of exposure for some of the health workers, doctors and nurses interviewed.

To meet the need for skilled labor, one of the administrative management strategies consisted of relocating health workers from various specialties to care for COVID-19 patients and, in the case of maternity hospitals, from gynecology to obstetrics. The lack of expertise to work on a little-known disease contributed to a feeling of insecurity shared at that time by health workers from São Luís and Pelotas.

The removal of health workers with comorbidities and, above all, illness due to COVID-19 resulted in work overload in the remaining health workers (30 to 35% in São Luís and about 25% in Niterói). After the relocation, another institutional action was a proposition to increase the workload of health workers. This situation resulted in changes in service schedules, further intensifying the workload of these health workers.

“There was no hiring at first. There was only an extension of the workload for those who wanted it.” (São Luís, female doctor 3)

“Leaves were suspended, vacations were suspended, because of COVID-19… there was an administrative direction in this sense, of having people on standby to cover absent people.” (Niterói, female nurse 1)

In the four maternity hospitals studied, some of the changes were the suspension of vacations and work permits, i.e., health workers’ rights, to maintain the workforce in that emergency. In the three municipalities, the changes were intense in the maternity hospitals and the work overload was often mentioned as another reason for illness.

“People were working much harder than they could.” (São Luís, male doctor 1)

The lack of health workers, in general, was highlighted, as well as the delay in hiring and the new hires quitting soon after taking up their positions. In general, the public administration carried out temporary contracts and tenders on an emergency basis to replace health workers on leave due to illness and comorbidities. However, in Pelotas and São Luís, this effort did not have a satisfactory effect, as the institutional rules required for selection and admission of new hires did not supply the immediate need for replacements. Another problem is that some of the new hires did not have the necessary experience for an intense job like the one experienced in healthcare at that time, to the point of quitting the job shortly after their hiring. In Niterói, hiring took place as needed, but as temporary work, without labor guarantees.

Ambiguities: Fear, conflict, cooperation. At the beginning of the health emergency, illness of health workers and changes in the intensity of work were described as a moment of great stress, but also of a lot of cooperation and solidarity among health workers who, when reporting this moment, were often surprised by the positive result of the work carried out even with teams that were reduced in size for months.

“And the number of medical leave certificates, the number of sick leaves increased, resulting in a huge work overload in the team, as it is quite difficult for us to have a shift with the full team, because one has a medical certificate, the other is away for some reason, some lost family members… and we have been experiencing this kind of stress daily.” (Niterói, female nurse 3)

“There were shifts in which I had several technical staff employees absent […] it was a miracle” (São Luís, female nurse 9)

Fear of contamination was felt among health workers at that time. According to the statements, older health workers or those with comorbidities, due to the greater risk of complications, in case of contamination, suffered even more from the dilemma of fulfilling their professional duties in the face of the risk of exposure to the virus. This context greatly affected the relationship of health workers with patients. Resistance, insecurity and even the refusal of health workers to care for women diagnosed with COVID-19 aggravated situations of conflict between managers and healthcare workers. Such ambiguity mixed fear, insecurity, and ethical duty, producing effects that hampered healthcare.

“When there was an older colleague on the team who stated, “I’m not going to do that because I’m too afraid of contaminating myself. So, there was this dilemma, a real Sophie’s choice: I have to do it, but I’m afraid to do it. It was an experience that brought much anguish to many people, many colleagues (…) in our way of caring, of seeing the patient, of seeing the other. I think that, in a way, this eliminated empathy.” (São Luís, male doctor 5)

Another element of tension concerns the use of protocols that included drugs without scientific evidence for the treatment of patients with a confirmed diagnosis of COVID-19. This fact was reported especially in São Luís and was the cause of conflicts among doctors and between them and the hospital management, and these clashes are yet another aggravating factor in the relationship among health workers.

“I was following the Ministry of Health protocol, which did not provide for the use of hydroxychloroquine and other medications. … and that, sometimes, generated a certain conflict because someone wanted to do it… And also, as there was nothing closed, it caused me doubts and insecurity.” (São Luís, male doctor 1)

The institutional support for the treatment of diseases acquired in the work environment, and other psychological problems resulting from that situation, was deemed insufficient, requiring them to seek psychological support individually in the private sector.

“I was the first to get COVID and I didn’t get any help from the hospital. I didn’t have access to exams, I didn’t have access to a CT scan, I had to pay it in a private service. I mean, I contaminated myself in the work environment and had no assistance, you know?” (São Luís, female doctor 2)

In Niterói, the considerable proportion of temporary employment relationships among health workers was pointed out as an element that contributed to even greater insecurity in terms of financial and emotional stress. The solidarity of teammates was reported as a great support for coping with the situation experienced.

The rate of illness among health workers due to COVID-19 varied among the cities studied, but the reported suffering did not vary in intensity, frequency, or origin. Fear of contagion and illness, insecurity associated with the disease, ignorance, stress, tension, resistance, cooperation, and solidarity were elements that intertwined and marked the experiences described.

Risk perception and safety strategies: Between work and home. The hospital environment represented risk and concern of health workers with their families. Various strategies have been created to prevent the spread of the virus in the home environment. Although some institutions have proposed paying for daily rates in hotels close to the maternity hospitals, our informants, mostly women, chose to redouble their care and stay at home. In the home environment, other spaces and care protocols were created to enable the professional to live with his family members, even at a distance. All these efforts did not alleviate the feeling of responsibility and guilt for putting their own families at risk. The distancing of older relatives, such as parents, was another point of suffering.

“On May, on Mother’s Day, I took a 15-day leave to be able to see my parents and they stayed there for another 15 days fulfilling a strict isolation. It was very difficult to stay away from my children to preserve them.” (Pelotas, female doctor 2)

Hostilities, open or veiled, suffered by health workers in public or private spaces, such as residential condos, also contributed to the feeling of isolation. The statements of the health workers from the maternity hospitals studied reveal the distance between media appreciation and the daily stigmatization that occurs in face-to-face interactions.

“I was the person who… the COVID nurse!! And then […] really […] I was excluded from everything […] I was excluded from family gatherings […] not that they were always getting together, you know?” (Pelotas, female nurse 3)

The speeches of health professionals consist of overlapping feelings such as sadness, anxiety, uncertainty, fear and revolt caused by the combination of elements that range from experiences of work overload, physical exhaustion, and difficult medical decisions in a context of little evidence from scientific studies, to risks and fears regarding the disease transmission, including experiences of private life marked by isolation and guilt for the possibility of transmission of the disease. In the case of Pelotas and São Luís, health workers reported an increase in alcohol and psychotropic medication consumption in that context.