INTRODUCTION

The Covid-19 outbreak, caused by the new coronavirus called SARS-CoV-2, began at the end of 2019 and spread globally from the beginning of 2020, being characterized as a pandemic and a Public Health Emergency of International Importance (PHEII). The pandemic surprised and affected all of humanity and required measures to control it, including hand hygiene, the use of personal protective equipment and social distancing¹. More recent previous pandemics included the “swine flu”, caused by a mutation of the influenza virus subtype H1N1, which began in 2009 and spread in 2010^2),(3, and the Spanish flu, caused by influenza A, subtype H1N1, which began in 1918⁴.

The lack of knowledge about various aspects related to the new coronavirus generated a lot of uncertainty and health professionals who were on the front line had to seek constantly updated knowledge to act based on evidence and best practices to provide the best possible quality of care. Given the severity and high infectivity of the disease, they suffered greater emotional and occupational stress, faced social tension, were at greater risk of becoming infected, work overload, ethical conflicts and moral suffering, anxiety disorders and depression^5)-(9.

Health education had to adapt during social distancing and technological advances allowed its virtual continuation. Several studies were generated that allowed the creation of several reviews on virtual teaching during the pandemic and the pedagogical, theoretical and practical approaches for its adaptation^10)-(16 and on the students’ mental health¹⁷, telehealth^18)-(21 and telemedicine ^22)-(28 in professional training and performance.

Fewer primary studies were dedicated to identifying other gaps in health curricula to prepare health professionals to work in pandemics²⁹, although several manuscripts were published to improve the health professional curriculum for this context^30)-(37 and on aspects of professional identity challenged by the pandemic, especially ethical dilemmas³⁸.

Affectivity is defined as “a set of psychic phenomena that reveal themselves as emotions and feelings; the human being’s capacity to promptly react to emotions and feelings.”³⁹ According to Ferreira and Acioly-Réigner, from Henry Wallon’s constructivist perspective, affectivity is understood as the functional domain that demonstrates different manifestations that become more complex throughout human development and that originate from a predominantly organic base until they develop dynamic relationships with cognition.⁴⁰

Taking into account the need for primary studies on how training could better prepare health professionals to deal with situations such as the Covid-19 pandemic, the aim of this study was to know the suggestions of professionals who worked with patients with Covid-19 on how to better prepare them to deal with this context.

METHOD

RESULTS

The study participants comprised 20 professionals, aged between 27 and 51 years old, with an average of 39.1 years [Standard Deviation (SD) = 7.5 and 95% Confidence Interval (95%CI) = 35.6 - 42.6]. The median number of their children was 1 (P25 - 75 = 0 - 2). The length of professional experience ranged from 2 to 26 years, with an average of 16.3 years (SD = 7.6 and 95% CI = 9.2 - 16.3).

Other profile characteristics of these professionals are depicted in Table 1, which shows that the majority were female, self-declared white and in the medical or nursing-related field.

Suggestions to better prepare health professionals to deal with the Covid pandemic were grouped into: suggestions for health care institutions and suggestions for health education institutions.

Among the suggestions for health care institutions, one of them was the implementation of well-designed care protocols and flowcharts to help them understand how to act, resulting in more homogeneous care and care integration. Another was the investment in regular and continuous professional development programs, not only to improve the quality of care but also to make professionals feel valued. In the context of crises and the pandemic, the program should prepare them to act, with theoretical information about Covid-19 and with theory and practice on biosafety, care for critically-ill patients, humanization and communication with family members. Additionally, the importance of managers valuing the psychological dimension of employees and providing psychological support was highlighted, due to the emotional overload generated by the Covid-19 pandemic. Chart 1 displays statements that illustrate some of these suggestions.

The participants’ suggestions for health education institutions are illustrated in Figure 1.

Figure 1 Suggestions from professionals who work in a high-complexity teaching hospital for health education institutions to prepare their health professionals to better deal with pandemics. 

As it can be observed, they included curricular insertion or increased workload of technical-scientific aspects to act in a pandemic and aspects for greater focus on human beings and comprehensive care, with theory and practice on the student’s relationships/communication with themselves, with patients and families and with team members from the same area of knowledge and interdisciplinary as a member and in their leadership and management.

Regarding the greater focus on humanization and comprehensive care, greater appreciation of the psychological aspects of the human being was suggested, as demonstrated by the statements below:

[...], how do you teach human beings, to be humane? It’s hard, isn’t it? [...] We are every day, all connected, interconnected. So, if we learn to look at each other as a team, as a group, as a community, say in a broad sense, society, [...], when we look at the patient and say ‘’Okay, the patient, he died’’, and we can understand that he is another one of us who left, I think the rest falls into place [...]. I’m looking at it in a more systemic way, but I think that’s it, everyone needs to understand each other a little better, a little more empathy, compassion (D4).

In this context, several suggestions were provided to improve the future professionals’ relationships with themselves, with self-care management in general, and to maintain emotional balance, manage stress and recognize their own limits, as illustrated below:

Things about psychology [...] help us to be okay with ourselves, so that you don’t become your nuisance. You should not be your nuisance [...] there should be more talk in health institutions about self-care, about looking at yourself. So, we are trained to look outside, look at those who are in need [...]. But and you? How do you do it? Who takes care of you? It’s a question that’s well-known, right: - Who takes care of those who take care?” It’s you who takes care of yourself! [...]. You have to be the best company for you [...]. There are days when we are so sad, that we have no strength. How am I going to take care of someone [...] with so much sadness inside? So [...] these things [...] must be taken into account, this is to improve education and to improve the world. The relationships. Have you ever thought about how much empathy that would awaken? (Psy).

The importance of learning to reflect on reality and seek knowledge was also highlighted, as illustrated below:

[...] discuss issues, especially what is happening around us [...]. What’s on the rise [...]. There are a lot of new things coming out. So, get us to debate, to seek out knowledge. It already combines the two things, you teach the student to seek knowledge, where are you going to do this. And really unite, exchange ideas, discuss (N).

To improve relationships with patients and families, humanization, embracement, knowledge of the patient’s perspective, management of strong emotions and communication of bad news were suggested, as in the statements below:

Ah, improve that grid, please [...] because [...] - “What is the most difficult within care? The person!”. The liver, we have medicine, the heart too, we know how to place an access, we have technology [...]. But what about the person? That soul, that being that is there? [...] When you look in the eye, people even find it strange [...] what should be the everyday life. Put it there: “How to deal with difficult people”, [...] “How to embrace, what is embracement, what is humanization?”. This has to go inside the university. [...] You need to take care of that angry person. [...] Say: - “I know it’s bad, I’m here, we’re going to help you” [...]. But no, they don’t do that. They want [...] to close people’s mouths (Psy).

Suggestions to promote collaborative work in multi- and interdisciplinary teams covered: knowledge of each team member’s perspective, development of empathy by team members, integration between care professionals and management and leadership skills.

Chart 2 displays some statements illustrating the content or greater load suggested to improve collaborative work in multi- and interdisciplinary teams.

Regarding the curricular components for better technical-scientific preparation in the training of health professionals to work in pandemics, many interviewees considered that their training had been predominantly theoretical and did not prepare them for future professional life, which made it difficult to work immediately after graduation. Therefore, the need for more practical classes with simulation was highlighted, initially, and internships in real-life professional practice scenarios with patients in emergency services and the intensive care units. To fill the theoretical and practical gap, an interdisciplinary discipline was suggested covering crisis medicine, health care, biosafety and new technologies, as in the following statement:

[...] a discipline in which you foresee [...] some type of situation or disease that is highly contagious and that could get out of control, like now, and that can and should happen, give some examples and try to characterize it a little and that you had a range of patients, a large number, within a short time, with impairment of their organic functions, in a very varied way, and see what you could do, what is your conduct towards these patients [... ]. Mainly on the issue of biosafety, for example washing your hands and wearing a mask [...] it would have to be debated for longer, together with these new technologies that have appeared on the market, whether they are effective or not, see which new products are that can improve this, if there is any barrier [...] Then, discuss this type of methodology and approach with technological innovation and deal in a practical way with a situation like this to train the teams (RD1).

DISCUSSION

In our study, we identified many significant aspects that can make professionals better able to work in pandemics such as Covid-19. Contributions to health care institutions included the implementation of protocols for patient care, regular professional development programs or those focused on biosafety and the care of critically-ill patients. Improvement programs would be useful not only to improve the quality of care, but also to make professionals feel valued and promote greater critical reflection in them, which would avoid mechanical action.

A comprehensive and organized system of specific institutional actions, in public and private hospital environments, aimed at employee development (permanent education)⁴² is essential to minimize avoidable damages and errors and improve team performance and, consequently, promote the quality and effectiveness of the services offered by the institution⁴³. In this context, managers play a crucial role in identifying the demands of their employees. The actions must include the development and dissemination of protocols with best practices, offering recycling and technical updates and making professionals aware of their social responsibility towards society as critical, conscious and participatory citizens ^42)-(44. A study of the initial 250,000 Covid hospitalizations in Brazil demonstrated that greater attention was paid to the availability of resources, such as ICU beds and ventilators, than to offering adequate training to health professionals who would deal with patients. According to the authors, if attention had also been paid to training, the number of preventable deaths could have been lower⁴⁵.

Regarding the contributions to educational institutions, one of the highlighted aspects was the greater focus on the teaching of psychology, on the student’s communication and relationships with themselves in relation to their self-care, including emotional balance and stress management, cultivation of humanistic values, such as empathy and solidarity, of their interpersonal communication, with patients, family members and team members, for the development of other aspects of professionalism, such as recognition of limits and reflection on reality, search for knowledge in everyday life and continuous updating. The interpersonal communication with the patient and family would encompass the humanization of care, embracing the patient, considering the perspective of the patient and of the healthcare team, demonstrating empathy and compassion for them, and knowing how to deal with them when they express strong emotions.

In a study carried out in Spain with nurses on the educational needs of nurses to face Covid-19, learning self-care, communication with patients and family members, demonstrating empathy, greater knowledge about stress and strategies for managing it were also suggested to control them and for the management of emotions. Moreover, the nurses suggested developing skills to speak and work with the general public and vulnerable groups and learning about how to deal with death and dying patients²⁹. In line with this study, Amin et al.³⁰ suggest that American schools place greater emphasis on humanism and humanistic care in the curricula at all levels of education, in different learning scenarios, strengthen professionalism and improve communication with patients and also promote in students: greater self-knowledge, acceptance, availability and expressiveness in the practice of care, interest and respect for dignity, construction of interpersonal bonds and relationships of trust, recognition and legitimization of the patient’s social, cultural and spiritual values and identification of emotional expressions. Na et al.³⁶ also recommend teaching strategies such as mindfulness to maintain well-being and self-care and Nadeem et al.³⁷ highlight the importance of preparing students and health professionals to prevent or deal with psychological trauma.

All of these elements are part of professionalism in its communication dimensions (intrapersonal and interpersonal) and the commitment to professional excellence and must be worked on throughout the curriculum at all times of health education. The need for learning them becomes even more evident when professionals face crisis situations such as the Covid-19 pandemic^46)-(49.

Communication in collaborative work in a multidisciplinary and interprofessional team, as a member and in its leadership, through interdisciplinary discussion of cases, to understand the role of each professional, value their vision and integration of health care was also suggested in our study.

These findings are in line with the study with nurses in Spain²⁹ and with several authors who highlight the extreme importance of developing competence for collaborative work and effective communication in an interprofessional team to better face the Covid-19 pandemic^33),(50),(51. In the Spanish study, moreover, the need for organization, resource management, and organizational and work induction and socialization were highlighted²⁹.

Regarding the suggestions for technical-scientific preparation, some participants in our study stated that their training had been predominantly theoretical, with little practical preparation to work in the professional reality, which made it difficult for them to work immediately after graduating. They also mentioned the importance of more classes on Covid-19 and, in addition to theory, a greater workload of simulated practical classes and internships in real work scenarios, in emergency internships and in intensive care units, to work in crisis medicine and with critical patients, to better prepare to identify signs of severity in patients and provide care to them, including carrying out invasive procedures. Classes with realistic simulation, as carried out in courses such as ATLS or ACLS, were highlighted as important learning opportunities for professional practice.

In the Spanish study, several technical, scientific and professional knowledge and skills were mentioned for mass crises, pandemics and catastrophes, covering biosafety and actions when dealing with critically-ill patients. In relation to biosafety, waste management and self-protection (equipment and other necessary measures such as hygiene), prevention and protection of vulnerable groups were highlighted. Aspects related to the clinical aspects and treatment of the aforementioned patients included basic training to work in intensive care units, emergency, surgery, intensive care resuscitation units and palliative care; use of technology and techniques in the operating rooms and use of surgical instruments²⁹. Other articles also point out the importance of knowledge and practices related to Covid-19^52),(53 and the need to address disasters in the nursing curriculum³¹.

Biosafety, regarding the appropriate use of personal protective measures and equipment and contamination prevention, was also mentioned in our study as an important content, as well as bioethics and bases for legal support, especially to act in scenarios with limited resources, considering the difficulty in making decisions about patients who could have access to the ventilator and the ICU.

In the Spanish study, in addition to bioethics, the need for transversal interpersonal knowledge and skills covering deontology, law and other disciplines was mentioned²⁹. Wald and Rudy³⁸ emphasize that the formation of the professional identity of future health professionals starts during training and continues throughout their career, being developed in medical education through critical reflection, relationships in a community of practice guided by mentors and by moral and emotional resilience. Then they reflect how dealing with the ethical dilemmas generated by the pandemic can challenge, inform and potentially transform the professional identity process of students and health professionals, favoring a more humanistic and morally resilient identity.

Other authors draw attention to the need to include content in the curriculum to develop competence in public health, including epidemiology, infectious diseases and health surveillance^32),(54),(55 and to include knowledge about the determinants of health, including social and economic conditions and policies that shape individual and community health and well-being, the structural causes and roots of inequities and understanding issues related to positions, privilege and marginalization, creative and critical thinking, self-reflection, the development of bonds of trust with communities and mental health³³. Moreover, some authors highlight the importance of a critical learning pedagogy in community services and working with the different aspects and social actors that are involved with it or exercise power over it, such as, for example, its leaders and political managers³⁵.

In our study, the professionals did not mention these aspects, probably because collective and public health is already covered in the curricula of health schools, including practices in communities. However, more reflection on the social responsibility of health professionals and more practices on health surveillance and biosafety could be considered.

The importance of developing scientific competence was another aspect highlighted by the participants in our study. This finding was similar to that found in the Spanish study, in which its participants referred to the need to acquire knowledge and research skills²⁹.

Therefore, our study shows the responsibility of healthcare institution managers to invest in the professional development of their employees to improve their professional performance during pandemics such as Covid-19, developing and disseminating protocols and offering training for technical updating and humanistic, psychological, social and moral development.

According to the perception of the authors of this study, another point of fundamental importance is the responsibility of those involved in the curriculum planning of health education institutions to include various aspects to better prepare their graduates to work in pandemics. The curriculum must include not only the comprehensive care of the patient, but also of the student, the future graduate, in their biopsychosocial, cultural and spiritual dimensions and not just their illness, with an expanded view of the social, economic and political determinants of the health-disease process of the population that leads to inequity and greater mortality in certain social groups, and must encourage the social responsibility of each professional in training.

Furthermore, more practices are needed that act as professional life and in the reality of work under supervision, more opportunities for reflection on the reality, interprofessional learning, collaborative collective work and shared leadership and people management and greater theoretical-practical content of various contents related to crisis medicine.

The limitation of our study is that it was carried out in only one institution. However, it brings contributions on several aspects that can be developed in the planning of health care institutions to better prepare their professionals and promote the quality of care provided, so that health institutions and teaching institutions can better prepare future professionals to deal with the Covid-19 pandemic and other pandemics, aiming to mitigate their impact on professionals, patients and society.

FINAL CONSIDERATIONS

We demonstrate that our study brought several topics relevant to the scientific community, with suggestions for professional training and preparation highlighted by professionals who worked in a health institution during the Covid-19 pandemic. The importance of developing continuing education and creating care protocols by health care institutions was highlighted. Moreover, topics that must be incorporated into curricula to improve and update teaching in health sciences, ranging from more humanistic aspects such as valuing psychological illness, communication and empathy to technical and practical training, with greater workload dedicated to topics such as intensive medicine, emergency and crisis medicine, to be emphasized in health training institutions. The results found seek to minimize the impacts of exceptional situations, such as the Covid-19 pandemic. We believe that our results can contribute to the future planning of the curriculum of health education courses, aiming to minimize the impact on professionals, patients and society.