Women health workers during the COVID-19 Pandemic: invisibility, overload, and ethical dilemmas

Abstract

Introduction  The COVID-19 pandemic has made the relationship between health, modes of production, and social organization unequivocally evident. In Brazil, the healthcare workforce is predominantly female and often overlooked.

Objectives  To analyze the working conditions faced by women health workers on the front lines of the fight against COVID-19 and to identify the psychosocial aspects they experienced during the pandemic.

Methods  Qualitative research using semi-structured interviews. Categories of analysis were developed, and emerging themes were grouped.

Results  Health workers described how the pre-existing precarious nature of healthcare work was exacerbated; they devised individual strategies to protect themselves and their families, with limitations on their own self-care. They remained responsible for domestic tasks and expanded care for family members, relatives, and neighbors. They experienced professional burnout, stigma for being frontline professionals, ethical conflicts, restricted activities, and recurring deaths. Paradoxically, protective measures stemmed from the workers’ strong ethical and emotional bond with caregiving.

Conclusion  An intensification of work was evident, with a greater overlap of domestic and professional responsibilities falling on women, without social support and decent working conditions, as factors generating work-related psychosocial distress.

Keywords:
Frontline Workers; Health Personnel; Women, Working; COVID-19; Psychology; Occupational Health; Ethical Dilemmas

Resumo

Introdução  A pandemia da Covid-19 contribuiu para tornar inequívoca a relação entre saúde, modo de produção e de organização social. No Brasil, a força de trabalho em saúde é predominantemente feminina e invisibilizada.

Objetivos  Analisar as condições de trabalho enfrentadas por trabalhadoras da saúde na linha de frente do combate à Covid-19 e identificar os aspectos psicossociais vivenciados durante o período pandêmico.

Métodos  Pesquisa qualitativa por meio de entrevistas semiestruturadas. Foram elaboradas categorias de análise e os temas emergentes agrupados.

Resultados  As trabalhadoras da saúde descreveram que a precarização do trabalho na saúde já existente foi agravada; foram criadas estratégias individuais para proteger a si e aos familiares, com limitações para o próprio cuidado. Continuaram responsáveis pelas tarefas domésticas e ampliaram o cuidado aos familiares, parentes e vizinhos. Vivenciaram esgotamento profissional, estigma por serem profissionais da linha de frente, conflitos éticos, atividades impedidas e as mortes recorrentes. Paradoxalmente, as situações de proteção derivaram do forte vínculo ético e emocional das trabalhadoras com o cuidado.

Conclusão  Foi evidenciada a intensificação do trabalho, com sobreposição de responsabilidades domésticas e profissionais maior sobre as mulheres, sem suporte social e condições dignas de trabalho, como aspectos geradores de sofrimento psicossocial relacionado ao trabalho.

Palavras-chave:
Trabalhadores da Linha de Frente; Profissionais da Saúde; Trabalhadoras; Covid-19; Fatores Psicossociais; Saúde do Trabalhador; Dilemas Éticos

Introduction

The first case of COVID-19 was diagnosed in Brazil in February 2020, and the first victim was a 57-year-old domestic worker¹. At the time, the country was already facing a chronic systemic crisis exacerbated by the effects of ultraliberal austerity policies². The Unified Health System (SUS) suffered from a shortage of resources at all levels of care. In this scenario, chronic problems were exacerbated and new challenges arose, amid a difficult political context³.

As the pandemic progressed, in addition to the escalating number of cases and deaths, the uncertainties inherent in an unprecedented health crisis compounded the situation. In this context, Brazilian healthcare professionals, working on the front lines⁴ or in support services, were affected by illness and stress and challenged to cope with an unprecedented situation³. They began to experience anxiety, insomnia, irritability, emotional instability, and episodes of crying. Many suffered from post-COVID symptoms⁵, a condition often misunderstood, generating persistent feelings of loneliness and injustice.

The pandemic has made the relationship between health, modes of production, and social organization unequivocal. As with other infectious diseases, the forms of illness and their severity reveal a strong link to prior living and health conditions, in which work plays a decisive role. The healthcare workforce in Brazil is predominantly composed of women and includes professionals in traditionally recognized fields, such as nursing, medicine, and dentistry, as well as workers who perform roles that are often rendered invisible, such as cleaning, kitchen work, administration, ambulance driving, and funeral services². The importance of these workers, who have endured precarious working conditions, inequalities, a hierarchical and hostile environment, as well as low wages, subcontracting, multiple jobs, and shifts across different facilities, became more evident during the pandemic. The COVID-19 pandemic highlighted the need to reflect on care work performed in the healthcare sector⁶.

Studies⁷,⁸ indicate that gender issues have received insufficient attention, resulting in negative impacts on female workers. They highlight significant gaps in research on the healthcare workforce during crises prior to COVID-19, as well as on healthcare professionals in low- and middle-income countries during crises.

Furthermore, the female burden resulting from gender domination and the subjugation of women in the capitalist context⁹ is evident, compounded by other forms of daily oppression associated with inequalities of gender, class, and race. It is noteworthy, for example, that nursing is a profession predominantly composed of black women¹⁰, who often occupy precarious positions, with lower wages and less social recognition. This scenario reveals how structural racism and the gendered division of labor are intertwined and overlap.

The COVID-19 pandemic and its repercussions for female health workers still warrant further study, given the persistence of problems and ongoing social, technological, and institutional changes. Research conducted in emergency settings has highlighted the need for long-term studies and analysis of structural impacts. In particular, the psychological effects are still being assessed, even years after the pandemic period.

This study aimed to analyze the working conditions experienced by female healthcare workers on the front lines of the fight against COVID-19 and to identify the psychosocial aspects experienced during the pandemic period.

Methods

Study Design

This qualitative study was part of the project “COVID-19 as a work-related illness,” which involved people who worked outside the home or from home during the pandemic. Workers from various categories participated. In this article, we analyzed interviews with female health workers, focusing on their experiences with productive and reproductive work.

Methodological Approach

The content was analyzed using a dialectical hermeneutic approach¹¹.

Research team

It involved a multidisciplinary and inter-institutional group of researchers, coordinated by the “Júlio de Mesquita Filho” São Paulo State University. The interviews were conducted by three psychologists working in the SUS and/or in university teaching, with training and experience in the field of occupational health.

Selection of participants

The research participants were healthcare workers who were on the front lines of patient care during the pandemic. The study was widely publicized by institutional partners, labor unions, the Public Ministry of Labor, and municipal health departments through email newsletters, website news, and WhatsApp groups. These partners referred interested workers, and at each interview, participants were asked to recommend new contacts, using the snowball sampling method.

Approach Method

Contacts were initially made via WhatsApp. The researchers explained the study’s objective and who had referred to the participant. This study utilized 15 interviews from the larger project; non-participation was not accounted for.

Context of data collection

The interviews took place virtually, from September 2021 to April 2022, via Google Meet, WhatsApp, and phone calls. No non-participants were present during the interviews.

Sample description

The sample included community health agents (four), nursing assistants (two), and nursing technicians (one), as well as psychologists (two), social workers (two), a pharmacist, a nutritionist, a physician, and a physical therapist. The participants were between 31 and 52 years old (mean: 40 years). Nine identified as white, five as mixed-race, and one as black. Nine were married, three were single, one was divorced, and we did not have that information for two.

Interviews

The interviews were semi-structured, based on a script divided into three thematic sections, comprising a total of 28 questions that addressed living and working conditions during the COVID-19 pandemic as well as health issues. The interviews, lasting about an hour and a half, were recorded on cell phones or laptops and later transcribed using the Windows 365 dictation-to-text feature. The interviewees are identified in this text as E (interviewee) followed by the interview number. No interviews were repeated. Field notes were taken during the interviews.

Data saturation

All professionals who accepted the invitation were interviewed. Inclusion was terminated due to data saturation, when similarities in content were identified and no additional data was recognized.

Data analysis

The analysis of the collected material took place in three stages, according to Minayo¹¹. After transcribing the interviews, the material was read exhaustively and systematically to identify common themes and develop categories of analysis that allowed the grouping of emerging themes. In the interpretive stage, the interviewees’ discourse was related to scientific literature. The content was analyzed within the framework of occupational health and social psychology of work.

Three authors coded the data without using software. The themes were derived from the analysis but were related to the interview script. The participants received the research report, and some expressed appreciation for the research content.

Ethical Considerations

The research project was approved by the Ethics Committee of the “Júlio de Mesquita Filho” São Paulo State University under opinion No. 4,290,745, dated September 31, 2020. All participants reviewed the informed consent form and provided verbal consent.

Results and discussion

All 15 participants worked in public health care services in the areas of primary care, urgent/emergency care, and hospital care, located mainly in the São Paulo Metropolitan Region, which was particularly affected by the COVID-19 pandemic.

The profile of the interviewees is consistent with the general data on healthcare workers presented by Machado et al.¹². This group consists mainly of women, with an average age over 40, predominantly white, followed by individuals of mixed-race and black descent, although the poor quality of data on race/ethnicity hinders a more precise understanding of the black population’s participation in this context¹³.

Two categories were established to guide the content analysis: one encompassing working conditions, domestic tasks, and caregiving in daily life during the crisis, and the other focused on vulnerabilities and the psychosocial impacts resulting from the pandemic.

Between crises and daily life: the amplification of chronic problems at work

In this category, working conditions were highlighted across different dimensions, including work processes, the work environment, and work organization. The workers reported situations such as outsourcing, staff shortages, layoffs, longer work hours, and intensified workloads.

The reorganization of work in Primary Care was also highlighted by the professionals, with impacts on the continuity of services. Multidisciplinary team meetings, contact with partners from other services, educational groups, and home visits were suspended. They also reported that, in addition to the risk of infection, fieldwork was hindered by a lack of resources, such as the unavailability of vehicles.

Various strategies were developed to maintain contact during physical distancing. In Primary Health Care Units (UBS), mechanisms were created such as collecting notes left by users and recording videos and podcasts to inform the population. Online activities were hampered in the outskirts and/or hillside areas, where internet signal was weak or absent. There were difficulties in scheduling online psychological consultations due to internet limitations and the lack of privacy for users to receive remote care at home.

The restructuring of Primary Health Care, which involved the dissolution of several Family Health Strategy (ESF) teams, resulted in deeper funding cuts and the deterioration of working conditions¹⁴ and exacerbated the vulnerability of the low-income population in the face of the pandemic¹⁵. Inequalities intersect, and the pandemic has revealed the dire consequences of a chronically neglected health sector in our society.

Another widely discussed aspect was the shortage of Personal Protective Equipment (PPE), which marked the workers’ experience. The accounts highlight critical factors contributing to the high risk of SARS-CoV-2 infection; for example, the pediatrician, who worked at Basic Health Units (UBS) in two municipalities, experienced this shortage at both workplaces.

In the study by Albuquerque, Souza, and Montarroyos¹⁶, a shortage of PPE items was reported by approximately half of the healthcare professionals. Although infection prevention and control measures were widely publicized, the context of contradictory information fueled by the federal government contributed to increasing the complexity of the public health situation¹⁷.

Almeida¹⁸ emphasizes that controlling the pandemic requires planning and management focused on work organization and collective safety. In this context, PPE is essential as a physical barrier to ensure safe conditions, and improvisations or relaxations are unacceptable¹⁹; however, workarounds were constant, as can be seen:

It got to the point where we had to count gloves—you’d come in, do everything, and then leave, because there weren’t enough to change. I even worked with a surgical apron and a disposable mask; they’d hang them up, and they’d use the same apron, while I only used disposable apron (E16, 32 years old, nursing assistant).

Due to the structural conditions of some work environments, such as the number of windows, the size of the rooms, and the flow of activities, combined with people’s behavior, it became very difficult to comply with health regulations. In many units, testing began to be conducted in outdoor areas. There were reports of the termination of contracts with the outsourced cleaning company in the midst of the pandemic, resulting in a shortage of soap, sanitizing products, and paper. Furthermore, there was no guidance regarding meal arrangements: without set breaks, staff could only have lunch when a lull in work occurred, which often happened at 3:00 PM, 4:00 PM, or 5:00 PM.

Political disputes and inaccurate narratives undermined the national response and delayed timely preventive measures at all levels. Albuquerque, Souza, and Montarroyos¹⁶ note that, from the outset of the pandemic, the federal government downplayed recommendations regarding social distancing and individual protective measures. Insufficient guidelines lacking scientific backing impacted SUS services at various levels, resulting in public health emergency management that exacerbated precarious working conditions, disproportionately affecting “invisible workers,” as termed by Machado et al.¹², who carried out orders silently and were rendered invisible by management, their supervisors, the healthcare team in general, and even the public.

The workload during the pandemic increased in several aspects: hours worked, type of intervention, emotional demands, absences/illnesses among colleagues, uncertainty regarding protocols, scarcity of resources at times, and intrusion into private life. The workers, in their various roles, described the intensification and increasing complexity of their workloads, highlighting the contradictions between expanded institutional demands and inadequate working conditions.

Reports reveal an increase in demand and work overload, accompanied by greater emotional demands in daily work life. A social worker who was working at a field hospital with five other professionals noted that they were unable to handle the 60 to 70 families seeking information in a single morning. “I couldn’t have breakfast, go to the bathroom, or eat lunch.”

Additionally, they mentioned uncertainty regarding protocols and a shortage of resources. The physical therapist in the Intensive Care Unit (ICU) reported that the workload had increased, as critically ill patients required intensive care: it was necessary to check test results several times a day, manage episodes of vomiting and diarrhea, monitor changes in dietary intake, and respond to constant clinical instability, which required frequent adjustments to treatment plans. Staff reductions, caused by absences due to infection or comorbidities, further exacerbated the situation. At one point, the professional was treating up to 19 critically ill patients, whereas the professional council had recommended a limit of ten. Similar conditions were identified by Jeleff et al.²⁰ in ICUs, where a lack of preparation and the delayed issuance of infection prevention and control guidelines, combined with excessive workloads, a shortage of PPE, and insufficient staff, triggered physical and mental strain, as well as a constant state of alert to cope with uncertainties and the severity of patients’ conditions.

Another factor was the increased use of digital technologies at work. A social worker attributed the intensification of the work pace to demands coming in via cell phone. At the end of 2021, she posted the following message, written in all caps on her profile: “I’m off duty, please respect that”. It is worth noting, in this context, the increase in double work shifts through holding two jobs or working on-call shifts, in which they faced the same precarious working conditions.

In addition to the intense, distressing, and threatening work environment, most participants lived with family members, which required social distancing to prevent infection, and these adjustments were experienced with suffering and worry. Experiences that had previously been silenced became visible.

These women remained responsible for domestic tasks and for caring for children, the elderly, and people with disabilities. The burden of daily tasks increased due to movement restrictions and the closure of schools and daycare centers. One community worker mentioned that she had to act as a teacher for three children in different grade levels. Several professionals mentioned caring for parents in their 80s who had some health impairments.

The markers of the gendered division of labor²¹ reveal that certain activities related to caregiving, education, health, and domestic work are socially assigned to women. They are also reflected in the transfer of domestic and caregiving tasks to other social groups. Situations were mentioned in which female workers relied on the support of another woman to perform these tasks, such as domestic workers or family members, mothers, mothers-in-law, or aunts. In the accounts, mothers were frequently cited as a source of support for the demands of care work. For example, the pharmacist reported that she became pregnant at the start of the pandemic, worked remotely, and relied on her mother’s presence. A doctor was also able to rely on her mother and stay at a hotel to protect her family members. In the cases of workers in higher-paying positions, family support was cited alongside other factors, such as the purchase of food and access to more technology for domestic work. This phenomenon can be understood in light of the delegation model formulated by Hirata and Kergoat²¹, in which a transfer of these activities among women is observed. This dynamic reveals that the gender division of labor is intertwined with other structural inequalities in the organization of work and social life.

Added to domestic routines were hygiene protocols for groceries, utensils, environments, and the body itself. A nursing assistant stated: “I became neurotic about the attire, the cleaning maniac.” Others mentioned adopting strict precautions, such as removing shoes upon arriving home, showering immediately, and washing clothes separately. Another aspect experienced was the restrictions on self-care in situations of SARS-CoV-2 infection or other illnesses. The workers had difficulty maintaining isolation due to their domestic tasks and responsibilities. A nursing technician, who worked at the Mobile Emergency Care Service (SAMU) and in a hospital, was the only woman in the house; “I had to take care of everyone, cook, wash, iron.” Even after contracting the virus and being on leave from work, she carried out all these activities while dealing with the symptoms of the illness. Upon returning to work, she said, “no one asks anything about how we’re doing”.

Therefore, the social process establishes a hierarchy of productive and reproductive activities between men and women, assigning them unequal roles at work, promoting the invisibility of women’s labor and the health issues associated with this context, without acknowledging the pain experienced in this process.

The invisibility of work in the health sector, especially in caregiving activities, corresponds to the way these practices are socially constructed and valued. Additionally, there is an internal hierarchy within the healthcare field that contributes to this invisibility. More highly valued professions, associated with biomedical knowledge, receive greater social and institutional recognition, while other occupations fundamental to daily care receive less visibility, prestige, and remuneration.

The results reinforce the findings of other studies and highlight the harmful consequences of the pandemic on the daily lives of female healthcare workers²². Similarly, they reveal the overlooked and undervalued aspect of care, which is often viewed as inherently feminine and unpaid²³. During the pandemic, the constant attention and stress related to caring for others extended to independent individuals, neighbors, relatives, and service users, as reported by community health workers. There was also an increase in the demands and pace of domestic chores, including maintaining household income. The data confirms that the distribution of tasks remains unequal in the domestic sphere, with these tasks considered essential for the sustainability of life²⁴,²⁵.

One interviewee, a community health agent, was part of the union as a representative of the health unit and participated in the monthly meeting to present the unit’s demands. She said, “The union group consists of about three [women]; we share everything with the group and talk to each other. The managers love to change the rules and think we won’t find out, but there’s the grapevine.” In this context, due to the imposed restrictions, union members had to become more familiar with digital technologies.

Exacerbated vulnerabilities: psychosocial impacts of the pandemic

The psychosocial impacts of the pandemic took various forms, with diverse dimensions and consequences. Mental health care was underestimated for the population and health professionals directly affected by the pandemic, in a context permeated by fears and insecurities. The workers experienced a lack of state support, without adequate preparation or training.

The ICU dietitian described an overwhelming sense of helplessness and loneliness. She would come home and watch live streams featuring renowned professionals to better prepare herself for the challenges. She reported that, without support or guidance, she felt completely unwelcome by the institution. She cited the case of a fellow nutritionist who contracted pneumonia, and when the team found out, there was great concern, both for their friendship and the risk of losing her, as she was already elderly. However, the boss’s first reaction was: “I’m going to cross her name off the shift. Who’s going to take her place?”. Situations like this made her feel like just a number. She also reported that she suffered five urinary tract infections because she began avoiding drinking water so she wouldn’t have to go to the bathroom, as a way to conserve scarce PPE. The pressure revealed constraints in work management that, at times, pushed humanization processes to the background.

Management has often ignored physical, emotional, cognitive, organizational, social, and environmental demands. The physical therapist at the Emergency Care Unit (UPA) described the lack of adequate working conditions as a major challenge, because the unit was not intended to be a place for inpatient care but had become one, on an ad hoc basis. She said: “imagine walking into the room and seeing it completely packed! Twenty people looking at you with eyes that say ‘help me!’ It really messed with my mental health... there were days when we had five cardiac arrests, five people dying during one shift!” She reported that, when she lay down, the sound of the ICU patients’ beeping ventilators came to her mind. She had persistent dermatitis that disrupted her sleep. She feels she lacked someone to talk to; to go out for some fresh air, drink water, do workplace exercises, something to relieve the tension. She reports that they were very confined in the hospital and didn’t know if it was raining or if it was cold. The lack of support was also highlighted by the primary care pediatrician who witnessed a moment of terror experienced by the psychologist who locked herself in the room and couldn’t get out. She noted that there was a lot of tension and, at no point, was any kind of support offered by management. These models minimized and disregarded needs across the board.

The lack of recognition at work compounded the stigma of being a frontline worker⁴. The physical therapist mentioned being excluded from family gatherings, and one of the nursing assistants was even met in the garage of her mother’s house, where her mother “played with a bottle of alcohol, started spraying it, and I started crying; she apologized.” The situation revealed prejudice, discrimination, humiliation, and other forms of violence²⁶. The professionals began to be shunned, excluded from social invitations, treated with fear and suspicion, and targeted by critical comments²⁷.

A nurse described being overcome by sadness at the start of the pandemic due to the change in routine, seeing empty streets, crowded markets, and people fighting over food. There were reports of emotional burnout, taking leave from work, and a daily routine marked by fears, anxieties, living with doubts, insecurities, losses, constant contradictions, feelings of inadequacy, exhaustion, devaluation at work, and prejudice, as found in the literature²²,²⁸,²⁹.

Emotional burnout was evident in the account of the nursing assistant who worked in the pediatric ICU; after the death of a two-and-a-half-year-old hospitalized infant, she was unable to continue working. She could not sleep, experienced symptoms of anxiety, diarrhea, sweating, and tachycardia when it was time to go on shift, to the point of fainting.

I made an appointment with the psychiatrist; I just cried, dying of embarrassment to see the psychiatrist, and I stayed there for about two hours. I stopped crying and she said: “I can see you’re not well.” I just said: “I’m on the front lines.” “I understand everything,” she replied. She welcomed me warmly; it was crucial in helping me (E16, 32 years old, nursing assistant).

This worker was on leave from work for a year and four months, unable to leave her room for five months, isolating herself from others. During the pandemic, illnesses and leaves of absence were marginalized, leading to a worsening of cases and underreporting of work-related health issues.

Regarding health issues, studies³⁰ indicate that insomnia is highly prevalent and associated with psychological reactions related to the COVID-19 pandemic, as experienced by female workers. Other studies have identified depressive disorders, anxiety, panic, somatic symptoms, self-censorship, guilt, post-traumatic stress disorder, delirium, psychosis, and even suicide³¹,³². Studies indicate that 44.45% of healthcare professionals reported professional burnout, highlighting the impact of the COVID-19 pandemic on working conditions and mental health³³.

Emotional changes marked the experience of professionals who began to deal with frequent deaths, in a context of restrictions on funerals and farewell rituals. The emotional toll of informing families of a death and the reactions to this impact can lead to burnout. The repetitive nature of this task increasingly exposes this group of professionals, without any protective or compensatory measures. The death scenario is made more difficult by the separation of family members and healthcare teams, triggering feelings of abandonment and loneliness³.

During the pandemic, death has ushered in a state of collective mourning in society³⁴. In field hospitals (mobile or temporary medical facilities set up quickly to treat victims in emergency situations), the emotional strain was intense; many patients and family members sought support from healthcare professionals. The intensity of loss and daily contact with death was described by a psychologist as follows: “There were days when I delivered five death notices on the same day. (...) When I had COVID, I relived all the deaths I had witnessed. All the hands I held until intubation”. In this sense, healthcare professionals may have experienced unacknowledged grief³⁵, the kind where there is no space to express one’s feelings, in which suffering is marked by a lack of support for the bereaved, leading to silencing, which hinders care.

With the restriction of in-person rituals, strategies for support and symbolic farewell rituals emerged, which contributed to the reframing of the losses caused by COVID-19³⁶. However, care for professionals facing deaths in healthcare services was scarce³⁷. This gap was acutely felt when deaths became very frequent. It must be considered that even without the actual loss of a family member or patient, the pandemic increased the risk of experiencing suffering, whether due to other losses (financial, employment, social distancing) or empathy with the suffering and social instability experienced³⁶.

Reports emerged regarding “impeded activities”, that is, tasks they were unable to perform as they would have liked and were forced to carry out, as mentioned by Clot³⁸. These impediments became part of the routine, manifesting in situations such as: the inability to provide quality care; the inability to refuse patients even under inadequate conditions; and difficulty in defending themselves, protecting themselves, their families, colleagues, and patients to the necessary extent. The impediment to activity immobilizes the subject’s internal dynamism, and the suffering can be understood through the loss of the meaning of work; the imposed inactivity affects the worker through the loss of processes of subjectivation.

Other challenges have accentuated the ethical dilemmas experienced by frontline professionals, as reported by the pharmacist:

we were pressured to use chloroquine. (...) Then came the guidance that we shouldn’t use it. With antiretrovirals too, people started using the one they said was good. I’d say, “Calm down, we need to look closely at the studies; it’s not quite like that.” We suffered because we weren’t invited t o participate.

The COVID-19 pandemic exposed several ethical dilemmas³⁹. The prioritization of the economy over human life, driven by the government and the business sector, compounded the shortage of ICU beds and ventilators, forcing healthcare professionals to make difficult decisions. Working on the front lines meant risking one’s own life and that of family members, especially given the shortage of PPE, which violated both safety standards and professional codes. The ethical dilemma permeated the pandemic, leading to a practice in which one life had to be preserved at the expense of another⁴⁰.

The scenario described can generate work-related trauma stemming from situations of impeded work, ethical dilemmas, and empathy in the face of suffering and death. Thus, it is possible to consider that healthcare professionals were at risk of post-traumatic stress disorder and vicarious trauma. The former is characterized by a delayed response related to the trauma experienced⁴¹. Vicarious trauma, or secondary traumatic stress, develops through observation or awareness of another’s trauma. Empathy, which is a working tool in the care professions, can be a vehicle for illness when encountering tragic, cruel, and intensely painful situations that have affected others³⁸. Therefore, these professionals should receive support and monitoring in the post-pandemic phase.

Paradoxically, protective measures stemmed from the strong ethical and emotional bond between workers and caregiving. The meaning attributed to the profession and the defense of the SUS strengthened resilience in the face of difficulties, as reported by the social worker when highlighting the role of collective struggle and professional recognition. Furthermore, the context of unemployment and restrictions imposed by the health crisis pressured many professionals to continue working. In summary, work took on an ambiguous meaning: on the one hand, professionals were subject to management’s impositions, which limited their control over their work; on the other, their identification with users’ needs provided them with an ethical-political strength that drove them to resist and remain in the profession.

Final Considerations

Five years after the start of the pandemic, researchers⁴² highlight the social nature of COVID-19 by revisiting the false or scientifically unsound information disseminated at the time and its impacts on the population and healthcare workers. They argue that, within a weakened social and institutional fabric, “if we wish to overcome a new pandemic, we must first cure illnesses that transcend biology”.

The effects of the pandemic on working and care conditions have been extensively explored in the literature, and the findings presented in this article corroborate previous studies. This research contributes by presenting the accounts of female workers, and the inclusion of these voices helps to generate a more comprehensive and diverse body of knowledge. Giving visibility to these experiences, which are often overlooked, strengthens processes of recognition and participation.

The pandemic was a concept learned through practical experience on a massive scale. This study revealed that the disregard for the lives and health of women workers in the sector predated the health crisis, which made the pandemic situation all the more tragic. Gender inequalities intensified, with the unequal division between productive and reproductive labor becoming even more pronounced.

It was found that lessons from previous public health emergencies were not assimilated, with gender issues not incorporated into the responses. Gender differences must be addressed in pandemic preparedness, response, and recovery plans⁴³, as vulnerable groups tend to be neglected, suffer more intensely, and have greater difficulty recovering after the virus is contained.

The participants’ experiences revealed constant fear and insecurity, work overload and pressure, lack of supplies, and extreme ethical conflicts. In a context of intensified domestic and care work, which remains stigmatized, socially devalued, and unpaid.

Studies on professionals who were unable to interrupt their activities during the pandemic can inform actions in future health crises. Structural and architectural changes are necessary, with well-ventilated and spacious environments, as well as technical support, continuing education, and training for emergency situations, as well as ensuring adequate staffing levels and reorganizing work to protect workers and users.

We have lost healthcare professionals due to deaths and resignations caused by excessive demands and the absence of limits imposed by the system. The healthcare sector encompasses activities of profound significance for those who feel called to this work, especially when performed under dignified conditions.

References

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• Data availability:
  The dataset supporting the results of this study is not available via open access, as it contains information that allows for the identification of participants. Access to the data may be requested from the corresponding author, upon justification and a commitment to maintain confidentiality and not share the data.
• Statement on the use of Artificial Intelligence:
  The authors declare that they used ChatGPT, version GPT 5.5 (free), from OpenAI, for language review and to improve the fluency and clarity of sections of the article. All content generated with the aid of the artificial intelligence tool was reviewed and validated by the authors.
• Presentation at a scientific event:
  The study was presented at the 5th International Colloquium on Activity Clinic, held October 18–20, 2023, at the University of São Paulo, São Paulo, SP, Brazil.
• Funding:
  The authors declare that the study was not subsidized.

Edited by

• Responsible editors:
  Maria Adelaide Araujo do Nascimento. https://orcid.org/0000-0002-4847-8762. Université Paris Saclay, INRAE, AgroParistech
  Leila Posenato Garcia. https://orcid.org/0000-0003-1146-2641. Fundação Jorge Duprat Figueiredo de Segurança e Medicina do Trabalho – FUNDACENTRO
  Lúcia Rotenberg. https://orcid.org/0000-0002-4132-2167. Fundação Oswaldo Cruz – FIOCRUZ
  Tânia Maria de Araújo. https://orcid.org/0000-0003-2766-7799. Universidade Estadual de Feira de Santana – UEFS

Data availability

The dataset supporting the results of this study is not available via open access, as it contains information that allows for the identification of participants. Access to the data may be requested from the corresponding author, upon justification and a commitment to maintain confidentiality and not share the data.

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  03 Dec 2025
• Reviewed
  17 Mar 2026
• Accepted
  22 Apr 2026