Introduction

The SARS-CoV-2 coronavirus disease was first reported in China on December 12, 2019, and reached Latin America through Brazil on February 25, 2020 ¹. Within days, on March 11, the World Health Organization (WHO) declared Covid-19 a pandemic ². The lack of global preparation to face a similar pandemic and the need to take urgent measures was notified months before the first cases were reported ³.

According to data from a study that included 185 countries, regarding morbidity and mortality due to COVID-19, at world level, the average infection and mortality rates were 16,482 and 291 cases per 100,000 inhabitants, respectively ⁴. Although the incidence was global, the regions with the highest incidence and mortality rates were North America, Europe and Central Asia, while the lowest rates were in South and East Asia and sub-Saharan Africa.

In the case of Latin America and the Caribbean, the average incidence rate was around 12,000 cases per 100,000 inhabitants, while the mortality rate was close to 250 cases per 100,000 inhabitants, although these are high figures, they are below the world average. Studies have shown that the higher incidence has been associated with the presence of chronic diseases and population aging, in addition to the low capacity of health services, especially in high social inequality contexts ⁴.

In Latin America, health systems were already deficient before the pandemic began, so many collapsed; shortage of resources, healthcare personnel, equipment and means of protection, in addition to the inability of governments to control the situation became evident and, unfortunately, these situations continue to worsen ^5). The lack of safe working conditions causes health problems, which is even more critical in the case of Healthcare personnel who are exposed to the infection due to the nature of the work they perform.

The effort and leading role assumed by healthcare personnel has earned them the recognition of the population, based on the understanding of the importance and complexity of their task. Nevertheless, they have also been the target of acts of violence, rejection and discrimination ⁶. Healthcare personnel faced the greatest risks, stress, long, tense and overloaded workdays, in which permanent concentration and vigilance were required to keep protective measures ⁷. These extreme working conditions, maintained during this period, have led to high rates of infection and even death ⁸.

WHO has issued recommendations on the proper use of personal protection equipment (PPE) consisting of gloves, medical (surgical) mask, goggles, face shield and medical gown ^9,10. However, with the development of the pandemic and the increase in new cases, a disruption in the supply chain, increase of prices and monopolization of PPE equipment, thus, resulting in shortages that jeopardizes the safety of healthcare workers ¹¹.

Therefore, the question arises as to whether the working conditions of healthcare personnel is adequate so they can perform their duties in a satisfactory and safe manner, as well as the factors that affect such working conditions. This is essential in order to take the necessary measures and, therefore, contribute to the control of the pandemic, so that the care and attention to health workers should be a priority in each country. To this end, an integrative review of the literature was carried out with the objective of determining the conditions in which the work of the healthcare personnel who faced the pandemic in the region was implemented; its consequences: and the behavior of the responsible stakeholder. A broad search for research based on surveys of healthcare personnel and statistical data on these issues was carried out.

Methodology

The integrative review followed Ganong's method ¹². This author suggests that the literature review for the assessment of other research conducted should be carried out in six stages, which were completed in this study:

Figure 1 shows the diagram summarizing the steps that were followed to search for and select the documents to prepare the integrative review.

Source: Own development.

Figure 1 Diagram of the phases involved in the search and selection of documents. 

Results

Table 1 lists the articles that were part of the sample, according to their author, title, type of study, subject-matter studied and the topics dealt with. Twenty five percent (25%) were conducted with samples that included healthcare personnel from 13, 17 and 20 Latin American countries ^6,13,14. The topics covered a wide range of problems, such as the availability of PPE ^6,13,14, training ^6,13, physical ^6,13,14 and mental health ¹³, institutional care ^13-14 and social security ⁶. Of the remaining studies, 25% worked with samples in Peru ^15,18,22, 16.8% in Ecuador ^16,20, Colombia ²¹, Mexico ²³, Argentina ¹⁹ and Guatemala ¹⁷, each of these four countries comprising 8.3% of the sample. Some 16.8% of these studies, such as those of Argentina ¹⁹ and Peru ¹⁸, dealt with all of the topics. Thus, 41.8% of the studies assessed the problem in a broad sense, in terms of countries and topics ^{6,13,14,18,19}. Some 33.2% focused on the availability of PPE, physical safety and working conditions ^15-17,20 and 25% fundamentally assessed mental health, among other topics ^21-23. The samples were comprised of physicians and nurses, laboratory personnel and personnel from other clinical, administrative and social security areas.

Discussion

Based on the objective established in order to determine the problems that affected working conditions of healthcare personnel who confronted the pandemic in the region, its consequences and the behavior of the responsible stakeholders, it has been shown that PPE was scarce in general ^13-18. The percentages indicating this situation are high, even for personnel with maximum exposure to the virus ¹⁸. Studies carried out by means of surveys made to healthcare personnel in several Latin American countries agreed that workers in the public sector had greater shortages of PPE and worse working conditions than those in the private sector ^17,19, were forced to reuse equipment due to shortages and had to acquire them with their own funds, which is unacceptable in such a dangerous, generalized and highly contagious pandemic situation ^13,18. The reuse of these means, although not recommended, is possible in cases of extreme shortage, under supervision and control measures that were not carried out ²⁴.

In some cases, minimum health conditions and disinfectant solutions were not available ¹⁷. Moreover, in many cases, the virus test was applied only if the worker showed symptoms, which contributed to infection in asymptomatic cases ¹⁵. Most of the personnel worked shifts of 12 hours or more ¹⁵. The combination of these factors was the main cause affecting the physical safety due to infection of healthcare personnel and their families, where the workers in the region were the most affected worldwide ^16,18,25. However, there are no regular statistics or studies that provide accurate figures by country or continent ²⁵.

Insufficient training to handle patients and lack of PPE were causes of infection ⁶. Few quantitative studies were found that addressed training levels in the region. The studies consulted agreed that there was a deficiency in the training of healthcare personnel to do their work safely and a poor knowledge of the safe handling of PPE and infected patients ^13,19. According to WHO data, of the 43.5 million health workers worldwide, half were nurses, of whom at least 2 million were not qualified ⁵. This indicates the need for ongoing training of healthcare personnel, which is a major weakness in the system ^10,14,21. Globally, although there are no accurate data, it was suggested that around 17,000 healthcare personnel died during the year 2020 and that every 30 minutes a healthcare personnel died as a victim of the pandemic, really alarming numbers ²⁶. It is estimated that between 10 and 20% of healthcare personnel in each country were infected, with nursing personnel being more affected due to their direct contact with patients ⁶. In the Americas, deaths of healthcare personnel due to infection accounted for one out of every seven deaths due to COVID-19 ²⁵. The high risk of infection, together with the insufficient availability of PPE and insufficient safety and patient management protocols, led to this alarming situation among healthcare personnel ⁶.

Physical insecurity due to violence against these personnel was manifested in very few cases in several countries ⁶. However, it is notorious that some were promoted by the police itself and some governments did not take the necessary measures to punish those responsible ⁶. Quantitative studies on violence against healthcare personnel are scarce. The results show that there were different forms of discrimination against healthcare personnel ^15,21. These are aspects that should have been addressed by the institutions that even provoked them in several cases ²¹. Psychological safety is as important as physical safety, as it is part of the necessary biosecurity, since it guarantees the individual's integrity and psychic balance ²⁷. It allows the personnel to be able to perform their work in a conscious manner and to apply safe protocols for the treatment of the patients. According to studies, the extreme working conditions mainly caused anxiety, fear and stress, which led to unfavorable psychological states and affected work safety ²⁷. The causes of these effects were the unavailability of PPE, the increase in the number of cases and the insufficient number of healthcare personnel ²².

Another affectation detected to a limited extent was burnout syndrome or professional exhaustion, which was manifested by exhaustion, indifference to work and reduction in professional efficiency ²³. This is a problem that was present before the onset of the pandemic, but was exacerbated by extreme working conditions.

In the studies consulted, great differences were observed in their results regarding the percentages of those affected from the psychological point of view. Stress was the most frequent affectation in its mild form ^13,21,23. There is agreement among authors that the workers who showed normal psychological conditions were a small percentage ^21,22. No experiences were found describing the implementation of measures for the necessary psychological care of healthcare personnel. Although it is known that the extreme conditions in which healthcare personnel work lead to psychological affectations and stress, these workers usually did not receive training or treatment from their institutions ^6,13.

Since the end of the 19th century, when it began to be considered that diseases could be controlled, the State began to take this role, as a stakeholder with the power and means to reach the greatest number of population, especially the most vulnerable and those with the most limited resources ²⁸. Health is a public good, a human right and therefore is the responsibility of the State, as part of the social protection of the population, and it is therefore up to the State to plan resources and implement actions and institutional instruments for its care ²⁹. However, since the last decades of the last century, the establishment of neoliberalism as an economic model in many Latin American countries removed the government's priority for public spending on health, including that of healthcare personnel ³⁰. As a result, they do not always have free access to diagnosis tests, do not have health insurance and in cases of infection they had to pay for their own medical expenses or those of their family members ¹⁸. Despite the steady increase in the number of infections in Latin America, which requires more resources, public health funding and budgets have been reduced in countries such as Peru, Brazil, Colombia, Argentina and Ecuador ^18,24,31,32.

However, a study of health policies applied during the pandemic in ten Latin American countries showed that there was a tendency to increase resources in the health sector, using emergency funds, budget reallocations, indebtedness and increased taxes on the highest incomes ³³; additionally, many of the policies did not involve the communities, a fundamental aspect for the control of the pandemic ³³. There is a need to strengthen legislation and oversight by governments on the responsibility and provision of PPE, other means and measures for safety and social protection. The necessary expenditures in PPE, personnel training and budget for the payment of salaries in the necessary positions, according to the demand of medical personnel, among other public health needs, mean a high investment that is less and less considered in governmental budgets ⁽³⁰⁾. The reduction of budgets had led to a gradual reduction of the salaries of medical personnel, who have also experienced payment problems ³⁴.

Despite the real economic limitations to acquire PPE, there are measures that can be taken in the social and psychological order. Therefore, it is recommended that the Ministry of Public Health, in its leading role, guide and control the work of health institutions in terms of the physical, economic, psychological and social care of their personnel. A fundamental aspect is the redesign of the social security law, which should financially support all healthcare personnel. From the preventive point of view, the creation of emergency reserves of health equipment and materials, essential for health crisis situations, should be considered, as well as working constantly on the training of healthcare personnel to face epidemics.

The small number of quantitative research studies found is a limitation in this study. Therefore, it is recommended to develop lines of research, especially for future assessment regarding the training received by healthcare personnel in general and nursing personnel in particular, especially in terms of what is required to confront any pandemic, as well as the forms of psychological care that are applied in the institutions where they work and that deal with the forms of violence and discrimination to which they are exposed.

Conclusions

The occupational safety of healthcare personnel was fundamentally affected by the insufficient supply of PPE, which led to an increase in infections. The feeling of insecurity, along with excessive working hours, led to psychological effects. There was a deficiency related to training, especially in the handling of PPE and other biosecurity measures. The labor and social security rights of healthcare personnel were violated and, in some cases, the legislation is not complete. There was a neglect of the working conditions and rights of healthcare personnel by the State and by the institutions, in addition to the insufficient resources that exist in the poor economies of Latin America.

Conflict of interests

The authors stated that there was no conflict of interests.

Funding

The authors stated that there was no funding of any nature.