Journal of Chemotherapy and Cancer Research

The Impact on Social Worker’s Work in Hospital Health in the Context of COVID-19 Pandemic: An Integrative Review

Iany Lugao Monteiro^* and Ana Raquel de Mello Chaves

Resident do Instituto Nacional de Cancer José Alencar Gomes da Silva (INCA). Rio de Janeiro (RJ), Brazil

^*Corresponding author
Iany Lugao Monteiro, Resident do Instituto Nacional de Cancer José Alencar Gomes da Silva (INCA). Rio de Janeiro (RJ), Brazil.

ABSTRACT
The work of the social worker in health during the COVID-19 pandemic period has been the subject of debates and academic productions about the category’s professional performance in Brazil. Significant considerations were given to changes in work processes and service flows, such as the call centre modality, issues that pervade the professional ethical and political dimensions, along with daily interprofessional relations in each social space. Therefore, the goal of this study was to conduct an integrative review of published articles that highlighted the impact of the COVID-19 pandemic on the work of health social workers at a time when the category was on the “front line” of serving the population. The methodology employed was a bibliographic survey of articles published in Brazil that were fully available in the databases Scielo, Lillacs, BVS, Portal CAPES, PUC, UFRJ, and Google Scholar. Four articles from experience reports that met the inclusion criteria were chosen and analysed. The findings show that social workers in the country were committed to ensuring population access to clinical protocols and changes in flows appropriate to the pandemic and guided by WHO - World Health Organization, in accordance with the legal bases present in its specific legislation, the principles of the Code of Ethics and the Political Ethical Project, the Parameters of Action of Social Workers in Health, as well as the guidelines of the CFESS-CRESS.

Keywords: Pandemic, Job, Social Worker, COVID-19, Social Work

Introduction
The year 2020 was marked by a health crisis unprecedented in human history. The economic crisis, combined with the health crisis caused by the new Coronavirus (SARS-COV2), resulted in global economic and social changes, affecting government systems and, in particular, health services. 

The global pandemic context had significant impacts on the living and working conditions of the population, as well as on the management of assistance services, on work processes beyond professional practise, and on the physical and emotional structure of health professionals. Considering the inextricable link between work stress and Coronavirus infection and death, in the face of a scarcity of adequate personal protective equipment and hospital machinery to provide health services related to this new disease. Work processes were modified, and there was a need to use health protocols, which was especially novel for social workers, who do not have specific disciplines in their professional training, such as behaviour disease and health practises. 

The hypothesis of this study is that there has been an intensification in the expressions of the social question in Brazil, which already has a disparate social inequality in its genesis, due to its socio-historical process of social formation of the capitalist society, which at the same time that institutes the wage earner and develops the productive forces of work, exposes social inequalities. This situation is aggravated by the global neoliberal reforms that have been in place since the 1970s and in Brazil since the 1990s, which, in response to the capital crisis, have had far-reaching consequences for the state and social policies. In this context, and in view of the social repercussions, notes and scientific elaborations were written in the field of Social Work to support and direct the adapted work of social workers during this pandemic period. The CFESS / CRESS group published a series of review articles, experience reports, and directions immediately following the “lockdown” decree in many locations on March 16, 2020. Furthermore, there were extensive debates promoted in classes by the category of social workers, live broadcasts made through social networks (“lives”), news and or virtual meetings to maintain reflection, awareness, foster dialogue, and the diffusion of ideas and intervention strategies in pandemic times. 

Thus, the purpose of this article is to present an integrative review of what was published and made available in databases from March to December 2020, in terms of innovations and changes in the work processes in which social workers are inserted, taking into account the demands of the population that uses the services that materialise the expressions of the social issue. The author’s professional placement as a social worker in a Ministry of Health residency programme sparked interest.

The health and economic crises hit the rich and poor unevenly. In other words, because of the country’s already precarious sanitary conditions, the most impoverished and vulnerable segment of the population (the target of social workers’ work) was put at greater risk, being more affected by the virus’s spread and the impossibility of maintaining the recommended quarantine,  due to the already precarious sanitary conditions in the country, the environment in which they live, as well as the conditions of public transportation, for example, which has historically been crowded and does not allow for any recommended physical distance.    

In this way, the pandemic drew attention to the importance of work. For those who rely on work for a living, the precariousness of labour relations, informal work, the absence of labour and income protection for their subsistence are represented in this pandemic. In light of the unemployment scenario that has spread to some and the insecurity of income guarantee, previously achieved by selling their autonomous workforce, to others. Work in capitalist society, according to Antunes, serves the interests of capital holders through exploitation of labour and precarious work, resulting in a widening of social inequalities [2].

Regarding social inequality, this is a priority factor in Brazil because of the difference in the possibility of quarantine by the most impoverished and workers of essential services who live primarily in the large slums of the metropolises. Add to this the lack of tests for the entire population (resulting in underreporting and ignorance of reality), for a better and more effective accuracy about the spread of the new Coronavirus, which knows how to be accelerated, in view of the number of contaminated and dead, and, as a result, a better direction of the State in actions of social policies that guarantee prevention.

However, what is confirmed is that the federal government emphasises the ultra-liberal project of the Brazilian extreme right, with conservative and fascist traits, intending to defend capital, favouring large landowners, who receive tax incentives, increases in income and income from public funds, as well as tax cuts, in a scenario that simultaneously removes more and more value from the working class, and reduces and eases labor, social security rights, presenting a predatory, coercive, violent and barbarism of the population’s social life, increasing social inequalities in the country.

In this context, which is permeated by precarious work and the population’s living and working conditions, has exacerbated the pandemic’s impact on the working class’s social and material conditions. In this logic, it is possible to confirm the strategy of volunteering and philanthropy combined with the temporary provision of basic income from emergency aid to the detriment of strengthening and continuity of social assistance policies. Bill 873/2020, which made possible emergency aid, amended Law 10, 835/2004, establishing the basic income of universal nationality, which allows for a transfer of income to be funded by the family that already has been included in the single register of social assistance and which benefit from the Bolsa Família Program (PBF1), as well as individual microentrepreneurs unemployed and low-income families (monthly income up to R $ 522.50, or income up to R $ 28,559.70 per person in 2018). First, this measure aimed to transfer to these individuals a monthly payment of R $ 600.00 during the pandemic period of 2020 and for up to 02 individuals, as well as for women who are heads of families (Alves, Siqueira, 2020).  Given the consequences of the pandemic this year and the worsening of the social issues, the emergency benefit, which had been suspended, has been the subject of political and economic debates for its reinstatement in 2021.

In terms of receiving emergency aid, most of the impoverished population have little digital access to the benefit. The requirement for the internet and a cell phone or computer, digital applications, and the requirement for a bank account specifically for this purpose and linking to an active national identity document, for example, constitute real barriers to many people’s access to the emergency aid.

Thus, it is evident that the Brazilian population’s living conditions have been impacted by the current health crisis. The pandemic caused by the new coronavirus manifested itself in a multifaceted crisis (economic, political, social, environmental, etc.) that had been ongoing since 2008. The new coronavirus exacerbated this crisis, which was used to justify cost-cutting processes such as worker dismissal, job scarcity, and an increase in workloads due to the increase of home office. Such situations, according to Alves and Siqueira, represent a scenario of worsening social inequalities, in which Brazil’s social, economic, and political reality, in 2020, has challenged everyone [1].

In this regard, much has been written about the pandemic and the virus in official and popular media. For example, microbiologist Átila Iamarino has been presenting videos on his online channels on YouTube to explain that although Brazil accounts for 2.5% of the world population, it represents 15% of COVID-19 cases and 14% of deaths worldwide, resulting in five times more deaths than the rest of the world. The total number of cases currently stands at 6,000,000 million.

It is important to note that even with the guidance of health authorities, some governments, including Brazil’s, have denied the impact of the pandemic, minimizing the severity of the disease and the need for quarantine and social isolation. Measures to assist the population, particularly the poorest, have been implemented, but with numerous deficiencies and obstacles, including a lack of ICU beds, a shortage of professionals, and an absence of diagnostic tests for all. Another issue is the ideological discourse of concern for the economy, with the return of jobs and the resumption of “normal” life, with the reopening of schools, the release of parks, and collective events, for example, even before the vaccination coverage of the entire population, and treatment available to all, considering the intention of those in power not to reduce the profits of capital with social expenditures. Regarding the current vaccination coverage, it appears that it still does not meet the immunisation needs of health workers who work to combat COVID-19 or other essential services provided to the population.

Social work has been aiding people since the 1940s, but it was only in 1998 that it was recognised as a health profession by the National Health Council in Resolution No. 218. Initially, it was meant to support medicine’s efforts to keep patients responsible for their treatment. However, several changes enabled the Social Service to act in the direction of considering the social determinants that interfere with the health-disease process, such as housing, work, and income, as well as promoting greater autonomy and empowerment to users [3]. This was only possible because of the 1970s Sanitary Reform, the Federal Constitution of 1988, the SUS (Integrality, Universality, and Social Participation) principles and legal basis of action, and the Political Ethical Project of Social Work in the 1990s.

Furthermore, in view of the current context of the State’s counter-reform, the intensification of the social issue with repercussions on the living and working conditions of the user population and under the work of social workers in the pandemic scenario, challenges are imposed on social workers from the health area, as in hospitals, due to the neoliberal conjuncture, which is also called upon to act in this context, with efficiency and responsibility, observing the legislation in force. 

The Performance Parameters of the Social Worker in Health, as well as the Profession Regulation laws and its 1993 Code of Ethics, support the performance of Social Workers in Health. It presents the following perspectives: service to users and their families through educational and socio-assistance actions; collaboration with the health team; promoting access to social rights through public policies; information sharing; investigation; planning; management; and case discussion, among others. Concerning the pandemic situation, article 03 of the Code of Ethics states that the social worker must “participate in relief programmes for the population in a situation of public calamity in the care and defence of their interests and needs” [4,5].

Therefore, in response to the new Coronavirus pandemic, the regulatory bodies of the Social Service category began to publish a series of instructions to guide the professional performance of social workers in the exercise of their function in service, strengthening commitments to the working-class, as well as technical and political aspects of the profession. “ “The universality of access to rights has historically been a struggle for the Brazilian Social Service, and it is necessary to distinguish institutional objectives from professional objectives.” 2020 [5].

To reflect on the objectives of work and assistance in accordance with ethics and the Code of ethics, the SUS principles and the professional political ethical project became guiding questions in discussions and reflections on the reconfiguration of Social Work work for the current pandemic moment.

In the context of hospital health, for example, new methods of work emerged in the year 2020, such as teleworking, as Matos points out, as an alternative for many services [6]. Other activities were redesigned or discontinued, and teams began to work on a rotation or shift schedule. In these cases, social workers were required to perform their specific duties in a different manner. Numerous discussions have also sparked on previously overcome problems in the field, including their abilities, roles, and professional ethic involving secrecy [7].
Thus, it appears that, given the particularities of this time, it is critical to ensure access to health care for the community, consistent with the standard of service rendered, as stated by CFESS which is an inalienable professional commitment [4].

Methodology
The methodology used was the bibliographic survey, which seeks dense literature for studies of the multiple determinations that make up a theme, thus making it possible to contribute subsequently to future research. An integrative literature review methodology was used for this research, which, when combined with the results of reality studies, facilitates the expansion of theoretical knowledge produced [8]. The following procedures were used: guiding question, sample selection, study categorization, analysis, result discussion, and presentation of the integrative review. The dialectical-critical method was used to analyse the data provided by the concrete reality

The following steps were taken to survey the articles:(1) Searching the databases LILACS, SCIELO, BVS, IBECS, BDENF, and “Coleciona SUS”; (2) Searching the CAPES website; and (3) Google Scholar / Scholar. Articles published outside the specified time period of March to December 2020, as well as objects of study that did not include the work of the Social Worker in Pandemic in the field of Health, were excluded from this study. In addition, article-based Theses or Dissertations in the field of health at levels of care other than hospital care were also accepted

The data collection process was divided into four stages. From July to October 2020, a search of the VHL library was conducted as the first stage with the overarching goal of determining “What is the impact of the COVID-19 pandemic on the work of social workers in hospitals in Brazil?,” “What are the social issue expressions that are presented in this context for professionals in their jobs?,” and “What is the work developed by category of social workers in the country?’’ The following keywords were initially listed: “Social Question”, “work”, “COVID-19”, “social protection” and equivalent expressions in English and Spanish, which returned 22 articles. However,  the majority of articles did not address topics related to the social worker’s work in health during the pandemic of the COVID-19, and recent articles from March to October 2020. According to the exclusion criteria, only 01 article addressed the Social Service and work object, with the three thematic categories of “Social Question,” “Work,” and “Social Work”  related to the field of health in a hospital setting

The second stage of the research was conducted on the “Portal da Capes” and a journal from the Universities PUC and UFRJ, which yielded 117 results, but no study in the stipulated period of the research.

The third stage involved conducting a search on Google Scholar, which returned 52 results, 27 of which were related to Social Work and Work in the Pandemic, but with a broad result, with several fields of activity in the health area, such as mental health, worker health, children and adolescents. As a result, a fourth study was conducted, this time limiting the reading of titles and abstracts to articles written by social workers who work in hospital health. Finally, only four of the total number of articles returned were related to the object. It has been noted that one of the articles discovered is the same as that found in the VHL. There were four articles for data analysis at the end of the bibliographic survey.

So, among the research limitations discovered, we can mention the difficulty in finding articles written and published during the specified period (March-December 2020) in databases, as well as the possibility of texts and articles in the “grey bibliography” that are not available in databases.
Following the sample selection phase, the studies began to be categorized. Table 1 displays the articles selected by the study that contemplated the inclusion criteria for full analysis according to the source, authorship, objectives, title of the study and means of publication.

Following the steps of the integrative review, we sought to carry out a critical analysis of the studies included in the integrative review and analysis through the correlation between the texts based on thematic categorization (social and political-economic context; work of social workers; incorrect demands and strategies), followed by discussion and analysis of the results, resulting in this integrative review, as shown in Table 4 below.

The articles in their entirety mainly highlight the work of the Social worker permeated by the worsening of the expressions of social issues in the demands of users. Thus, the theme that stands out is about the work of the Social Service professional in practice in the pandemic, demanding for the professional to reappropriate the ethical and political accumulation to rethink remote actions, with tele-attendance and tele-consultation, maintaining the quality of services in professional practise, respect for users, educational reflections and the ethical dimension [12].

These articles, which focus on Social Work and Health, the Pandemic, and the Work of Social Workers, are reports of social workers’ experiences in health, in the hospital context, and in the context of the Pandemic. They intend to present changes in care by reflecting on the characteristics of this professional, as well as the concern for maintaining sanitary, protection, and hygiene protocols. Modifying the location of the service room; changes in work routines and flows; searching for an adequate service guarantee; reducing hospitalizations to keep users and companions; clarification on interdisciplinary actions; flows and humanization of the team are examples of actions described.

According to the authors Vale, Nascimento, and Barros, the Social Service experience report acting in the pandemic goes through a reflection on the work process to ensure the quality and ethical-political commitment of the social worker [10]. The authors relied on the CFESS / CRESS set’s specific guidelines to direct what would be changed in the workflow in the pandemic context, while adhering to health protocols.

Another point that appears in the productions refers to the intensification of the expressions of the “Social Question” and the precariousness of public policies and SUS (de) financing is cited as an obstacle in most studies (texts 1, 2 and 4).     In addition to following routines and workflows on all articles

Matos states that a social worker’s obligation in the practise of his or her profession is to seek out alternatives and recommend improvements to social policies [12]. According to Iamamoto, the professional’s role should not only include policy implementation, but also the development of democratic proposals as part of the professional routine [13[. In this regard, the articles are consistent and outline strategies in accordance with the directives of the Federal and Regional Councils, particularly in the states of Piau, Rio de Janeiro, and Bahia. They are also linked to the category’s hegemonic professional political ethical project (articles 2; 3), and they discuss dialectical historical materialism as a guide for analysing social reality (articles 1

The identification of the particularities of the social expressions through which the category operates in daily life, is another point in common with all reports of experience, under the aspect of social context of unemployment, informality in the generation of income, extreme poverty, impossibility of maintaining isolation social and hygiene and sanitary aspects due to the social and housing, transportation and work context to which the working class is subjected. Predominant factor for the spread of the virus and cases of death, which aggravated the pandemic and the impact on the living conditions of users and the working class in Brazil. A fact that could have been mitigated through social governmental actions focused not only on emergency assistance, but also on economic strengthening of existing public policies. As an illustration of the predominance of SUS, which ensured care in the most severe cases, including ICU beds and access to health care for the entire population

To combat the pandemic, the Ministry of Health added a 20% bonus to the amount of the scholarship paid to residents in recognition of their efforts and as an incentive to fight against it” [9].

However, such workload violates 2010 Law 12,317, which established a 30-hour workday for professionals. In this case, the unhealthy working conditions and bonus during a pandemic period are used to determine the precariousness of the worker / student who will later be reimbursed for private health services. Each author raises issues deserving of attention and discussion in light of the difficulties encountered in this pandemic context, in the current situation. The majority of them (articles 1; 2 and 3) highlight difficulties when they relate to inappropriate demands, such as communication of death, provision of clinical information, and issuance of medical reports - attributions that are not within the category’s competence and are even prohibited by specific medical category laws, as well as routines of visits and appointment scheduling.  Concerning issues of work intensification, all authors emphasise worker exhaustion and the need for intervention consistent with the materialisation of the Ethical-Political Project, as defined in the social worker in health’s regulations and parameters, as well as its code of conduct. It is also common for references to uncertainties and fears, as well as a lack of individual protection inputs, to appear multiple times in the texts, implying a deterioration in the physical and emotional well-being of professionals, with an emphasis on articles 2 and 3. Additionally, the articles discuss the aggravation of social inequalities, which are exacerbated by the economic and political context of ultraneoliberal and conservative governments, which are more concerned with necropolitics than with social policies, imposing limits. This context was exemplified by the nearly 200 thousand deaths in Brazil as a result of the COVID-19 pandemic. Thus, social workers describe the difficulties they face in the hospital setting, as well as the strategies they develop during the course of their work, as illustrated below:

Academic calendar suspension; fear and insecurity; adaptation to new workflows; lack of protective equipment; erroneous demands; lack of investment in information technology; intensification and work overload; physical and mental illness 2020 [9].
Daily telephone contact by the doctor for newsletters on the clinical status of patients admitted to the ICU, Stabilization, and COVID, with accompanying information provided by the doctor; the ongoing debates resulted in the hiring of professionals for the COVID ward; debates over the use of PPE’s; creation of a POP- Standard Operating Procedure for service in the COVID wing; negotiation via the POP- Standard Operating Procedure [3]. 

Along with the flow changes that impacted professional practise, there are those that impact service users, such as the presence or absence of a companion in a hospital setting during a pandemic, authorization for family members to enter, and assurance of virtual visit. In general, those who proposed accompanying patients in health services faced a difficult choice between entering the hospital and remaining until the hospitalisation was complete or leaving your family member, friend, or companion in the care of the hospital team, depending on the patients’ health status. Not to mention the need for quarantine and/or family support. In this sense, nobody abandons the treatment or the patient voluntarily; they do because they are socially determined by their environment.

Another significant aspect was the ethical dimension, which pervaded the recreation and adaptation of professional work during pandemics, as well as the issue of professional secrecy, which must be shared with the user to protect both the user’s and the professional’s health [4,7]. In this scenario, technological initiatives were taken to ensure, despite constraints, that families received information, rights were shared, and remote assistance was available. On the other hand, it is possible to discern the persistence of contradictions in daily socio-institutional activities that the professional project seeks to resolve, given that the profession is a member of the working class subject to the constraints of capitalist society. Thus, it is necessary to continue fighting for the professional ethical-political project, a project of social transformation, and a project of life defence, as well as against all setbacks to the working class’s conquests, denouncing the dismantling of public services and the defunding of social and political policies. In this pandemic era, resisting excessive demands for professional work has become more difficult. Vasconcelos emphasises the importance of additional research in professional practise in this regard [14]. The author emphasises the importance of theses in Social Work because they facilitate communication with the profession in practise, with proposals, and thus advance the professional project’s materiality.

“The absence of mediations with the Social Service and the professional project of a large number of theses in mediations involving the challenges, possibilities, and constraints faced by professionals in daily practise have undoubtedly resulted in losses in their critical and purposeful appropriation by the entire professional category. (...) In the context of a fragmented reality, entangled by common sense conceptions in close relationship with bourgeois morality” [14].

It is evident that the articles found contribute to this goal, as they offer a critical analysis of social reality based on reports of daily professional experiences in an ultra-liberal context where capitalist interests are prioritised over the human interests of the Brazilian population during a pandemic caused by viral disease with accelerated spread, and in this context, social workers have a critical role to play [15-20].

Final Considerations
Confronted with a difficult and provocative scenario in the pandemic hospital context, which has been described as a context of public calamity, social workers, through the work processes into which they are inserted, reported, created, and recreated professional practises, are defining their presence and importance in the context of health, in serving and defending the interests of patients.

The impact of social workers’ work was diverse, demonstrating their commitment to ethical and quality performance in accordance with the tenth principle of the Code of Ethics, namely “commitment to the quality of services provided to the population and intellectual development from a professional competence perspective” [5].

The following general directions emerged from this perspective: recognition of the ultra-liberal political and economic context, as well as the impacts on the living and working conditions of the hospital user population, as expressed in the configurations of social service demands, as well as the challenges and opportunities faced by these professionals.

The severe sanitary crisis and wave of mass unemployment, exacerbated further by Constitutional Amendment 95/2016, and only R $ 600 reais in aid as a government strategy to combat the pandemic for the population, in a context where the population was unable to conduct adequate isolation and confinement and was unable to engage in mostly informal and unprotected labour activity As a result, social workers in health care have been critical in ensuring that the most vulnerable have access to the social security system and public policies (social security, social assistance, transportation, food, the judiciary) [21-25].

Thus, the analysed experiences demonstrate that the scenario remains difficult, with uncertainties about what may come next, given the ongoing pandemic, and abstracted and analysed aspects of social reality. This scenario necessitates that social workers engage in continuous reflective processes and seek strategies to combat social injustices that are consistent with their ethical-political commitment to the working class in general and health service users in particular.

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