Mental health in Health professionals during Post-pandemic Covid-19 in Bogotá, Colombia: an Interpretative phenomenological Study.

In December, 2019, an outbreak of a novel coronavirus pneumonia occurred in Wuhan (Hubei, China), and subsequently attracted worldwide attention. It raised as a worldwide concern as it spiraled into a pandemic. Colombia had the first confirmed case the 6 of March of 2020, and now (14 of April) has around 3000 confirmed cases, 127 deaths, in 29 of the 33 departments. It has happened, despite the measures of national quarantine, closing the borders, and the surveillance of active cases (3). The most affected city is Bogotá, the capital, with 2159 cases, but the numbers are increasing every day. Facing this largescale infectious public health event, medical staff worldwide are under both physical and psychological pressure. Studies in China has showed how frontline healthcare workers experience fear of being infected and spreading the virus to their families, particularly those working in isolation wards and accident and emergency departments. Chen describe how in China, the staff worried as well about the shortage of protective equipment and feelings of incapability when faced with critically ill patient. Therefore, we are wondering how health workers re-build their lived experiences as professionals during the pandemic and how they understand their mental health processes related to those experiences in the post-pandemic period. Additionally, we are wondering how other staff members such as administrative and operative or support personnel and family members of health workers experienced the pandemic. This understanding will provide insights for policies and interventions focused on those populations and furthermore contribute to improve the wellbeing of them at work and the attention they provide to the patients. In this interpretative phenomenological study, we will pay attention to this topic through three different approaches: burnt out, street level bureaucracy and capabilities. Concept of Burn out There is a traditional development of research related with psychosocial risk factor in the job environment. This research has clarified the key role that such factors have on worker wellbeing. One of the most recognize effect is the Burnout syndrome define as chronic and maladaptive mental state coping with stress, which leads to exhaustion and emotional distancing at work. Some literature refers that professionals working in dangerous and/or vulnerable settings experience tiredness and burnout. Huertas, i.e. found that the main feelings that professionals working with Internally Displaced Persons are impotence, sadness, fear and frustration. According to Khera, worldwide, people who work in organisations trying to help refugees for example, try to rebuild their lives after suffering atrocities, huge losses, deeply traumatic events and grave injustices. Despite their best efforts, those workers are rarely able to meet the basic needs of refugees, let alone end their suffering. Consequently, people working with refugees are confronted on a daily basis with victims of injustice who continue to suffer in extremis. The danger of working in this context is that workers can suffer with stress-related syndromes such as ‘compassion fatigue’ (the diminished ability or willingness to be empathic towards suffering clients and ‘burn out’. We will pay attention in that sense to the participants, exploring among other topic, how they interpreted their experiences during the pandemic and we will pay attention of burn out, in this sense. Concept of street level bureaucracy According to the sociologist Lipsky (1969), the implementation of public policy in everyday practice is in hands of so-called street-level bureaucrats who actually apply these policies. The term street level bureaucrats refer to policy staff and professionals who are in the first line of attention of clients, or as this case, patients. These professionals tend to have significant independence and responsibility, which can result in substantial impact on the lives of the people they interact with. Therefore, the notion of street-level bureaucracy refers to two dimensions of the policy process: performing discretion and performing autonomy. Discretion is defined as the “power to decide or act according to one’s judgement”. As Lipsky explains, professionals have considerable discretion in determining the nature, amount and quality of benefits and sanctions provided by their agencies. Although their discretion is formally circumscribed by rules and subject to relatively close supervision, these professionals have relative autonomy in relation to the organizational authority for which they work. Lipsky points out that although they are normally regarded as low-level employees, public service professionals’ actions constitute the services ‘delivered’ by government. It is public service professionals’ decisions that construct agencies’ policies. Their discretionary actions determine how policies are actually applied, who receives benefits and sanctions of government programs and who obtains access to government rights and benefits. Frontline professionals frequently make decisions, not only about which clients they will and can help or not, but also about how they will help clients. In doing so, frontline professionals balance compassion and flexibility with impartiality and rule application. This is the main dilemma street-level bureaucrats face. While flexibility and professional discretion are necessary to translate policies into practices, as well as to implement uniform policies and programs in unique situations and for diverse groups of people. We are wondering how dealing with the discretion and autonomy during the pandemic, may have an additional stress, facing for example the decision of which patient can use the intensive care unit bed, as some other authors as Verbrugger have mentioned, as ‘How much is a life worth?”. Capabilities approach It is important to take in to account the new definition of health proposed by Huber as one based on the resilience or capacity to cope and maintain and restore one’s integrity, equilibrium and sense of wellbeing. Some authors described that vulnerability and resilience vary among individuals as well as groups. Not everyone is affected in the same way by poverty or by an epidemic. Other authors as Senn and Nussbaum have proposed the capabilities approach. Capabilities approach focuses on positive freedom, a person's actual ability to be or do something, rather than on negative freedom approaches, which are common in economics and simply focuses on non-interference. The last stage of this study will be based in this approach to find the things that could be improved in order to develop in deep the wellness for the health professionals, staff and family members of health professionals. RESEARCH DESIGN, METHODS AND PROCEDURES The study will be conducted at the Hospital Universitario San Ignacio, in Bogotá. The inclusion criteria for this research will be health professionals who worked at the Hospital Universitario San Ignacio during the pandemic. It includes medical doctors, nurses, physiotherapist, and other health professionals who were working at the hospital during that period. It will be done through a purposive sampling, opening the invitation to anyone to would like to participate and fulfill the inclusion criteria. In the second stage, we will invite to participate other members of the staff of the hospital, who are not health professionals, but contribute to face the pandemic, including stretcher-bearers, fuller staff, administrative personal and family members of the health workers. Recruitment of participants will be via a snowball sampling strategy until reaching saturation point. This study will use an Interpretative phenomenological analysis (IPA). IPA is a qualitative approach, which aims to provide detailed examinations of personal lived experience. As Smith explained, It produces an account of lived experience in its own terms rather than one prescribed by pre-existing theoretical preconceptions and it recognises that this is an interpretative endeavour as humans are sense-making organisms. IPA tries to examining the detailed experience of each case in turn, prior to the move to more general claims. IPA is a particularly useful methodology for examining topics which are complex, ambiguous and emotionally laden. We will use an interpretative phenomenological analysis qualitative approach based on the hermeneutic version of phenomenology. This explored how human beings make sense of a major life experience on a personal level. We will use interpretative phenomenology analysis to explore and to capture the reflections of health professionals experiences, staff members and family members of the health professionals. Our aim is to understand, in detail, what the participant experiences were and how participants made sense of what had happened to them during the pandemic. In addition, for the workshops, this study will use elements of Participatory Action Research approach Lingard argued that in action research studies, research is not done on or with participants; research is carried out and integrated by the participants in partnership with the researchers. Action research is an iterative process in which researchers and practitioners act together in the context of an identified problem to discover and effect positive change within a mutually acceptable ethical framework. According to Kemmis, Participatory Research has three particular attributes: shared ownership of research projects, community based analysis of social problems and an orientation toward community action.The base of the Participatory Action Research introduced by Freire, involves the community in the process of acknowledging, identifying and defining their own problems, analyzing them, and developing strategies to manage them. In this process, there is a facilitator who will coordinate and permit the participation of all members of the community reducing power imbalances and ensuring their confidence in their participation.