Humanizing intensive nursing care for people with COVID-19

Objective: to understand the impact of music on the intensive care for COVID-19 as an instrument to humanize assistance from the perspective of nurses who work on assistance. Methods: qualitative study carried out with seven intensive care nurses working in the COVID-19 Intensive Care Unit of a public state hospital. Sample reached through theoretical saturation. Data were collected using interviews through the on-line application WhatsApp, guided by a semi-structured guide. Results: the following discursive categories emerged: Feelings of health professionals and humanized actions in intensive care; Music therapy to provide integral care for people with COVID-19 in the score of intensive care; Living in the moment; Music therapy as an instrument for spirituality in the intensive care environment. Conclusion: the nursing intensive care did not only carry out a biological treatment, but considered all aspects of the human being, using to do so humanization by music. Descriptors: Coronavirus Infections; Pandemics; Critical Care; Humanization of Assistance; Nursing. RESUMO Objetivo: compreender o impacto da música na terapia intensiva para COVID-19 como instrumento de humanização da assistência na perspectiva de enfermeiros assistenciais. Métodos: estudo qualitativo realizado com sete enfermeiros intensivistas atuantes em uma Unidade de Terapia Intensiva para COVID-19 de um hospital público estadual. Amostra alcançada por saturação teórica. Para a coleta de dados, utilizou-se entrevista online pelo aplicativo WhatsApp, norteada por um roteiro semiestruturado. Resultados: emergiram as categorias discursivas: Sentimentos dos profissionais de saúde e ações humanizadas no ambiente da terapia intensiva; A musicoterapia proporcionando integralidade da assistência a pessoas com COVID-19 no âmbito da terapia intensiva; Vivenciando o momento; Musicoterapia como instrumento de espiritualidade no ambiente da terapia intensiva. Conclusão: o cuidado intensivo em enfermagem não se deteve apenas ao âmbito biológico, mas incluiu aspectos integrais do ser humano por meio da humanização pela música. Descritores: Infecções por Coronavírus; Pandemias; Cuidados Críticos; Humanização da Assistência; Enfermagem. 1Universidade Federal da Paraíba. João Pessoa, PB, Brazil. 2Hospital Metropolitano Dom José Maria Pires. Santa Rita, PB, Brazil. Corresponding author: Sergio Vital da Silva Junior Programa de Pós-graduação em Enfermagem da Universidade Federal da Paraíba, Campus I Lot. Cidade Universitária, CEP: 58051-900. João Pessoa, PB, Brazil. E-mail: sergioenfe1@gmail.com EDITOR IN CHIEF: Ana Fatima Carvalho Fernandes ASSOCIATE EDITOR: Francisca Diana da Silva Negreiros Sergio Vital da Silva Junior1 Aline Gomes Machado2 Anny Michelle Rodrigues da Silva Alves2 Katia Jaqueline da Silva Cordeiro2 Maíra Bonfim Barbosa2 Gilberto Costa Teodozio2 Maria Eliane Moreira Freire1 How to cite this article: Silva Junior SV, Machado AG, Alves AMRS, Cordeiro KJS, Barbosa MB, Teodozio GC, et al. Humanizing intensive nursing care for people with COVID-19. Rev Rene. 2021;22:e62584. DOI: https://doi.org/10.15253/2175-6783.20212262584 Silva Junior SV, Machado AG, Alves AMRS, Cordeiro KJS, Barbosa MB, Teodozio GC, et al Rev Rene. 2021;22:e62584. 2 Introduction Nursing is both a science and a profession with an important role in the care of individuals and the community. It seeks to promote the wellbeing of human beings and improve their quality of life(1). In the scope of health care, technological procedures and hospital routines contribute for a mechanical assistance, with risks to the autonomy of the patient and their families(2). Intensive care, for critical patients, is one of the main settings where nursing attention is needed. There, the work process is marked by complex and invasive procedures, which expose the nursing team to stress. This can lead to repercussions regarding the safety of the patient, and diminish the quality of the care provided(3). At the beginning of 2020, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), responsible for the Coronavirus Disease 2019 (COVID-19), quickly spread throughout the world(4). The World Health Organization (WHO), in January 30, 2020, declared that the COVID-19 outbreak was a public health emergency, characterizing it as a pandemic(5). Up to March 2021, there were 124,378,693 confirmed COVID-19 cases throughout the world, with 2,736,980 deaths. Brazil, up to the same month, confirmed 12,130,019 cases and 300,000 deaths caused by the disease(6). It has been observed that music in the intensive care environment generates, in general, satisfactory effects, such as relaxation and feelings of wellbeing, which can promote feelings of love and gratitude that are extremely needed in such an environment(7). Considering this subject, the following question emerges: what is the impact of music therapy in the humanization of nursing care in Intensive Care Units, directed to people with COVID-19? To answer this question, this researched aimed to understand the impact of music on the intensive care for COVID-19 as an instrument to humanize assistance from the perspective of nurses who work on assistance. Methods Qualitative study developed with seven intensive care nurses who work in the Intensive Care Unit of a hospital in the metropolitan region of João Pessoa, in Paraíba, Brazil. This hospital is a cardiology and neurology complex associated with the State Health Secretariat from Paraíba, and only attends the Single Health System. It was restructured in 2020 to be a reference hospital for those affected by SARS-CoV-2, in moderate-to-severe conditions. The sample was selected by convenience, and the following inclusion criteria were adopted: being an intensive care nurse in the aforementioned service, providing care in the field of COVID-19, and having participated in the music therapy intervention carried out in the sector mentioned. The exclusion criteria were: nurses who only work in administrative tasks in the sector. In the day of intervention, there were ten nurses, two of whom preferred not to participate because they felt uncomfortable participating in the interview. One other nurse, who only worked in administrative functions, was excluded. At first, a music therapy activity was proposed to mitigate the feelings of affliction, stress, and loss being experienced by professionals working in the Intensive Care Units for COVID-19. The professionals in the frontlines of this assistance had stated how difficult it has been to deal, daily, with these losses, also mentioning the difficulties treating people with COVID-19, this new disease with severe and systemic impact, in addition to uncertain clinical evolutions and treatment. The intervention was carried out in a single moment, in the morning, by three nurses from another ward of the hospital who made themselves available and contributed to this investigation. These nurses have knowledge about music and singing techniques and were aided by a guitar. The members of the music team dressed in the appropriate personal protection equipment, followed the health recommendations about proper distance and those indicated to avoid


Introduction
Nursing is both a science and a profession with an important role in the care of individuals and the community. It seeks to promote the wellbeing of human beings and improve their quality of life (1) . In the scope of health care, technological procedures and hospital routines contribute for a mechanical assistance, with risks to the autonomy of the patient and their families (2) .
Intensive care, for critical patients, is one of the main settings where nursing attention is needed. There, the work process is marked by complex and invasive procedures, which expose the nursing team to stress. This can lead to repercussions regarding the safety of the patient, and diminish the quality of the care provided (3) .
At the beginning of 2020, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), responsible for the Coronavirus Disease 2019 (CO-VID-19), quickly spread throughout the world (4) . The World Health Organization (WHO), in January 30, 2020, declared that the COVID-19 outbreak was a public health emergency, characterizing it as a pandemic (5) . Up to March 2021, there were 124,378,693 confirmed COVID-19 cases throughout the world, with 2,736,980 deaths. Brazil, up to the same month, confirmed 12,130,019 cases and 300,000 deaths caused by the disease (6) .
It has been observed that music in the intensive care environment generates, in general, satisfactory effects, such as relaxation and feelings of wellbeing, which can promote feelings of love and gratitude that are extremely needed in such an environment (7) . Considering this subject, the following question emerges: what is the impact of music therapy in the humanization of nursing care in Intensive Care Units, directed to people with COVID-19? To answer this question, this researched aimed to understand the impact of music on the intensive care for COVID-19 as an instrument to humanize assistance from the perspective of nurses who work on assistance.

Methods
Qualitative study developed with seven intensive care nurses who work in the Intensive Care Unit of a hospital in the metropolitan region of João Pessoa, in Paraíba, Brazil. This hospital is a cardiology and neurology complex associated with the State Health Secretariat from Paraíba, and only attends the Single Health System. It was restructured in 2020 to be a reference hospital for those affected by SARS-CoV-2, in moderate-to-severe conditions. The sample was selected by convenience, and the following inclusion criteria were adopted: being an intensive care nurse in the aforementioned service, providing care in the field of COVID-19, and having participated in the music therapy intervention carried out in the sector mentioned. The exclusion criteria were: nurses who only work in administrative tasks in the sector. In the day of intervention, there were ten nurses, two of whom preferred not to participate because they felt uncomfortable participating in the interview. One other nurse, who only worked in administrative functions, was excluded.
At first, a music therapy activity was proposed to mitigate the feelings of affliction, stress, and loss being experienced by professionals working in the Intensive Care Units for COVID-19. The professionals in the frontlines of this assistance had stated how difficult it has been to deal, daily, with these losses, also mentioning the difficulties treating people with CO-VID-19, this new disease with severe and systemic impact, in addition to uncertain clinical evolutions and treatment.
The intervention was carried out in a single moment, in the morning, by three nurses from another ward of the hospital who made themselves available and contributed to this investigation. These nurses have knowledge about music and singing techniques and were aided by a guitar. The members of the music team dressed in the appropriate personal protection equipment, followed the health recommendations about proper distance and those indicated to avoid crossed infections between patients in severe conditions, and, for one hour, sang. They sang, especially, gospel music and other songs aimed at encouraging the patients, regardless of their state of consciousness, and the workers on duty at the time.
When the activity was finished, researchers explained the aim of the investigation and how these nurses could participate in it. It stands out that the nurses were only asked to participate in the intervention after the musical intervention, to minimize the potential for bias, since they could be concerned about answering the questions rather than focusing on the musical intervention. After their acceptance, the Free and Informed Consent Form was presented to indicate formal agreement. The participants were asked for their telephone numbers, and an appropriate moment was scheduled with them for data collection.
To make data collection viable, an on-line interview was carried out via the phone application What-sApp. The interview was guided by a semi-structured script elaborated by the authors of this study, all of whom are nurses who provide assistance in the Intensive Care Unit. The script included aspects observed during the practice of assistance in the struggle against COVID-19. The instrument included subjective questions about the impact of music therapy as an instrument to humanize nursing assistance in the scope of the COVID-19 Intensive Care Unit. Sociodemographic aspects and formation did not seem important in this investigation, since it seeks to explicit the humanizing practices in this field of assistance, not necessarily describing the profile of the professionals who work with COVID-19. The data collection stage took place in August 2020, and was considered finished once the theoretical saturation of data was reached (8) .
According to the schedule, the researcher typed the following questions in the application and sent them to the participants: 1 -What did you feel during the music intervention in the COVID-19 Intensive Care Unit? 2 -What called your attention during the music intervention in this setting? 3 -Do you think that this intervention can interfere in the improvement of patients? If so, how? 4 -Do you think this intervention can interfere in the emotional support provided to the professionals? If so, how? The researcher asked the participants to answer the questions in audio, and when the response was received, it was transcribed in full into a text editor, thus forming the corpus of this research. The audios, after this stage, were stored in an external HD, kept under the responsibility of the authors. Confidentiality was maintained and the files were completely erased from the cellphones.
The analysis of the empirical material was carried out using word clouds and content analysis carried out using the software R Pour Lês Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ). This is a freeware, based on the software R, which allows for the processing and statistical analysis of the texts produced.
Content analysis was carried out in three stages: pre-analysis, material exploration, and treatment of the results, the latter carried out by inference and interpretation (9) . Four categories emerged from the empirical data: Feelings of health professionals and humanized actions in intensive care; Music therapy to provide integral care for people with COVID-19 in the score of intensive care; Living in the moment; Music therapy as an instrument for spirituality in the intensive care environment. After categorization, data were analyzed under the light of the pertinent literature. This research used the protocol Consolidated Criteria for Reporting Qualitative Research (COREQ) (10) .
It should be mentioned that the excerpts from the empirical data were codified using the letters ENF, followed by a number which indicated the order in which the interviews were transcribed, thus guaranteeing the confidentiality of the respondents. This research respected all ethical norms of researches involving human beings in the country, participation was voluntary and anonymous, and it was approved by the Research Ethics Committee of the University Hospital Lauro Wanderley, receiving the Certificate of Ethical Appreciation No. 36384920.6.0000.5183 and being approved under opinion No. 4,216,420/2020.

Results
The discourse of the participants in the investigation led to the creation of four categories, which were analyzed using the word cloud per class shown in Figure 1.  Regarding Category 4, Music therapy as an instrument for spirituality in the intensive care environment, the discourses of the participant nurses showed that, using music therapy practices, nurses also provide spiritual care for those involved in the health--disease process, emphasizing an integral and holistic type of care, be it for the citizen who uses the health services or for the professional responsible for the technical-scientific care in the Intensive Care Unit. This category is based on the following statements: What called my attention was that, regardless of the belief, the religious denomination, we all believe in a superior being that can do all things.
A merciful, compassionate, unmeasurable, omnipresent, omniscient God, a God of cure, who, even though we do not deserve, loves us and accepts us as we are, even with so many differences, we believe in the same God, which makes us His children and all equal (ENF 1). I believe that a music intervention, regardless of style, relieves the soul, soften our pain, connects people, and in this case, specially, brings us closer to God (ENF 2). Particularly, I enjoy to listen or sing songs as I work, I cannot explain it, but music changes you and the environment around you, there is not only a desire to care, but also a desire to present God to each patient, their needs, it brought me satisfaction to discover that through the power of prayer I can bring a new life to people, not to count how gratifying it is for us who often find ourselves tired, and to know that the patient is fighting with you to win, there is no better gift (ENF 6).

Discussion
Since this was a qualitative investigation, carried out in an extremely unhealthy environment, the COVID-19 Intensive Care Unit, and due to the fact that data were collected on-line, the responses were limited. The fact that there was no in-person interview meant that only what they said could be perceived, and the interviewer could not make use of other characteristics, such as environmental, emotional, or the facial expressions of the individuals.
This research contributes for the practice of nursing, especially in the scope of COVID-19 intensive care, as it presents the aspects of humanization by music therapy in this setting. As a result, it enables actions that guarantee that people affected by COVID-19 receive an integral assistance and emotional support, and that the same is true to the professionals who are providing them with health care.
COVID-19 has had a relevant impact in the daily lives of people, and anyone working during the pandemic is at risk, which is the case of the nursing team. Nurses are under the constant risk of infection, death, and emotional symptoms, which make pre-existing diseases more severe and lead these professionals to feel stress and emotionally hurt (11) .
In the nursing assistance during the COVID-19 pandemic, intensive care professionals should be continuously monitored, so their emotional needs can be attended immediately. It stands out that a psychology service must be available at any moment during assistance, with trained and qualified professionals to attend to the demand (12) , due to the need to prevent mental diseases in these professionals.
The term "humanization" is an ethical construct in health care, since it is not restricted to feeling empathy for the user or calling them by their names instead of using numerical codes; it also includes understanding the feelings presented by individuals who need supportive and loyal professional care, a care which values the human being (13) . In this regard, the nurse must use strategies to carry out assistance in an efficient way, using methods and humanizing health care through embracing and dialogical interactions. This is how nurses form a therapeutic bond with patients and their relatives, making it possible to provide adequate attention and integral assistance (2) .
Humane care is a challenge when the environment induces one to carry out mechanical health care, using only hard technologies. Therefore, caring for individuals in nursing implies the use of technical-scientific aspects inherent to the field of action and care, but also allows for the experiences of those involved in the caring process to assume a central position (14) .
It stands out that in COVID-19 intensive care, patients cannot have relatives nearby, to avoid the transmission of the virus. This makes individual suffering worse due to the absence of face-to-face contact in the hospital environment (15) . In addition, health professionals, especially those in the nursing team, suffer relevant physical and emotional harm as they struggle against COVID-19, since, during care, nursing practices go beyond their technical aspect, permeating scientific and emotional ones (16) . The importance of actions that aim to provide humanized care stands out, as does the possibility of providing a humane environment and making it possible for nursing professionals to be in a workplace where mental disease is less likely.
To mitigate the negative impact patients and professionals experienced in the last few days, due to intensive hospital care for COVID-19, strategies of interacting through music have a privileged space, since music therapy allows for behavioral and psychological improvements, diminishing, for instance, signs and symptoms of stress, depression, and irritability (17) .
Music therapy is a tool of the humanizing process in nursing care, focusing both on the environment and on the direct relations of assistance to the hospitalized person. The nurse can implement therapy through music, diminishing stress and the anxiety of the patient (18) .
This research shows how important music therapy is in the context of COVID-19, for making it possible to reflect on the assistance provided during the pandemic that emerged in 2020. On this regard, the statements of the professionals who work in the field of intensive care point out that the practice mentioned can promote humanization not only because they improve the environment using music therapy, but because they allow these professionals to be emotio-nally touched, making them think about how important their lives and actions are for the health care of patients with SARS-CoV-2.
It stands out that, considering the limited number of participants and the complexity of the moment experienced during this research, new studies must be carried out, to better understand the phenomenon presented here.

Conclusion
Nursing actions have been humanized by providing integral health care, since, in addition to biological care for life support, there was also the care provided by music therapy, which provided emotional comfort to the nurses who were present at the time of intervention.

Collaborations
Silva Junior SV, Machado AG, Alves AMRS, Cordeiro KJS, Barbosa MB, Teodozio GC, and Freire MEM contributed for the conception and for the project, data analysis and interpretation, article writing, in the relevant critical review of the intellectual content and the final approval of the version to be published.