Repercussions experienced by health professionals working with Integrative and Complementary Practices during the pandemic* Repercussões vivenciadas por profissionais de saúde atendidos com Práticas Integrativas e Complementares durante a pandemia

Objective: to analyze the repercussions experienced by he - alth professionals who were assisted with the use of inte grative and complementary practices during the pandemic of COVID-19. Methods: qualitative study whose data were collected through interviews, which were transcribed and submitted to thematic content analysis. Results: 12 female health professionals participated and pointed out the im portance of the inclusion of integrative and complementa - ry practices in strengthening the well-being of health pro fessionals in the Unified Health System and the relevance of offering these services in the pandemic scenario, as it helped them face stress, insomnia, mental fatigue, and an - xiety. Two categories emerged: Sensation of valorization, welcoming, recognition and care, and Repercussions on the emotional and physical health of the workers. Conclusion: the data showed the positive repercussions of Integrative and Complementary Practices developed by health profes sionals, demonstrating the potentiality of these practices in promoting mental health. Contributions to practice: the implementation of actions with the use of Integrative and Complementary Practices by managers constitutes a form of care by health professionals in the Unified Health System, as these result in quality of life, promotion, and restoration of physical and mental health of the individuals assisted. Descriptors:


Introduction
Integrative and Complementary Health Practices (PICS) encompass systems and resources that act on different aspects of health, as they seek to stimulate the natural mechanisms of health prevention and recovery from diseases, whether physical or mental, through effective and safe technologies (1)(2) . These practices, which are designated as traditional medicine and/or alternative and complementary medicine (1) , present a broad view of the health-disease process, in which the therapeutic bond and the perspective of the individual at the center of the process are valued, prioritizing quality of life and integration of the human being with the environment in which he/she lives, aiming at global health promotion and stimulating self-care (3) . Since 2006, with the approval in Brazil of the National Policy of Integrative and Complementary Practices in the Unified Health System, the use of PICS has gained recognition as a strategy for valuing, offering alternative and complementary knowledge and care in public health services (1)(2) .
Among the PICS, auriculotherapy, described as a non-invasive therapy, performs stimuli in the auricular pavilion, acting in health maintenance, treatment, or disease prevention (4) . Also noteworthy are: reiki, defined as a natural technique of imposition of hands, in which there is a transfer of universal vital energy (Ki) to the individual (receiver), promotes physical, mental, emotional, and spiritual balance through energy harmonization, with the purpose of prevention, recovery, and well-being (4) ; and aromatherapy, defined as the therapeutic use of essential extracts in intense concentration, derived from plants, being an accessible and non-invasive therapy, used for the improvement of psychological health and promotion of well-being (4)(5) . Moreover, data showed a 324% increase in the supply of these PICS from 2017 to 2019, of which, auriculotherapy was the complementary therapy with the highest growth in attendance, followed by others, such as reiki and aromatherapy (6) .
In the pandemic scenario, especially at times of high demand for mental health services, this need stood out, since health workers, directly and indirectly involved in facing the pandemic, were exposed daily to situations that triggered worries, physical and mental overload, uncertainties, tensions, stress, anguishes, exhaustion, or burnout, anxiety, depression, loss of sleep quality, fear of contagion or transmission of the coronavirus (COVID-19) to family members, making them more susceptible to the development of psychological suffering/mental disorder (7)(8)(9) , which demanded attention and care to this population with the need to promote mental health and well-being, aiming to improve the quality of life of these individuals (8) .
Studies point out that healthcare workers, when assisted with the use of PICS, report improvement in their physical and mental health (10)(11) . However, despite the positive evidence of these practices in promoting the mental health of health professionals, there is a scarcity of programs of attention to this group of workers, and of other interventions for the prevention of work-related diseases and for the promotion of health (11) .
Considering the panorama of COVID-19, coupled with the strenuous workload that health professionals already carried before the pandemic, and considering the satisfactory results of the PICS, especially in symptoms of anxiety, depression, insomnia, stress, fear, among others, resulting in quality of life in a comprehensive way to the individual, the question is: How did the experience of being assisted by integrative and complementary practices during the COVID-19 pandemic impact the lives of health professionals?
To this end, the objective of this study was to analyze the repercussions experienced by health professionals who were assisted with the use of integrative and complementary practices during the pandemic of COVID-19.

Methods
This is a qualitative study, developed with 12 professionals who worked in the Unified Health Sys-tem, in a Midwestern capital, during the COVID-19 pandemic and who were treated with PICS, five of them working in two Family Health Units and seven in a University Hospital.
Health professionals were understood as those who worked in health services or health care and surveillance establishments, ranging from nurses and physicians to receptionists, security guards, and cooks, among others (12) .
The assistance to the professionals was provided by two nurses/teachers, who were trained in PICS and developed actions in an extension project in these health units. Auriculotherapy, reiki, and aromatherapy were chosen due to their potential to promote global human care, as well as the expertise of the nurses who performed the applications.
All professionals received care, from August to October 2020 through an extension project linked to the study, with auriculotherapy and aromatherapy, and those who presented more significant complaints were treated with the use of reiki. Each participant received, on average, five sessions, with the minimum being three, and the maximum, nine sessions. Among the 12 participants, nine received auriculotherapy and aromatherapy using lavender essential oil (Lavandula angustifolia) and reiki, and three received only aromatherapy and auriculotherapy.
Regarding the auriculotherapy actions, the Chinese, French, and Brazilian School maps were followed. The points, shen men, liver and sympathetic or neurovegetative system were stimulated in all (12) participants, followed by the kidney point in 11 participants. Based on anxiety, hypothalamus, and liver yang one in 10, the heart emotion point was used in nine practitioners, and the vice point was applied in eight. The gallbladder, adrenal, zero point, and adrenal points were stimulated in seven, and, in half (6) of the participants, the Heart point stimulated. In addition to these, other points were stimulated, namely stomach, pineal gland, bladder, muscle relaxation, mouth, small intestine, and spleen/pancreas (5) , neurasthenia, tranquilizer, lower back, and anxiety-preoccupation (4) , nicotine, joint point, thoracic spine, lung, and large intestine (3) respectively in total points used. The application of reiki followed the precepts of the Mikao Usui school, and aromatherapy was performed through the application of lavender essential oil (lavandula angustifolia).
All professionals who received at least three consultations with the PICS through the linked extension project were invited to participate. The inclusion criterion of three appointments was defined by the researchers considering the orientation of studies that identify positive repercussions of the PICS, such as improvement in quality of life, physical and mental well-being based on three sessions for the practices used (13)(14) . Participants who were absent due to illness, vacation or leave of absence during the interviews were excluded. To minimize conflict biases, the interviews were carried out by the student, a member of the research, since the other researchers were responsible for providing care using the PICS to the participating professionals.
Data collection was carried out from November 2020 to January 2021, by means of a semi-structured interview, with questions regarding knowledge about PICS, the identification of effects of the practices on life, and evaluation of the care received through auriculotherapy, reiki, and aromatherapy.
The interviews were conducted by telephone call at a predefined time and date and scheduled with the interviewee upon prior acceptance of participation and signature of the Free and Informed Consent Form. The interviews lasted an average of twelve minutes, 18 minutes being the maximum, and four minutes the minimum. There was no search for data saturation, since the interviews were carried out with all the study participants.
Besides the transcribed interviews, another source of data were the attendance and follow-up forms used during the consultations with PICS, named "Ficha", followed by the cardinal number referring to the consultation. The data extracted from these were related to the characterization of the professionals, number of appointments, type of therapy received, auriculotherapy points, reactions after the appointments, main complaint and symptoms reported, as well as their follow-up. Seeking to maintain the confidentiality and anonymity of the participants, the speeches were coded by the letter "P", randomly added to the cardinal number. The authors chose to assume during the text, the female gender, because there was in its totality the participation of women as subjects in the research.
For data analysis, the thematic content analysis (15) was established in three stages: a) Pre-analysis; b) exploration of the material and c) interpretation of results, in which two categories were identified: a) feeling of appreciation, welcoming, recognition and care and b) repercussions on the emotional and physical health of female workers. The data were manually transcribed and categorized by the researcher.

Results
Among the 12 professionals attended, the roles were: one nursing assistant, one pharmacist, one receptionist, two nurses, three Community Health Agents, and four nursing technicians, all in the age range of 30 to 39 years. Based on the speeches of the participants, two categories emerged: Feeling of valorization, welcoming, recognition and care; and Repercussions on the emotional and physical health of the workers.

Feeling of appreciation, welcome, recognition, and care
It was observed that with the offer of these practices to health workers, feelings of welcoming, appreciation and recognition were triggered through the care and therapeutic listening provided by the nurses who performed the care with the use of the PICS. The care with the use of integrative practices was also an opportunity for care and attention for those who were directly exposed to COVID- 19 The reports point out that, by having access to therapies, the professionals felt honored by their leaders, and started to be seen as subjects that need mental health care, which had repercussions in work motivation and in the quality of care provided: A lot of times, the health care is very much put aside, they demand a lot of production, demand a lot, but many times they forget, and then from the moment they have this look, people already feel a little more motivated, they already feel a little more within the whole process, and then this even improves the quality of assistance (P9). These therapies are important because it is another way to be welcomed, to have attention, it improves a lot the psychological, emotional, and physical aspects (P2).

Repercussions on the emotional and physical health of female workers
We identified reports referring to the feeling of relaxation, reduction of anxiety symptoms, and the possibility of reflecting better on the adversities experienced, which favored keeping calm and a better relationship with the problems of everyday life: I managed to control my anxiety, which was a lot, so I could be calmer (P10 The participants also reported significant improvements in the quality of nighttime sleep, which led to a medication readjustment in one of the cases:  It was observed that they pointed improvement in pain complaints and in osteoarticular discomforts, which allowed the reestablishment of life activities and more quality of life: It had quality of life, because it did not have these pains, I felt relief, just that I did not feel these discomforts

Discussion
The qualitative approach facilitated the understanding of the complexity of suffering triggered by the pandemic for the group studied; moreover, the results demonstrate the positive impact of care with the use of integrative and complementary practices in the lives of health professionals, highlighting them as a therapeutic strategy of relevant importance for this population. The use of PICS, as a therapeutic method in the care of female workers who work against CO-VID-19, is an advantageous strategy, due to its fast, safe, and non-invasive applicability, constituting a viable health promotion strategy in the current context (16) . Results of similar studies show the positive impact on the well-being, improvement of stress symptoms, and mental health of healthcare professionals assisted with the use of complementary therapies (6,17) .
Through the speech of the subjects, it can be observed how, either individually or globally, the care contributed to the promotion of health of professionals. It is noteworthy that this professional category has been open to the practices, especially in the workplace due to their mental health demands, often arising from the interference of the work environment and occupational risks (16) , a fact observed in the speeches that point to the satisfaction of the participants. In view of this issue, the consultations with PICS can result in the prevention of diseases, favor a healthier workplace, and improve the quality of life of workers by improving pain complaints and anxiety, for example (18) . The reasons for this search and adherence to these practices may be related to dissatisfaction with conventional medicine interventions and lack of bonding between the patient and the health professional (3) . In view of the above, studies point out the difference in the approach and conduction of care with these therapies, because the patient is placed as the center of care, which promotes a feeling of personal appreciation, welcoming, and greater bond between professional and patient (1,3,19) .
In agreement, it is noteworthy that through the PICS it was possible to provide the professionals with comprehensive care and assistance, considering a wider range of factors in the process of illness and restoration of health, focusing on emotional harmony, and understanding the causes of their illness (19) . Another study shows that the PICS inserted in a Health Center, for the integral care of employees, enabled the redefinition of the self-care processes of the team, besides promoting more quality in the work process (20) , which reinforces the importance of caring for those who care.
The reports of the participants emphasize the consequences that the pandemic of COVID-19 caused in their work routine, which resulted in physical and emotional stress. This fact is also associated with the fact that they are all women, representing the predominance of the female gender in the world of health work and, therefore, it is also necessary to consider that the complaints related to extra working hours extend to domestic chores and daily life. Women are responsible for caring for the home and children, even when they work outside (21) , and this may be related to various psychological suffering, such as sleep disorders, stress, depressive disorders and pain and somatic complaints among this population, information that agrees with the complaints cited by the participants in this study (22)(23) .
Regarding the PICS care, which, as the reports showed, resulted in positive effects on anxiety symptoms, sleep disorders, and stress, similar studies (16,(24)(25) emphasize that some auriculotherapy sessions were able to reduce anxiety, depression, and stress symptoms among nursing professionals, helping them face the processes of psycho-emotional suffering that were notably exacerbated during the pandemic of the new coronavirus.
Regarding the actions of aromatherapy, they contribute the emotional response and mental health of nursing professionals, which includes regulation of self-esteem, reduction of anxiety levels, reduction of sleep disorders and stress reduction, helping to maintain quality of life (26) . About reiki, participants of an experimental study obtained improvement in the mental domain and quality of life after the sessions (23) , demonstrating that this practice acts positively on stress symptoms and on the increase of self-confidence, being beneficial for healthcare workers.
Corroborating these results, the use of PICS, as a strategy of promotion, prevention, and treatment, leads to integral care of the individual and can reduce the overuse of medication and the constant medicalization of life (3) , a fact that also occurred in this study, when one of the participants mentioned a readjustment in the use of hypnotic medications, showing the positive impact of these therapies.
Other emotional repercussions were perceived by the participants, such as: the decrease of fear for the new coronavirus contagion; concerns; and how to deal with interpersonal relationships both in the work and family environment. Results like this one confirm that the PICS promote immediate and long--term benefits, by decreasing concerns, emotions in relationships, in the family environment and at work of the participants (21,27) .
Besides the repercussions on mental health, the results pointed out that the sessions promoted benefits regarding the physical symptoms. And, in this sense, the literature points out that complementary therapies act in a restorative manner in the individuals assisted, by providing a perception of reduction of pain complaints with fewer side effects, and by also being beneficial for the emotional (3,19) . And they show to be effective in musculoskeletal discomforts, contributing to the relief of low back pain, generated due to the overload of work by the nursing team (28) .
The efforts of nursing professionals regarding the mobilization to participate in interventions with PICS and recommend them to other workers are remarkable, which reinforces the need to continue exploring projects/interventions with this population, since they result in integration of patient care, whether the patient is a health professional or from another area (21) . Moreover, the PICS represent a powerful contribution to the quality of life and among workers, by promoting self-knowledge that helps social relationships and self-care, improving the care for others and advancing towards integrality (6,19) .
Given the above, integrative, and complementary health practices stand out as therapeutic resources that promote quality of life for professionals, being considered important strategies for the mitigation of psychological suffering and for the physical care of health workers in the current context of the pandemic (6,29) .

Study limitations
Among the limitations of this study, we mention the fact that the interviews were conducted by telephone, which may have impacted the bond and the availability of the participants to answer the questions with the consequent abbreviation of the inter-views. Moreover, we highlight the fact that the places for the application of the PICS were improvised in the middle of the professionals' work field, which may have impacted the intensity of relaxation and positive sensations for the participants.

Contributions to practice
It is believed that the data from this study can contribute for managers to consider the implementation of actions with the PICS as a form of care for health professionals in the Unified Health System, since these actions result in quality of life, promotion, and restoration of physical and mental health of the individuals assisted.

Conclusion
It is perceived that the consultations with the use of integrative and complementary health practices provided a feeling of valorization, welcoming, recognition, and care, besides promoting repercussions on the emotional and physical health of the workers assisted.
We highlight the participants' comments about the importance of including these practices to strengthen the well-being of health professionals in the Unified Health System and emphasize the relevance of offering these services using integrative and complementary health practices in the pandemic scenario, which helped them cope with stress, insomnia, mental fatigue, and anxiety.
Final approval of the version to be published: Santos VHM, Maia MCW, Rézio LA, Bittencourt MN, Leite VF. Agreement to be responsible for all aspects of the manuscript related to the accuracy or completeness of any part of the work to be properly investigated and resolved: Santos VHM, Maia MCW.