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Non-clinical support workers of a referral hospital in Bahia in the face of Covid-19: essential and invisible
Trabalhadores de apoio de um hospital de referência na Bahia no enfrentamento da covid-19: essenciais e invisíveis

Emily Lima Carvalho – Carvalho, Emily Lima
Ph.D. student of the Postgraduate Program in Collective Health, Universidade Federal da Bahia (UFBA)
Master’s Degree in Community Health at Universidade Federal da Bahia (UFBA)
Nurse at Instituto Federal de Educação, Ciência e Tecnologia Baiano (IF Baiano), campus Governador Mangabeira – BA
E-mail: emily_lima_carvalho@hotmail.com
ORCID: https://orcid.org/0000-0002-1145-9306

Marcelo Eduardo Pfeiffer Castellanos – Castellanos, Marcelo Eduardo Pfeiffer
Associate Professor at Instituto de Saúde Coletiva, Universidade Federal da Bahia (UFBA)
Ph.D. in Collective Health at Universidade Estadual de Campinas (Unicamp)
Sociologist
E-mail: mcastellanos73@gmail.com
ORCID: https://orcid.org/0000-0002-4977-5574

Ana Maria Freitas Teixeira – Teixeira, Ana Maria Freitas
Associate Professor at Universidade Federal do Recôncavo da Bahia (UFRB), Centro de Cultura, Linguagens e Tecnologias Aplicadas (CECULT)
Ph.D. in Educational Sciences Sociology - Université Paris 8
E-mail: a.f.teixeira@hotmail.com
ORCID: https://orcid.org/0000-0001-9029-3676
Mônica Angelim Gomes de Lima – Lima, Mônica Angelim Gomes de
Associate Professor IV at the Department of Preventive and Social Medicine, Faculty of Medicine of Bahia, Universidade Federal da Bahia (UFBA)
Ph.D. in Public Health, Universidade Federal da Bahia (UFBA)
E-mail: monicangelim@gmail.com
ORCID: https://orcid.org/0000-0003-3364-8439

Alain Lucien Louis Coulon – Coulon, Alain Lucien Louis
Professor Emeritus; Full Professor in Educational Sciences, Université Paris 8
Visiting Professor at Faculty of Medicine, Universidade Federal da Bahia (UFBA).
Ph.D. in Educational Sciences, Université Paris 8
Associate Professor in Languages and Human Sciences, Université Paris 8
E-mail: acoulon00@gmail.com
ORCID: https://orcid.org/0000-0001-5354-101X

Abstract
In the context of hospital work during Covid-19, it must be acknowledged that the non-clinical support activities carried out by stretcher-bearers, cleaning staff, and administrative assistants are essential for the work process. This article analyzed the results of an exploratory stage of a broader research with these workers in a referral hospital for Covid-19 unit in the state of Bahia. Three semi-structured interviews were selected, produced from the perspective of getting these workers to talk about their work, using assumptions of ethnomethodology and ergonomics. The analysis took place on the work activities and their interfaces with a stretcher-bearer, a cleaning worker and an administrative assistant. The study showed that these workers were made invisible by the social devaluation of their activities and level of schooling and endure despite the circumstances and overwork; and evidenced how essential these services are due to the interdependence between support work and care work and their contributions to patient and team safety. In conclusion, it is necessary to create strategies so that these workers are appreciated socially, financially and institutionally.
Keywords: Occupational health; Covid-19; Hospital services; Health workforce; Health personnel.

Resumo
No contexto do trabalho hospitalar durante a covid-19, é preciso reconhecer que as atividades de apoio exercidas por maqueiros, agentes de limpeza e auxiliares administrativos são imprescindíveis para o processo de trabalho. Esse artigo analisou resultados de uma etapa exploratória de uma pesquisa ampla com esses trabalhadores dentro de uma unidade hospitalar referência para covid-19 no Estado da Bahia. Foram selecionadas três entrevistas semiestruturadas produzidas a partir da perspectiva do ‘fazer falar’ sobre o trabalho, utilizando pressupostos da etnometodologia e da ergonomia. A análise incidiu sobre as atividades de trabalho de um maqueiro, um agente de limpeza e uma auxiliar administrativa, problematizadas a partir da díade essencialidade-invisibilidade. O estudo demonstrou que esses trabalhadores são invisibilizados pela desvalorização social de suas atividades e nível de escolaridade e resistem apesar das circunstâncias e do sobretrabalho; e evidenciou a essencialidade desses serviços pela interdependência entre o trabalho de apoio e o trabalho assistencial e suas contribuições para a segurança do paciente e da equipe. Conclui-se que é necessário criar estratégias para que esses trabalhadores sejam valorizados social, financeira e institucionalmente.
Palavras-chave: saúde do trabalhador; covid-19; serviços hospitalares; mão de obra em saúde; pessoal de saúde.

Introduction
During the Covid-19 pandemic, the spotlights were turned mainly towards health workers, who responded to a multiplication of work demands, in a context of health and social crisis. This performance amidst a high degree of transmissibility, the limited knowledge about the disease and the severity of the cases, led to the broad social recognition of health workers and their (controversial) representation as \'heroes\'. Which workers are thus represented? Certainly the professionals involved with direct assistance: physicians, nurses, physical therapists, all with university degrees, who occupy the highest positions in the occupational hierarchical pyramid of health institutions1.
However, there are many support workers present in the hospital environment and also responsible for the successful health care: stretcher bearers, ambulance drivers, cleaning staff, administrative assistants, telephone operators, receptionists, maids, maintenance assistants, security guards, etc. In Brazil, an unprecedented study recently developed by Fiocruz2 found that, during the pandemic, health service workers categorized as \'invisible and peripheral\', essential for carrying out the work process in health, do not feel safe or protected to carry out their work (53%), were not trained to deal with the new health scenario to which they are exposed (54.4%) and deal with an excess work load (50.9%).
Therefore, it becomes necessary to disclose the experience of these workers to understand their mode of action and contexts of practice amidst the pandemic. Listening to these men and women is an essential task to identify and give visibility to their contribution to health work, which occurs despite the health work precarization process they experience, which reduces their access to the worker protection system. The identification and analysis of these experiences, situated in contexts of vulnerabilization (labor and pandemic), provide relevant elements for the action of managers, workers and researchers in the field of health.
A systematic literature review (in progress, DOI: 10.17605/osf.io/kcedw) identified a total of 50 scientific articles published between January 2020 and May 2021, which showed results of qualitative research on health workers working in hospitals, carried out during the Covid-19 pandemic. Only six of these articles included non-clinical workers without a university degree: half of these included cleaning, maintenance and/or administration workers3,4,5 and the remainder did not specify occupations, designating them as \'other workers\'6,7,8. None of these publications showed specific results on the work and health conditions of support workers. This result indicates their ‘invisibility’ in scientific research.
The use of the term “invisible” as a work qualifier indicates the group of workers who perform activities “that are neglected, ignored and/or devalued by employers, consumers, other workers and, ultimately, the system itself” (Legal, Sanitary, etc.)9. This term can be applied to activities that are socially, politically and economically devalued, that is, in terms of material rewards (remuneration), symbolic recognition (prestige) and working conditions and social protection (broader labor rights and regulation), such as which will be analyzed in this article. Overall, these workers are subordinate to ‘visible’ workers. Visible work is more often related to activities that achieve high levels of creativity and high wages; are well positioned in the job market; are socially recognized and provide full personal fulfillment10.
Those who perform manual labor are generally seen as inferior, as they perform marginalized tasks, although essential to society11. These activities are often considered “dirty work”12, as they involve devalued (social stains), stigmatizing (moral stains) and degrading tasks (physical stains)13. This idea has been used to analyze hospital waste collection activities and the preparation of bodies for funeral rites in the hospital context14.
This stigmatizing connotation can increase the feeling of social isolation suffered by health workers during the pandemic, as well as the degree of sacrifice to remain at work. A study with janitors at a referral hospital for Covid-19 in India showed a sense of accomplishment by these workers related to the contribution of their work and their personal sacrifice to remain active, even in the face of occupational stigma, the social isolation intensified in the context of the pandemic and the negative impacts of these situations on their quality of life15.
Within this scenario, this article aims at understanding the experiences of support workers at a referral hospital for Covid-19 in the state of Bahia, Brazil, focusing on the problematization of the essentiality-invisibility dyad as a marker of appreciation and subalternity. Understanding the condition of invisible workers, in their multiple experiences, especially in a critical situation such as facing a pandemic, helps to highlight what is obscured at institutions, in research on work in health and in the area of worker\'s health. Therefore, it becomes important to consider the specific institutional practices and contexts in which this invisibility occurs, from the hiring methods, to the interactions produced in the development of work activities, passing through the worker’s recognition.

Methods
A qualitative research was carried out on the work performed by members of the transportation, cleaning and administrative support teams of a large public hospital in the state of Bahia, Brazil. It is a hospital specialized in infectious and contagious diseases, with a lot of experience in the care of general infections, HIV and neuroinfections. Due to its expertise, this unit was chosen as a referral state hospital in the contingency plan to face the Covid-19 pandemic in the state of Bahia16. For that purpose, the hospital had to carry out adaptations and expansions that included the interruption of its outpatient services, the transformation of these units and the surgical center into inpatient units and the conversion of common ward beds into intensive care unit (ICU) beds, dedicated exclusively towards the care of severe cases of Covid-19. Thus, ICU beds increased from 20 to around 90 beds, distributed into old and new adult ICUs. Moreover, there was a change in the rationality of internal circulation in the hospital and within the units, requiring the need to quickly apprehend new forms of displacement, aiming to avoid the crossing between infected routes and clean ones, and to isolate the clinical teams of the ICUs.
These transformations involved the temporary hiring of many professionals, the intensification of the work pace, the definition and adoption of new protocols and the remodeling of hospital spaces. Regarding the support workers, the hiring of staff was not uniform across categories and was carried out at a lower intensity and pace.
The analyzed empirical data were produced by conducting online/virtual interviews, between June and December 2021, due to the epidemiological scenario. All participants signed the free and informed consent form. These interviews were conducted by researchers with experience in qualitative research, guided by a script of questions and the principle of \'making people talk\' about work and life, proposed by ethnomethodology17 and ergonomics18. From these perspectives, it is understood that individuals know exactly what and why they are performing a certain action and it is through language that it becomes possible to communicate social reality, describe it and, at the same time, constitute it. Thus, the interviews were used to resume and define the workers’ own reality experienced by them in the context of Covid-19.
Twenty-two semi-structured interviews were carried out with seven stretcher bearers, nine cleaning workers and six administrative assistants, 11 men and 10 women, aged 22 to 53 years old, 19 self-declared black (black or brown), one white and two without this information. The interviews lasted between 28 minutes and 1h49min, all of which were recorded and transcribed. The transcriptions were made by a professional hired to do it and verified by members of the research team.
For the development of specific points of discussion, we selected three representative interviews, prioritizing: diversity of occupations; variety of descriptions about the work conditions; presence of elements of analysis on the essentiality-invisibility dyad. The analysis was guided by the following questions: 1) Which worker performances and activities are not highlighted by managers, other workers and users, remaining hidden behind the scenes of the work process? 2) What impacts on the worker are produced by maintaining these performances and activities?
The analysis categories and interpretations presented herein were discussed by the group of researchers who constitute the authors of this article. The interviews were carried out within the scope of the research “Analysis of health surveillance models and strategies in the Covid-19 pandemic (2020-2022)”, funded by the Ministry of Science, Technology, Innovations and Communications, the Ministry of Health and the National Council of Scientific and Technological Development; and approved by the Research Ethics Committee (CAAE: 36866620.2.0000.5030).

Results
The respondents have the following profiles: stretcher bearer – a brown man, aged 40 years old, with a family income between one and three minimum wages, high school education and four years of experience in the institution (STB5); administrative assistant – a brown woman, 21 years old, with a family income between one and three minimum wages, incomplete higher education and two years of experience in the institution (ADM5); cleaning worker – a black man, 35 years old, family income of up to one minimum wage, incomplete elementary education and eight years of experience in the institution (CLN5). The duration of these interviews varied between 1h10min and 1h24min.
In the scenario of transformation of the hospital unit, the support work also underwent redefinitions of work activities, processes and conditions, with an increase in the workload and a decrease in the number of days off, amidst a context of pressure, anxiety and fear, with consequences for health and personal life. The interviewees demonstrated their commitment to maintaining work activities and complying with institutional expectations and highlighted the use of their expertise to increase the viability, safety and effectiveness of their work and the activities carried out by other workers, in an obvious defense of the essentiality of their jobs. This activation, however, took place in the midst of conflicts and/or processes of (de)legitimization related to the invisibility of the support work. Based on the analysis of these reports, two main categories emerged: social (de)valuation of support work; and interdependence of support and assistance activities.

Social (de)valuation of \'support\' work
The reports of members of the cleaning, intrahospital transportation and administrative service teams, disclose different forms of valuing and devaluing the place and the performed activities. While the valuation was limited to the recognition of personal skills and occasional appreciation, the devaluation was evidenced by scenes of disqualification of the knowledges and experiences of the support workers and by the absence of material and symbolic counterparts adequate to the formal and effective recognition of the essentiality of their work.
Sometimes, the contact with care teams resulted in conflicts, involving disputes over authority and professional hierarchies, in which contempt appears as a meaning attributed to the work, experience and knowledge of support workers.
“One sees it like this, in the attitude of the nurse or the technician... I don\'t know whether they belittle it, because we’re a stretcher bearer... And [they believe that] the stretcher bearer doesn\'t understand anything, the stretcher bearer doesn\'t know anything, the stretcher bearer didn\'t study for that … they even come up to you speaking in an altered tone.” (STB5)

“There are many others, they say \'he\'s a street sweeper, he\'s no good; he works in cleaning, it is trash’. And many know that if it weren\'t for the street sweepers, one would depend on the other... They understood that you can have money, you can have everything, but if you don\'t have good care, a good work team... an environment where you\'re going to work right, you will not be able to survive with a disease like that.” (CLN5)

The above reports indicate contempt for the support worker. The stretcher bearer indicates that the disqualification of their knowledge and experience is related to their level of training. The cleaning worker feels despised because their work activity brings them closer to the stigmatized social place attributed to street sweepers who carry out urban cleaning, even though they draw attention to the coexistence of other views about their work.
Contempt was also expressed in the actions of other professionals who took the product of support work as irrelevant, even when the workers sought to meet the required work:

“...the CCIH requires us to always cover the keyboard, cover the part of the telephone and these things. And then when we cover it, we leave everything covered, sometimes many people come and remove the plastic cover and say it bothers them, they don\'t like it. But we always try to keep the focus and leave it covered.” (CLN5)

Faced with situations of overload, pressure and labor conflicts, these workers found support in mutual support networks, among colleagues and immediate superiors, in order to favor their permanence at work.

“I think she [the leader] understands a lot and, during the pandemic, she gave a lot of support, as a way to thank us, she said: \'Thank you for being here\', because she knew that we were carrying it as if it was a weight there, because it was not a normal thing, there was this overload, because [new] support professionals only arrived later… Meanwhile, it was just us, one to control everything. We were very overworked. So she understood… and nowadays she always asks: ‘Are you ok? Are you feeling well? Do you want to go down? Do you want to change to the night shift or do you want this?\'... So, I can only thank her, and the people in charge too, who always take part with us, like that... they’re much closer to us.” (ADM5)

The administrative assistant makes this comment after describing their intense work in the organization of an ICU, which has become an institutional problem. It can be observed that the immediate superior recognizes that employee’s value and the contribution of their work, by taking an interest in their physical and mental health status, with an attitude of listening and negotiation regarding their next tasks and work shifts. There is a practical counterpart to this recognition, even if it is eventual and limited to the interpersonal relationships established between them.
The cleaning worker below provides an example of solidarity between colleagues, in which they emphasize a relationship of care by guiding them on important practical measures so they do not become contaminated.

“…we always focus on not harming the coworker both in cleaning, as in everything else, because if you touch something infected there, you have to say: ‘friend, be careful because this bacteria is very resistant and you cannot leave the bag open, you can\'t touch it without gloves, you can\'t pick it up without gloves... [check] if the mask is on your face\'” (CLN5)

The appreciation of support work and resistance to its devaluation gain strength in view of the recognition of their contribution to carrying out assistance activities, as shown below.
Interdependence of support and assistance activities
The essentiality of support activities is anchored in the interdependence between different work processes. For example, for the health care of patients admitted to the ICU to occur, performing imaging tests for diagnosis is a routine procedure. During the pandemic, patient transportation from the ICU to the bioimaging services occurred more frequently and under stricter safety guidelines, creating new demands for stretcher bearers. The hospital cleaning service was carried out under stricter hospital infection control protocols, increasing the number of tasks and workload involved in its performance. The opening of new ICUs and successive remodeling of the hospital space, throughout the pandemic, involved the essential work of the administrative teams, in planning, monitoring and evaluation activities, without which the spaces, supplies and teams would not be available for assistance.
This essentiality of the work of support teams, however, is not always recognized by other workers and managers. An example was evidenced in the report of the work required for the rapid expansion of ICU beds. The experience of the administrative assistant was put into effect to organize a new ICU that had serious operational problems, which were not overcome despite successive attempts by the heads of this service:

“[In one ICU] it was a mess... we didn\'t have logistics, we didn\'t have capacity... [The stockroom] doesn\'t want to know if an ICU has been opened and you don\'t know how to organize it. They want you to get organized to [request the material for] that number of beds… And I told her [the coordinator]: \'We need to sort out this sector, because it\'s a mess and the team is relying on the mess\'... I started [to] align with her. She said: \'look, create a flow, the team has to order today, put it in the DME [department stockroom] and supply tomorrow. And the team has to understand that this amount is for that day’.” (ADM5)
There is a concern with the availability of supplies and the rational use of materials, in order to guarantee the clinical team performance with the containment of unnecessary expenses. Faced with the level of disorganization of that ICU, the administrative assistant supported the creation of flows for the storage and use of materials, a job that went beyond her main functions. This professional reports that she even called from home to ensure that the arrangements were being fulfilled. The inadequate dimensioning of support professionals for the organization and monitoring of the ICU made this professional dedicate several extra shifts to fulfill this task.

“I was always pestering them, because otherwise the staff wouldn\'t keep it up… when there was this business of opening the ICUs, there wasn\'t enough administrative staff, so it ended up that other colleagues and I did a lot of extra work. Me, mostly, I was here every day. There was a month during the pandemic when I only had four days off during the entire month. It was overtime after overtime, overtime at night, overtime during the day, I had dark circles under my eyes” (ADM5)

This, however, does not occur without consequences for the health of these professionals, exhausted in the face of so many pressures and demands:

"When everything calmed down... this work of fixing up the sector, I don\'t want it anymore, as if it traumatized me." (ADM5)

The overwork undertaken by these workers brought benefits to the institution but had a negative impact on their mental health. Cleaning workers and stretcher bearers also reported suffering strong demand pressure and emotional impacts related to post-death procedures, in the context of the pandemic, such as the successive terminal cleanings and monitoring of family members to identify bodies, respectively.
In the case of stretcher bearers, the intensification of their workload and the inexperience of some newly hired professionals required the frequent use of their professional experience to guarantee patient safety:

“Many nurses and technicians came without any experience. As stretcher bearers, we already had the experience... There are things that are not my responsibility... But we get there and say: \'hey, this thing, it is like that, let\'s put the respirator on that side\', \'hey, be careful, the patient\'s tracheo [tracheostomy] is being pulled here\'... Many nurses did not have this experience and we perceived it... and then we helped as much as possible... Transportation was very complex, leaving the ICU to take patients to CT scans... with our experience, we already know... But the nurses have to do that... do the checklist... [But] sometimes, they forget... they are human beings. They forget to check the oxygen cylinder and ask for the maintenance of that cylinder... But we always look. And there are some that… [they ask] ‘hey, stretcher bearer, is the cylinder full?’. And I say: yes, it\'s still full\'... (STB5)

When this support is understood by another professional as a performance that is not compatible with the training and position occupied by the stretcher bearer in the hospital\'s occupational hierarchy, conflicts arise, as previously mentioned:

“We see it... in the attitude of the nurse or nurse technician... I don\'t know if we’re belittled, because we’re stretcher bearers. And the stretcher bearer doesn\'t know anything... they didn\'t study for that. There are things we advise on behalf of the patients... we have to be very careful with them and leave the differences aside, the indifference aside.” (STB5, emphasis added by us)

The stretcher bearer describes how and why they emphasize their experience and knowledge to carry out the task: patient safety. Even if this involves interprofessional conflicts, calling into question professional jurisdictions and institutional rules. According to the institutional protocol for safe transportation, this action is not part of the attributions associated with the stretcher bearer’s role, as it is up to the care team to evaluate and test the equipment and devices used for the transportation of patients. The stretcher bearer must comply with the guidelines of the care team. However, given the lack of specific training and the inexperience demonstrated by the newly hired workers, the stretcher bearer highlights their experience as a symbolic resource in favor of carrying out the necessary care for safe transportation, thus breaking professional hierarchies and institutional rules (and their invisibility!), exposing themselves to conflicts at work.
The cleaning staff, in turn, also had its role expanded and the work intensified during the pandemic, whose actions were crucial for the success in controlling the risks of infection in the hospital unit:

“For someone to enter this sector, part of a room... to touch something, we had to clean it, if we didn\'t clean it, they would be afraid of catching Covid. Many understood it in the wards, nursing technicians, nurses... [that] if it weren\'t for us, [if] the team didn\'t clean the surfaces... they wouldn\'t touch [many things]: materials, doors, windows, in many places, the bed." (CLN5)

During the Covid-19 pandemic, the cleaning of surfaces and materials in hospital environments was reinforced, considering the possibility of transmission of the virus by fomites. In addition to having an increased workload, the cleaning teams worked under more intense surveillance: “We were already under heavy scrutiny all the time, both from the board of directors and all… So we kept the focus on always paying more attention…” (CLN5). The knowledge of the risks of infection and the fear of becoming contaminated, which also increased during the pandemic, helped the care and management teams to observe the indispensable nature of the invisible work of by the cleaning staff, also considered as such by the cleaning team itself.

Discussion
Taking into perspective the results presented herein and the questions posed in the methodological section, we can say that the results reinforce the relevance of the essentiality/invisibility dyad as an analysis key to understand the reported experiences, by pointing out contradictions experienced by support workers, rather more intense in the context of the pandemic.
Processes of devaluation and invisibilization of the activities described herein and of the support workers themselves were identified. Circumstantial forms of valuing and visibility of their work were also described, based on the recognition of their essentiality. However, such acknowledgment was not expressed in concrete improvements in working conditions and/or gains in material rewards for these workers. Furthermore, despite the worsening of their working conditions, there were no reported institutional programmatic actions of protection and support specifically aimed at support workers. In this sense, we can raise the hypothesis that the visibility of the essentiality of the support worker, during the pandemic, was limited to the sphere of interpersonal relationships, without generating changes in the power relations established in the hospital space, improvements in working conditions or labor achievements.
This situation is even more a matter of concern when we consider the effective contribution of support workers in coping with the pandemic, without which the standard of excellence of the aforementioned hospital would not have been attained. The negative effect of the invisibility of this work on the workers\' health is also reinforced when we consider the high level of emotional and physical pressure under which these workers acted, while maintaining a strong institutional commitment, even in the face of the increasing number and types of activities to be carried out19, the interruption of their days off and the expansion of their work shifts, in view of the inadequate dimensioning of the workforce. This situation involved a strong sense of accomplishment for these workers related to their work contribution and their personal sacrifice to remain active, as already identified in the literature15.
In a scenario of frequent adaptations, many impacts on work routines were absorbed by the support staff. They mobilized the knowledge produced in their daily work to effectively contribute to the quality, operational efficiency, safety and strategic planning of care work, protecting clinical teams and patients from accidents, adverse events and contamination.
However, in a society with a history of slavery such as Brazil, menial jobs are usually seen as lowly and the workers responsible for these activities receive low wages, have fewer advantages and labor protection and less recognition from the government (through regulations and public policies). These are typical characteristics of the invisible formal work, reinforced by broader social inequalities (gender, race/skin color, social class) that make it even more difficult to change one\'s occupational status20.
In line with the scientific literature on the invisibility of work, we identified the reduction of support workers to the functions they perform, abstracting from the process the people who performed them, in a sort of delegitimization of these workers’ experience9. This devaluation was expressed by our interviewees through the idea of contempt. In the case of the cleaning workers, there is a process of stigmatization related to the idea of “dirty work”, which is related to the worker’s moral depreciation. For the stretcher bearers, contempt was more related to these workers’ occupational demeaning and devaluation of their level of training. Administrative workers, on the other hand, had to deal with an inadequate dimensioning of the workforce, despite the overload, with their needs being disregarded.
These situations probably also refer to a \'non-place\' of these workers as health professionals2, which obliterates the interdependence between clinical and support work.
However, the feeling of contempt was relativized by specific recognitions, present in only one report. A similar result was found among hospital cleaning workers during the pandemic: the increased workload dissociated from the recognition beyond few expressions of gratitude15,20.
These workers’ moral commitment stands out, on the one hand, regarding their motivation to comply with the assigned tasks and, on the other hand, in assuming their experiences and knowledges with self-confidence to intervene in situations identified as being of potential danger for patients (stretch bearer), for co-workers (cleaning worker) and the institution (administrative assistant), even when this led to conflicts and overwork, related or not to the scope of their main activities.
The work considered simple, basic and repetitive became more demanding, complex and controlled by protocols. The workers made adjustments between the assigned work and the actual work that can be analyzed from the category “dramatic use of the self”, proposed by ergology. For Schwartz21, the use of the self takes place “through the choices of what use one wants to make compared to the uses that others want to make of us”22. These are conscious choices or not, since we are a historical body “disciplined by the learning and experiences of previous renormalizations, which bring conscious knowledges and values... and [are] disseminated within our body”22.
The strategy assumed by the stretch bearer and the administrative assistant, by highlighting their work experience beyond what is expected for their functions, can be understood as an expression of this dramatic use of the self to operate an update of previous norms. In this sense, conflict is not only and primarily interpersonal. First of all, it expresses a dispute between the “use of oneself” (what the subject makes of oneself) and the “use of oneself by others”. Therefore, it expresses a struggle for autonomy at work and for the definition of the meanings of work.
This is ‘behind-the-scenes’ work, invisible, but which gains the main scene in the conflict, when support workers mobilize their know-how and practical reasoning17 to face work situations that require adaptation, effectiveness and agility in changing institutional contexts that require “a critical evaluation of the previous norms”22 and the creation of new organizational arrangements.
The acknowledgement of these activities limited to the interpersonal scope – based on praise from immediate superiors or generalized recognition from top managers – limits the potential for (self)organization and appreciation of these categories in the institution and in the broader social context, reducing the possibilities for change in this scenario. A study with cleaning workers in a Canadian hospital pointed out that, despite making efforts to disassociate themselves from the negative stereotypes associated with their work, they receive little support from managers and colleagues who occupy hierarchically superior positions to effectively fight their invisibility and attain greater respect23. The lack of studies on this situation in the field of workers\' health in Brazil makes it difficult to discuss the topic and change this context2.
Finally, the extraordinary work carried out by the support teams in the context of the pandemic does not go unnoticed in their lives, since the stress that results from this work reflects as emotional impacts, an aspect that deserves to be better analyzed in the context of research on workers\' health. The creation of mutual support networks and exchange of experiences among colleagues emerge, in the analysis presented herein, as a possibility of resisting the exhaustion produced during the daily work at the hospital, especially in health crises that put life and death in evidence.

Final considerations
The categories of invisible work and dirty work were relevant for understanding the experiences of support workers in the hospital environment. Together with the idea of essentiality, these categories allowed analyzing the processes of material and symbolic (de)valuation of these workers. During the Covid-19 pandemic, these professionals dealt with work overload, contempt and low protection support, especially in terms of mental health, but they remained active, despite the conflicts and work overload they faced.
Amidst such contradictions, support workers contributed to the success of the health work process, based on their experience and moral commitment to the performance of their duties, providing a sufficiently safe atmosphere for patients and other workers. The present study demonstrated the potentiality of the essentiality-invisibility dyad to analyze contradictory processes present in the daily lives of hospital support workers, emphasizing the need for a change in institutional culture and formal recognition with symbolic and material gains that may change their working conditions, strengthen labor rights and promote appreciation.

Authors’ contributions
EL Carvalho contributed to the research project and design, data collection, selection and analysis, manuscript writing and review; MEP Castellanos contributed to the research project and design, data collection, selection and analysis, manuscript writing and review; ANF Teixeira contributed to the research project and design, data collection and analysis, manuscript writing and review; MA Gomes contributed to the research project and design, data analysis, manuscript writing and review; and ALL Coulon contributed to the research project and design, data analysis, manuscript writing and review.

Sources of funding
Ministry of Science, Technology and Innovation - National Council for Scientific and Technological Development.
Ministry of Science, Technology, Innovations and Communications
Ministry of Health

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