The COVID-19 pandemic had several repercussions on prison staff, but the currently available evidence has mainly ignored these effects. This qualitative study aimed to understand the impact of COVID-19 on the prison system through the narratives of health and security professionals, using the methodological framework of the constructivist grounded theory proposed by Charmaz. The sample included 10 healthcare workers and 10 security professionals. Data collection took place between October and November 2022 through individual in-depth interviews. The data were analyzed using the MaxQDA software. Three categories of interrelated data emerged: (1) “Confrontation and disruption” caused by the COVID-19 pandemic in the prison system; (2) “Between disinfodemic and solicitude” referring to the tension between information management and the practice of care centered on the needs of inmates; and, finally, (3) “Reorganization and mitigation strategies during the fight against COVID-19”. Continuous education and the development of specific skills are essential to enable professionals to face the challenges and complex demands that arise in prison contexts. The daily routines professionals had previously taken for granted were disrupted by COVID-19. Thus, investing in adequate training and emotional support programs is crucial to promote the resilience and well-being of these professionals, ensuring an efficient and quality response to critical events.  The COVID-19 pandemic has expanded and emphasized the multiple threats to public health and human rights that have long been associated with the prison system . AccordiWith more than 11.5 million people imprisoned worldwide , the oveThe system’s response to the COVID-19 crisis reflects the Foucauldian “principles of segregation, segmentation, and surveillance” . The meaOther measures to prevent the spread of the virus were also fundamental, such as protocols for the regular disinfection of the prison’s physical spaces and the use of personal protective equipment, carrying out large-scale tests, providing information and psychological support, and prioritizing the vaccination campaign ,16,17. APrison staff were essential during the pandemic, having to adapt to changes in the prison system and assume new responsibilities . This caLikewise, prison staff is disproportionately at high risk for COVID-19 consequences in prison facilities since they move between correctional institutions and their communities ,24, and The main health concerns and dangers related to COVID-19 from a transmission and containment perspective are covered in the most recent evidence on COVID-19 and prisons . HoweverAlthough there is some qualitative research available ,31,32, tThe present study aimed to understand qualitatively the impact of COVID-19 on the prison system through the perceptions and practices of health and security professionals. In this sense, the research question was: How do healthcare and prison staff perceive and deal with the impact of COVID-19 in a Brazilian high-security prison? We hope this study creates a robust field of knowledge and generates guidelines for the implementation of effective measures capable of dealing with future catastrophe scenarios.This study is part of a larger research project aimed at assessing the effects of the pandemic on the prison system in the state of Paraná, Brazil. The present study used a Constructivist Grounded Theory design (CGT) based on the principles of Kathy Charmaz . This apThis study was conducted and reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist . The study was carried out in a maximum-security prison with a capacity for 960 male persons located in the municipality of Maringá—northwest of the State of Paraná—in Brazil. The facility was built with the initial objective of only receiving individuals who were awaiting trial, but, due to the shortage of vacancies in other prisons, it ended up receiving convicted individuals. This choice was made because this is one of the largest prison facilities in one of the Brazilian states most affected by the COVID-19 pandemic .The participants were included incrementally, according to the principles of CGT , first bA maximum variation purposive sample was used to guarantee a heterogeneous sample in terms of age and professional experience. Participants were healthcare and security professionals with a strategic role in the prisons during the pandemic. Study eligibility depended on the following criteria: (a) work experience in a prison before the onset of the COVID-19 pandemic; (b) preset format work during the data collection period; and (c) ability to understand and communicate in Portuguese.The theoretical sample included 10 health professionals and 10 security professionals (prison officers) who voluntarily participated in the in-depth qualitative interviews. This number was determined by theoretical saturation, as recommended by Charmaz . Data collection was conducted over 2 months (from October to November 2022), for reasons of organization and functioning of the unit. We identified target participants through the research team’s professional network. Before signing a consent form, those who manifested interest in the research were given a participant information leaflet.The interviews were carried out by only one nurse, with large clinical activity in prison facilities (W.C.B.). A semi-structured interview guide prepared by the researchers and based on available evidence was used as an instrument for data collection ,21. The Before starting data collection, the instrument was validated by three experts with PhDs and experience in qualitative research, who validated the content, form, and clarity of the questions, obtaining an agreement level of greater than 90%.Given that data collection was concomitant with data analysis, the interview script was modified according to emerging themes, in particular, to improve understanding of the phenomenon under study . Field nThe interviews were carried out in a specific place at the institution, which ensured the privacy of the interviews. All interviews were conducted in person. There were no repeat interviews. The interviews lasted between 40 min and 90 min, with an average duration of 60 min, and were recorded in audio and transcribed in full.In order to ensure the accuracy of the citation translations, they were first translated into English and then back-translated into Portuguese. The sample excerpts were numbered according to the role of the participant, being HealthCare Professionals (HCP) and Security Professionals (SP).® Software–version 2018  to facilitate data management as well as store it  Its start was frightening because it was a new disease with an uncertain evolution, long hospitalization periods, and many cases progressing to death.(HCP4)It was emotionally draining […] dealing with fear during the pandemic was one of the hardest things. The fact that we don’t know much about the virus and all the resulting complications; deaths happening daily due to the various difficulties health teams faced everywhere.(HCP3)At first, there was a bit of despair, but then I started following other health professionals, and I realized that our front line wasn’t really that much of a front line. Compared to my friends working in the ICU (Intensive Care Units), hospitals, and UPAS (Emergency Care Units), so I think that, relatively, it was not as difficult as what was faced at the entrance doors. (HCP6)Prior knowledge about infectious diseases made the participants fear both personal contamination and the possibility of transmitting the virus to their loved ones, reducing contact with the outside world.Knowing the impact that an infectious disease has, the biggest concern was taking it to our families, so we reduced the number of trips home […] when the initial fear subsided, there was a concern about elaborating or trying to minimize the impact of the pandemic. (HCP2)It was difficult, I won’t say it was easy, I had to control what I would take home, it was complicated, I was afraid, I had already been infected and I was afraid. In September, I had a bad time, I didn’t go to the hospital, I was afraid to take it back home, and it was complicated. (SP5)Given the unprecedented character of the pandemic and the structural limitations, the participants underline the difficulty of identifying the chains of infection within the prison. Their share of responsibility for the transmissibility of the disease was recognized, as they were the ones who entered and left the prison unit daily.The agents of the penal system were the main vehicles of transmission because they left the prison daily, so when cases arose, it was because they brought it from the community. (SP9)The prison officers were the ones who brought the disease into the prison. (SP4)[…] the virus was contagious, but it didn’t seem as aggressive outside as it did inside the system […]”. This perception may be related to the specific challenges experienced within the prison system, such as the difficulty of adequate physical distancing, the scarcity of resources, and limited access to health care. Some security professionals perceive the prison context as more dangerous concerning the spread of the virus compared to other community contexts. In this regard, SP9 mentions: “[…] Human resources are needed. We don’t have enough human resources to provide a quality health service. (HCP2)The health area is very precarious […] we have no voice, we are not recognized or even remembered.(HCP9)[…] we have a big shortage of employees, […] (the institution) should hire more people.(HCP1)The difficulty in finding cells inside the prison for the isolation of positive cases was identified as a challenge for the participants. Given that overcrowding is a recurring problem, there is a regular demand for cells to accommodate a large number of inmates. In this sense, finding space for isolation cells created significant disruption.[…] all incoming prisoners, even those without COVID-19, had to be quarantined, and we didn’t have space for that, and that created a certain operational difficulty.(SP7)With the implementation of protocols for the care of suspected or confirmed cases of COVID-19, participants reported a sense of unpredictability in the face of the evolution of the pandemic in the prison system. This fact determined that new information and guidelines were constantly emerging. Added to this is the lack of prior experience in dealing with a pandemic of this magnitude and the need to adapt quickly to changes. At the same time, the complexity of the prison environment also exacerbated feelings of uncertainty among all those involved on the front lines. In several cases, working hours were extended to respond to needs, and sometimes feelings of detachment from the outside reality arose.We made decisions according to protocol […], but always with a feeling of uncertainty about everything we did. Whether it was good or not, I don’t know […] but at the same time, it relieves me, seeing that other places have gone through the same situation, where the problem was the same.(HCP6)Non-health professionals were always asking questions, wanting answers […] some new behavior raised questions, everything was new. Behaviors changed from one day to the next and we had to adapt.(HCP5)We had to work long hours, which was very complicated because we didn’t see the family.(SP1)During the COVID-19 pandemic, fighting the disinfodemic and showing concern were recognized as key strategies to ensure the safety and well-being of inmates, as well as the prison staff involved.A disinfodemic describes the large-scale spread of false, unreliable, or misleading information. Health professionals faced the challenge of dealing with a significant volume of information about COVID-19. Therefore, they had to adopt strategies such as the active search for reliable sources and the constant updating of scientific knowledge. In the initial phase of the pandemic, there was concern among workers about the misinformation associated with COVID-19, which generated high skepticism. In parallel, participants report having responsibility for filtering and disseminating accurate and up-to-date information, with the aim of promoting an adequate understanding of the disease and preventive measures among inmates and their families.In the beginning, it was a new experience, but as the days went by, it brought fear and insecurity, culminating in skepticism […] I didn’t believe in anything anymore.(HCP10)We had a large amount of information, much of it inaccurate. We serve as multipliers of information not only in our functions but also to the prison population and staff. We experience difficulties with several misguided guidelines without scientific basis that have been released.(HCP4)Health professionals point out a limitation, the lack of communication during the pandemic. Several factors may have had an impact on the capacity to respond and manage the health crisis in prisons, causing delays in the dissemination of information, such as health guidelines, safety protocols, and updates on COVID-19 cases.There are no meetings to discuss or talk about assistance, standardization of conduct, or procedures with the security team and the health sector.(HCP4)The exchange of information and moments of debriefing between colleagues was evaluated as a positive aspect of managing day-to-day situations in the pandemic context. This collaboration allowed professionals to share experiences, coping strategies, and up-to-date knowledge on disease management in a challenging environment. This interaction and collaboration between colleagues contributed to improving the care provided to prisoners and to strengthening the health team in facing the pandemic in a prison context.I can say that crucial facilitating aspects in this context were the support and information shared with/among co-workers. They were fundamental!(HCP9)The moments of sharing between peers were important, I see more in that sense, the positive points.(HCP2)We stayed up late, discussing what could be done even more in an environment that is conducive to the proliferation of these microorganisms and we work directly with confined people, a higher-risk environment. Our concern was mainly to try to reduce the effects here.(HCP2)In many cases, prisoners’ access to the health sector within the prison units went through the scrutiny of prison agents. These professionals usually act as intermediaries between prisoners and health professionals. In this context, solicitude emerges as a possibility of openness and acceptance of the other through an intersubjective relationship that provides attention and care.Our role is to be the link because one thing they (inmates) usually say is that we are their hands and feet, so we try to have a good relationship. When there is good contact and mutual respect, this favors the relationship. (SP2)The participants’ concern to promote monitoring and the creation of an environment conducive to dialogue is highlighted, particularly at times when inmates adopt extreme measures to make themselves heard. Different forms of protest were mentioned, such as making noise, shouting, banging on the railings, or even starting riots to draw the attention of the authorities and demand medical attention.At certain times they (inmates) start to get excited, so the tendency is to knock, shout, kick, to knock on doors. They think that by doing this, they will speed up the process, but sometimes they don’t […] that’s how they do it.(SP2)The reorganization and implementation of COVID-19 mitigation strategies in prisons was a complex process due to the specific characteristics of this environment. The closed nature of prisons and close contact among inmates has posed challenges in preventing the spread of the virus.Health professionals highlight the concern with the underreporting of cases in the prison system. Additionally, they mention that there is a lack of adequate and accurate records of COVID-19 cases within prisons, which may lead to an underestimation of the real extent of the disease in these institutions. […] The doctor did not frequently ask for the screening test. In the UPA (Emergency care unit) all people are tested. She (the doctor) tests one case or another, the most serious, but it is not transverse conduct for all symptomatic inmates. (HCP6)Participants evaluate virus mitigation strategies as positive points in prisons. They further recognize that the implementation of these measures was crucial to reducing the risks of spreading COVID-19 and ensuring the safety of both inmates and staff.There was a greater demand among employees for prevention and this was a positive point. (SP10)The changes were effective, I believe so […] they made it much easier for the virus not to spread. (SP3)I believe that some measures were effective in reducing exposure to the SARS-CoV-2 virus, however, the administration should have provided masks with greater protection capacity. (HCP2) […] one of the strategies was the departure of inmates who had some comorbidity. It was very complicated […] because there are crimes that could not go home.The compassionate release of prisoners was also a measure to mitigate the virus, particularly for individuals with greater vulnerability to COVID-19, but always depending on the type of crime committed. HCP6 mentions: Awareness of maintaining hygiene standards even after the COVID-19 pandemic is an important aspect highlighted by the participants. Although the pandemic has increased the need for hygiene measures and precautions to prevent the spread of the virus, it is necessary to maintain these practices in the long term.It is important to continue using a mask, especially when there is a risk of infection, just adjust the use of a mask, alcohol gel, and gloves. (SP8)We’ve already lost a lot of people […], we have to learn from what happened. And we must be careful, wear a mask, and get vaccinated, or we run the risk of coming back again. (HCP1)The implementation of stricter screening measures for the early identification of suspected cases, increased testing of inmates and staff, increased access to Personal Protective Equipment (PPE), and specific training on prevention and response to COVID-19, in addition to establishing an efficient flow of communication, were strategies adopted to mitigate the virus.We had several strategies, we adopted protocols within the prison units, and we had a lower mortality rate because, through DEPEN , some ordinances determined the carrying out of screening tests and prohibited, for example, visits, the delivery of food and hygiene goods. (HCP2)We produced fabric masks for the inmates and the agents, aprons and caps for us and for the hospitals […] the PPE was in short supply everywhere, all the stock was running out, and that was one of the strategies that we also had to invent. (HCP6)We implemented continuous education to create moments of discussion and training with prison agents. In the first phase of the pandemic, we were concerned with clarifying the doubts of security professionals. (HCP2)Some professionals noticed improvements in resources and processes within the prison system resulting from the measures implemented due to COVID-19. Emphasis on the availability of gel alcohol dispensers in strategic locations, the expansion of the supply of hygiene products, the implementation of cleaning protocols, and awareness of the importance of personal hygiene. These changes were seen as positive, as they contributed to the promotion of a healthier environment.The placement of alcohol dispensers in the corridors, in strategic locations, and in the toilet, to wash hands, has increased significantly. It was even good because we have always wanted it, but we didn’t have it. Then, liquid soap and paper towels to dry hands started to appear, which was something very scarce. (HCP6) The prison environment is somewhat unsanitary, so hygiene measures ended up making the environment cleaner. (SP7) Likewise, vaccination against COVID-19 brought peace of mind to the professionals involved, considerably reducing the risk of contamination and the possible serious effects of the disease.Encouraging people to take the vaccine and booster doses became my main focus […] receiving materials for the rapid COVID tests and vaccine doses has positively eased the policy of social isolation. (HCP10) […] and after the vaccine things got easier […] and the prisoners joined in. (HCP1) Professionals also mentioned that by restricting visits it was possible to reduce the likelihood of the virus entering the prison environment.Regarding facilitating actions, the cancellation of visits, quarantines after leaving the unit for care, and the creation of a sentinel unit in suspected or confirmed cases of COVID-19. (PS4) The inmate was left without a visit and isolated and that was positive to control and not turn the pandemic (in prison). (PS7)In this sense, virtual visits were instituted as an alternative to the suspension of face-to-face visits. Perceptions about virtual visits varied, ranging from recognizing their importance in guaranteeing the proximity of family ties to expediting the holding of court hearings, despite the lack of training and digital literacy in their use.Online visits were positive, it worked well. The system already existed and was perfected. Before, the connection was precarious, but it has improved, court hearings with video were also a gain. (SP5) […] The system of visits by videoconference was initiated without any training or IT support being offered to the professionals who would carry out this task. This was detrimental to overworked professionals and also to visitors and prisoners.  (HCP8)Videoconferencing visits helped a lot because there was no contact between people.(SP8)Participants have the perception that prison is a complex environment permeated by prejudices and stigma, which determines the need for a holistic and humanized approach, capable of considering individual particularities, with a view to their reintegration and resocialization. […] here is not a bunch of people […] society thinks that the person is arrested and disappears […] the prisoner will continue eating, living, needing medical attention, that’s why the State has to wake up and see that one-day people will get out… whether they will leave “worse” or “better”, depends on the available staff and structure. (SP9) […] We value doing our best, we refrain from passing judgment. As representatives of the State, we go and find solutions. (SP8)In this study, we aimed to understand the impact of COVID-19 on the prison system through the narratives of health and security personnel. These narratives cast doubt on widely held notions about the effective control of COVID-19 in prison environments and clarify the problems and obstacles the pandemic has presented prison staff and inmates. Like previous studies, participants showed fear of contracting COVID-19 and of being vehicles of transmission, putting their family members at risk ,40.Fear can have an undesired effect, generating emotions of powerlessness that can lead to defensive responses instead of an active approach . AdditioParticipants in our study pointed out uncertainties regarding COVID-19, which according to Liu Ye [Although prison staff and inmates are subject to measures of varying complexity instituted to control COVID-19, they were all required to follow the same guidelines in the use of Personal Protective Equipment (PPE) and social distancing, reflecting a regulatory uniformity imposed by institutional power. This observation is related to the ideas of Michel Foucault, who discussed the concept of biopolitics , which rDuring the pandemic, important challenges were highlighted by prison staff due to the high labor demands and pressures ,44. ManaAlthough participants generally recognized they were capable of protecting themselves against COVID-19 in the workplace, some mentioned working in unhealthy conditions, perceiving a negative impact on mental health brought about by issues related to the pandemic, and frequent concerns about the possibility of becoming infected in the workplace and taking the virus from the prison into their personal environment .Foucault argues that power relations are not limited to the scope of law or violence, nor are they limited to contractual or merely repressive aspects. According to him, power operates as a network in constant circulation, where individuals are not only passive or consenting targets but also centers imparting this power ,46. ThisIn this context, the shortage of PPE, the difficulties in maintaining physical distance, and the lack of consolidated information about the necessary care in relation to the disease, reveal the limitations and challenges faced by the staff. This situation generated anxiety among the staff since they were working in an environment where most people were advised to stay at home selves . The intFoucault  highlighHealth and security professionals faced difficulties when handling the detainees’ demands. Prison officers perceived themselves as spokespersons for the detainees within the prison, but often the dialogue between the parties was not satisfactory. The findings of this study must be interpreted considering the broader power dynamics that occur in prison institutions . The empAs in our findings, the literature indicates the possibility of underreported COVID-19 cases in prisons ,49, due The inmates’ distrust of the health care they receive can be understood as a manifestation of the disciplinary power that permeates the prison environment, where the surveillance and control exercised by the staff can result in a perception of negligence or lack of care . In contAlthough the need to implement measures to control the virus within prisons is widely discussed, professionals reported difficulties in following these guidelines and implementing protocols. These guidelines include structural changes, such as reducing the number of inmates, cells for preventive isolation, and improving ventilation to reduce the potential for transmission in prisons. In addition, efforts to increase vaccination coverage were considered important, especially among prison officers .Given the resource constraints, some participants expressed concerns about the acquisition of personal protective and hygiene materials, such as masks, gloves, and other essential items. Faced with this situation, professionals took the initiative and the inmates dedicated themselves to the production of protective equipment for local prison institutions, in addition to supplying materials to hospitals. Other studies have reported this difficulty faced by inmates, who often improvise their own personal protective equipment, highlighting the importance of solicitude and mutual care among these people .To mitigate the impacts of the pandemic on the prison system, drastic measures were implemented to eliminate or reduce COVID-19 infections in prisons. These measures included the early release of incarcerated individuals, especially those at higher risk of serious complications due to COVID-19; the suspension of social or legal visits to detained persons; the quarantine of newly incarcerated individuals; and the reinforcement of hand hygiene . This stIt is necessary to direct resources toward alternatives to incarceration and approaches that prioritize the health and well-being of individuals, recognizing that the prison system poses significant challenges to the protection of public health and guaranteeing respect for human rights .Our findings suggest that the shortage of qualified professionals is a significant obstacle, representing one of the greatest challenges to containing the spread of COVID-19 in prisons . In lineMisinformation about COVID-19 has also been prolific, threatening not just individuals but societies as a whole. This leads people who ignore scientific advice to put themselves in harm’s way, widens the lack of confidence in politicians and governments, and diverts the media’s efforts, which work reactively to refute untruths rather than proactively producing information from new data. In this sense, and similarly to other studies , our finThe performance of health professionals in the elaboration of mitigation strategies is important since their knowledge and experience are fundamental for the collective construction of knowledge during the COVID-19 pandemic . In thisOne of the strengths of the present study was the use of a sample that includes health and safety professionals with varied experiences, providing a comprehensive view of perceptions and practices in the prison context. Furthermore, the qualitative approach adopted in the study allowed an in-depth analysis of the qualitative data so that it resonates with the voices of the participants. Lastly, the study fills a knowledge gap, given that the findings have the potential to inform the implementation of measures that promote better health and safety for incarcerated individuals.However, some limitations must be considered. One of the limitations of the study is that it only included data from a prison in the south of Brazil, which limits the transferability of the results to other prison contexts. The interviews took place in prisons during the times when correctional personnel were on duty. Due to time constraints, it was not possible to guarantee that the interviews would go without pause. It is important to consider that the study was carried out in a certain period of time (the third year of the COVID-19 era), reflecting the perceptions and practices of professionals during this specific period of the pandemic. Given that the evolution of COVID-19 had different trajectories in different Brazilian states, the findings may not reflect the reality of the prison system at the national level.It is essential to highlight the need for more research with quantitative and qualitative approaches of a longitudinal nature to deepen the understanding of the impact of the pandemic in the prison context. Future research should also validate our findings including samples with maximum variation in terms of geographic location and type of prison unit.The study presents the challenges faced by health and security professionals in the performance of their duties during the pandemic. Based on these perceptions, it was possible to identify the support needs of these professionals, such as emotional support, additional resources, or specialized training . The current study has implications of great relevance for health practice in the prison context. By understanding the complexities and challenges faced by health professionals in this specific environment, it is possible to identify measures and strategies that help to reduce the impacts of the pandemic and ensure the provision of adequate care to incarcerated individuals. This deeper understanding contributes toward improving health practices and allows for a more effective and targeted approach to health promotion and disease prevention within the prison system, where the use of digital technologies can facilitate bringing services closer to the community.Another important implication of this study is the possibility of developing targeted interventions to address the specific challenges of the prison system during the pandemic. This would allow the development of more effective programs and policies, such as mental health programs, infection prevention education, and improved training in biosecurity measures. Meanwhile, these measures can also reduce other contagious diseases , highly prevalent in prisons .The leaders of a prison organization must consider implementing comprehensive and regular testing policies and protocols, as well as prevention and control measures, to ensure the safety and well-being of inmates and prison staff and prepare for future disaster scenarios. Finally, carrying out this in-depth qualitative study contributes to the advancement of scientific knowledge about the pandemic in the prison context. By filling existing knowledge gaps, the study provides a broader understanding of the challenges faced and best practices in coping with the pandemic in prisons. This is fundamental to support future research and guide interventions and policies in the prison system.As far as we know, this is one of the first attempts to explore the impact of COVID-19 on the prison system, providing important insights through the lens of prison staff. In the context of the pandemic, research in prison units is a rarely explored field due to the novelty and complexity of the disease.Prison is, by nature, an environment where one is likely to feel confined. Moreover, qualitative analysis revealed a sense of “feeling trapped” due to several changes associated with the pandemic and the legacy factors that still prevail in prison settings. One of the main aspects highlighted by participants was the fear of contracting the disease and subsequently transmitting it to their loved ones. This fear reflects concern for their own health and the responsibility to protect those in close contact with them. The unavailability of clear and up-to-date guidelines on disease prevention and management protocols in the prison environment made it difficult to make appropriate decisions and effectively implement preventive measures. This generated uncertainties and difficulties in adopting practices that could minimize the spread of the virus among inmates and health and security workers. Another challenge was the shortage of personal protective materials and equipment, essential to guarantee the safety of prison professionals. Likewise, staff clearly struggled to navigate humanity in the prison and solicitude was a necessary condition to respect inmate vulnerability inmates.


The COVID-19 pandemic has significantly impacted on the delivery of clinical trials in the UK, posing complicated organisational challenges and requiring adaptations, especially to exercise intervention studies based in the community. We aim to identify the challenges of public involvement, recruitment, consent, follow-up, intervention and the healthcare professional delivery aspects of a feasibility study of exercise in hypertensive primary care patients during the COVID-19 pandemic. While these challenges elicited many reactive changes which were specific to, and only relevant in the context of ‘lockdown’ requirements, some of the protocol developments that came about during this unprecedented period have great potential to inform more permanent practices for carrying out this type of research. To this end, we detail the necessary adaptations to many elements of the feasibility study and critically reflect on our approach to redesigning and amending this ongoing project in order to maintain its viability to date. Some of the more major protocol adaptations, such as moving the study to remote means wherever possible, had further unforeseen and undesirable outcomes  with regards to extra resources required to deliver the study. However, other changes improved the efficiency of the study, such as the remote informed consent and the direct advertising with prescreening survey. The adaptations to the study have clear links to the UK Plan for the future of research delivery. It is intended that this specific documentation and critical evaluation will help those planning or delivering similar studies to do so in a more resource efficient and effective way. In conclusion, it is essential to reflect and respond with protocol changes in the current climate in order to deliver clinical research successfully, as in the case of this particular study. The protocol developments documented provide a useful resource to other researchers and research managers tasked with delivering physical activity/applied research trials in a ‘post covid’ environment.The structured approach to the redesign of this clinical trial clearly highlights the advantage of having integrated and comprehensive patient and public involvement.Recommendations are being made based on the delivery of a small-scale feasibility study.The adaptations and implications identified may not be generalisable to all types of study design.The recent outbreak of COVID-19et alTo help plan and undertake clinical research in the current climate, a structured approach to the redesign of clinical trials is described by Karzai The Medidata group recently identified that data completeness and collection have been a key problem in the pandemicHere, we critically reflect on our approach to redesigning/amending a feasibility study of the impact of isometric exercise (IE) on arterial hypertension in otherwise healthy adults. This trial involved identification of people with stage 1 hypertension,et al suggested that nearly 500 000 fewer people were identified and treated for hypertension in mainland UK from March 2020 to 2021 compared with the previous year.We estimate that workload to deliver this project increased by >50% with the advent of COVID-19, for example, the Study Steering Committee needed to meet 3 monthly versus 6 monthly. The physical exercise nature of the trial also brought specific challenges for governance, safety and conduct, including evaluation of participant eligibility and informed consent along with the prescription of IE originally designed to be face-to-face. The study includes physiological measures of fidelity, for example, BP and heart rate (HR) responses to exercise, and remote monitoring systems needed to be developed for reliable collection of these data. By nature, exercise interventions require ongoing participant motivationWe aim to identify the challenges of patient and public involvement, recruitment, consent, follow-up, intervention aspects and primary care staff delivery of a feasibility study of exercise during the COVID-19 pandemic.Study delivery has benefited from lay members of the project management group, which allowed an integrated approach to redesign. Their previous experience and insight have been invaluable when commenting on important issues, offering a patient perspective to all elements of the redesign including: patient access to technology, use of personal protective equipment (PPE), optimising reminder texts (to mitigate attrition) and improving the participant documents and resources. As acknowledged by the NIHR,The considerable time delays caused by COVID-19 restrictions along with the numerous amendments contributed to the significant increase in workload for the research team; arguably this disproportionately impacts on lay members whose continued involvement is no longer commensurate with initial commitment expectations. Interestingly, similar difficulties have resulted in many COVID-19 trials sacrificing valuable PPIE to meet time constraint pressures.As a result of COVID-19 restrictions, alterations had to be made to the study protocol, along with ethical amendments and this inevitably introduced significant delay to delivery of the study.As a result of social distancing guidelines, participants were asked to carry out home BP readings with the investigator via video call. This was to ensure accurate home BP measurements according to National Institute for Health and Care Excellence guidelines.Due to reduced face-to-face contact with participants, it was necessary to develop a remote reminder system to mitigate increased risk of drop out. The sending of the messages was completely automated and made use of an SMS API provided by a large provider, with this system now reusable for future studies.The pandemic made recruitment more challenging for several reasons including a reduction of patients identified with stage 1 hypertension on GP records, reduced access to GP administrative staff and less provision of research active staff in primary care.et al,Searches of GP records yielded considerably fewer patients than pilot work had indicated. This is primarily attributed to: reduced attendances at GP clinics, suspension of routine health checks , reduced recording of hypertension in primary care  and lack of repeat attendance for suspected hypertension. This hypothesis is supported by the findings of Dale As a result of persistent difficulties with recruiting in primary care, the study was approved for delivery in all NHS settings with additional direct to patient advertising. This targeted potential participants geographically via Facebook social media within reasonable travel distance of a research site. In addition, those displaying interest in subjects that may predispose them to being attracted to the study were targeted. Users seeing the advert could click through to a prescreening survey to find out whether they were eligible to take part in the study and register their details.The requirement to reduce face-to-face contact with participants meant that, although consent remained a requirement, this process had to be managed virtually with the HCP on the video call and participants completing and signing an online form. In line with the drive for research to be enabled by digital tools,The IE intervention used is a wall squat  protocolTo accurately prescribe an individual specific wall squat angle, participants must complete at least three-stages of a five-stage incremental IE test (IIET).The IIET stayed the same apart from the time delay of having to establish the status of the exercise type as non-aerosol generating; expert consensus from the Physiological Society was not available until 20 May 2020.It was originally planned to recruit 2–4 primary care sites in the Southeast based on feasibility searches performed before the pandemic. Between November 2019 and February 2020, one site had committed in principle as a research site. The onset of COVID-19 and unprecedented demands on the NHS, in particular, primary care, led to initial difficulties in identifying principal investigators at prospective sites due to uncertainty of workload. Identification of appropriate HCPs with the capacity to deliver the intervention was already a challenge. This was exacerbated by the fact that GP principal investigators were focused on the COVID-19 response and, later, COVID-19 intervention studies and vaccination.The Future of UK Clinical Research Delivery.Embedding clinical research in the NHS is a key theme in the vision of Delivery of clinical trials in a safe and reliable way has always been complex, requiring good governance and ethical frameworks as well as robust infrastructure. While there are many randomised controlled trials of exercise either published or planned, their use is more limited than conventional trials of medicinal products. In addition, there are barriers to the prescription of exercise by HCPs. These issues became more acute during the COVID-19 pandemic where, quite reasonably, trials directed at intervention in COVID-19 were prioritised.We have discussed several predictable hurdles the pandemic created for recruitment to a feasibility study of IE. Other unexpected problems have also arisen, such as a significant reduction in the number of people identified with stage 1 hypertension. Ironically, the pandemic presented opportunities such as unprecedented speed and fluidity of change to the study approach. Remote consent and screening of patients, automated reminders and video validation of BP technique were all developed, approved and tested more rapidly as a result of necessity. However, this impacted directly on our original commitment to ensure equality of access due to the associated IT requirements and level of IT literacy required to engage remotely, for example, need for webcams, two screens open, etc. Overall, a willingness to constantly reflect and respond with protocol changes is essential in the current climate.Since we were unable to identify eligible patients through primary care, we sought and gained approval for direct marketing of the study resulting in a tremendous response , indicating public willingness and enthusiasm for this type of research. Central databases, opt-in to research and direct marketing (where appropriate), are likely to be much more effective methods for future study recruitment.Finally, it may be worth considering a consensus statement from leaders in the field of exercise research to find common ways to enhance recruitment to trials of exercise to augment current clinical practice.In closing, while this study is still ongoing due to the delays caused by COVID-19, it is evident that we would not have been able to achieve our recruitment targets and the necessary data collection without successfully implementing the changes discussed.


Assess whether the spine surgical approach for degenerative diseases can influence the physical capacity of patients and its correlation with cardiorespiratory function.A prospective study was conducted on 9 patients of both genders, aged between eighteen and sixty, scheduled for spinal surgery for degenerative disease in the lumbar segment. Patients underwent treadmill stress test two times, fifteen days before and sixty days after the surgery. A cardiologist performed the test according to the Bruce protocol with a progressive increase in incline and speed.There were no statistically significant differences between pre- and postoperative assessments for the parameters evaluated in the treadmill stress test. Forty-four percent of patients needed to interrupt the test postoperatively due to dyspnea (p=0.023).Level of Evidence II; Lesser quality RCT .The improvement obtained with spinal surgery does not have statistically significant relevance in tiredness, pain, and fatigue in the lower limbs and low back pain. Some patients could not complete the examination after surgery due to poor physical conditioning, and it was necessary to interrupt the examination due to dyspnea.  Low back pain is considered chronic if lasts longer than six months. It is estimated that 70 to 85% of the world's population will experience back pain at some point in their lives. In Brazil about ten million of Brazilians suffer with disabilities caused by low back pain, which is considered a public health problem. LBP can be caused by several factors, such as inflammation, muscle weakness and degenerative diseases. Disc degeneration is related to environmental effects, injuries caused by trauma, smoking, atherosclerosis and the natural aging. The lumbar spine is divided according to its functional capacity; in anterior, middle, and posterior. The anterior portion of spine is made up of the intervertebral discs and vertebral bodies. The middle portion consists of the spinal canal and pedicles. The posterior portion is responsible for directing the functional units in the movements of anterior/lateral flexion, extension and rotation. The intervertebral disc works as a hydraulic system, absorbing shock and distributing the load evenly. Thus, the amount of water in its composition it is proportional to its absorption capacity. Interverterbal disc collagen production occurs in three phases: the initial one, where there is abundant collagen production; the maturation phase, which maintains collagen renewal; and, finally, the degenerative phase, where there is a decrease in renewal. As it is an avascular structure, the nutrition of the disc occurs by diffusion. Anatomically described, the soluble regulators of cell function indicate the aging and senescence of the disc - which consists of a nucleus pulposus surrounded by an annulus fibrosus. The nucleus pulposus acts allows the vertebral disc to withstand forces of compression and torsion, permitting the liquid exchange between capillaries and vertebral discs and the axis of vertical movement between two vertebrae. The fibrous annulus, on the other hand, participates in the stabilization and movement of the vertebral bodies and loads dampening. However, with aging, its biomechanical efficiency starts to decrease due to dehydration. The nucleus pulposus progressively loses its capacity to hold water and the annulus fibrosus begins to lose its elasticity, demonstrating the degradation of the nutrition mechanism and then resulting in disc degeneration. New studies show that the main factors influencing healthy and degenerated intervertebral disc are: mechanical load, genetic influences, diffusion of nutrients and oxygen through the intervertebral disc matrix.The search for chronic low back pain treatment is growing. In this study, we sought to assess the physical capacity of patients undergoing surgical treatment of the spine through the treadmill stress test. In addition to diagnosing cardiovascular diseases, the treadmill stress test also determines prognosis and assesses therapeutic responses to exercise tolerance, in addition to being a test considered to be of low risk. The patient is submitted to a programmed physical effort, which allows the assessment of their clinical, electrocardiographic, hemodynamic, metabolic, autonomic and ventilatory responses. The test will enable the evaluation of the therapeutic interventions results and the patient's actual physical conditions.The treatment of chronic low back pain, among its many causes, includes several therapeutic options, from conservative treatment to surgical intervention.The aim of this study was to assess whether the spine surgical approach for degenerative diseases can influence the physical capacity of patients, correlating it with cardiorespiratory function.This study was approved by the research ethics committee and (number 2.904.787/2018) was carried out in accordance with the 1995 Declaration of Helsinki in the period from May 2019 to May 2020. Nine patients of both genders, aged between eighteen and sixty years, scheduled for spinal surgery for degenerative disease in the lumbar segment were included.Patients with neuromuscular diseases, history of cardiovascular diseases, spine fractures, any sequelae on spine, pelvis and lower limbs diseases were excluded due to limitations in performing the treadmill stress test.A prospective study was carried out, with qualitative and quantitative data collection. Patients were submitted to the exercise test in two moments, which would be done fifteen days before the surgical procedure and sixty days after the surgery. For this purpose, a treadmill was used for thirty minutes, and vital signs such as blood pressure, respiratory and heart rate were measured.The test was performed by a cardiologist according to the Bruce protocol with a progressive increment in inclination and speed, to assess functional capacity.Data collection began after approval by the Research Ethics Committee and the signing of the free and informed consent form by the volunteers.A significance level of 0.05 (5%) was defined for this work. We chose to use non-parametric tests, as the dataset has a low sampling. Pre and post operative tests were compared using the Wilcoxon test, as the data are paired.Nine patients were included, 6 females and 3 males. The minimum age was 18 years and the maximum age was 62 years with an average of 45 years.All patients included had the degenerative condition of the lumbar spine as their underlying disease, and all underwent spinal arthrodesis with instrumentation of up to 3 levels.When evaluating the associated comorbidities, we considered as obesity patients those with a body mass index (BMI) above 35 and overweight BMI ranging from 28 to 34.9. The distribution of comorbidities was presented in When we analyzed the reason for the interruption of the test , we obse16,17,18 There was no difference regarding gender distribution, even with the prevalence of female with 66.7% and male with 33.3% . This prevalence of female gender was found in several literature review papers for chronic low back pain. The obesity was the most recurrent comorbidity in this study, with 44.4%, and it may be one of the variables with the most interference in the postoperative evaluation. Patients had an increase in body weight, which may be due to improved pain, mood, and reduced use of oral medications, which could lead to an improvement in gastrointestinal feelings. In several papers, obesity has been listed as an important factor in etiology and pain. One of these studies was carried out with an epidemiological profile of Brazil.This study evaluated the surgical approach in the treatment of degenerative disease of the spine, with a treadmill stress test performed in the preoperative and postoperative periods (3-month). The mean age of patients was 44.6 years, with a low variability, keeping the data homogeneous and in accordance with the previous literature.In the comparison pre and postoperative for the treadmill stress tests, our aim was to evaluate the patient's physiological changes after the surgery improvement in the low back pain and the limitation it could be causing. However, it was not significant between these two moments. No previous similar study was found in literature. The moments (pre- and postoperative) and the reasons of treadmill stress test interruption were evaluated. It was found that there is a statistical difference between the moments for the distribution of dyspnea, where the percentage raised from 0.0% in the preoperative period (p = 0.023) to more than 44% in the postoperative period, which led us to think that even with the improvement in pain and functional limitation, obesity may influence the dyspnea, since even some patients being smokers or former smokers, they did not present preoperative dyspnea. We did not find papers to make a comparison with the data obtained in our study.This study presents us with some questions and directs us to new variables to be observed in the surgical treatment of the spine, emphasizing the importance of metabolic disorders and obesity, for example, not only as triggering factors, but also as harmful factors in the intra and postoperative. Relevant information was given to patients, such as problems encountered in the postoperative period. Aiming to improve clinical conditions and quality of life, trained multidisciplinary professionals such as nutritionists, psychologists and physiotherapists were suggested. We can also think that dyspnea may not have been observed, as the mechanical disorder of chronic low back pain would not allow this patient to make great efforts, which may not allow an activity that would cause dyspnea. The removal of this factor associated with the time of postoperative convalescence could add another factor not analyzed. Perhaps the need for earlier and more intense rehabilitation after surgery, after removing the mechanical factor, could be the best option to improve this limiting clinical condition. Some limitations of our study must be presented – small sample and short follow-up - however, it could provide us with new possibilities for study, leading to future research.Improvement achieved with spinal surgery does not have a statistically significant in tiredness, pain, and fatigue in the lower limbs in patients with chronic low back pain.Regarding patients who were not able to complete the treadmill stress test due to physical limitations after surgery, this probably occur due to poor physical conditioning, being necessary to interrupt the test due to dyspnea.


The population consisted of 41 nursing professionals, with 31 observations being made before and after the intervention. Analyzes were performed using descriptive statistics and the McNemar non-parametric test. A significance level of 5% was adopted.after the intervention, there was an increase in compliance with prevention practices of surgical antisepsis and professional hand hygiene, skin antisepsis with chlorhexidine, waiting for the time of the effect of alcoholic chlorhexidine and compliance with the sterile technique.the educational intervention showed an effect on increasing compliance with catheter-associated infection prevention practices. Knowledge about infection prevention is of paramount importance, as the growing infectious dissemination in bloodstream can lead to high costs in patient care, increased length of hospital stay and a higher morbidity and mortality rate-2.The involvement of healthcare-associated infections (HAI) and nosocomial bacteremia in newborns are directly associated with mechanical ventilation duration, birth weight and the need to use devices for the survival of these children, such as central venous catheter (CVC). The insertion of this device is carried out by trained doctors and nurses, and the nurse in charge is responsible for training the nursing team in relation to device care. It is also noteworthy that PICC insertions in the Neonatal Intensive Care Unit (NICU) are mostly performed by nurses and it is up to these professionals to comply with the guidelines regarding their handling as well as to recognize early signs and symptoms related to mechanical, thrombotic and infectious complications.Among intravenous devices, peripherally inserted central catheters (PICC) are most commonly used to ensure durability of central venous access and can be inserted at the bedside by trained professionals. Complications involving infectious phlebitis, catheter obstructions, bleeding, among others, can occur, and the longer the device remains, the greater the chances of acquiring HAIs. Thus, direct care with device preservation and weighting are necessary.PICCs are used for newborns (NB) who need administration of antibiotic therapy, infusion of hyperosmolar solutions or solutions with non-physiological pH for 6 or more days-8. Descriptive study with a quantitative approach, which contemplated the density of CVC-BSI in Brazil, showed that, from 2015 to 2019, there was an increase in infections of this nature, which represented an average of 7.55 infections per 1,000 catheter-days. While in Europe, the incidence rates of sepsis associated with CVC accounted for 20% of this type of event and have a mortality rate of around 30%. In the United States, an average of 250,000 CVC-BSI notifications occur per year, a mortality rate of 25% and treatment costs reaching up to 60,000 dollars for each event.Studies warn that CVC use has increased rates of central venous catheter-associated bloodstream infection (CVC-BSI) in NICUs. Among them, the Guidelines for the Prevention of Intravascular Catheter-Related Infections recommended using the bundle, which consists of a set of care for certain risk situations, such as actions that prevent adverse events (AE) arising from using devices invasive. The care recommended by PICC insertion and maintenance bundles are: hand hygiene; hub disinfection before being accessed; maximum barrier precautions; hygiene techniques when changing dressings; insertion site selection using aseptic techniques with chlorhexidine; waiting for the action time of chlorhexidine; and daily assessment of the need for the PICC to remain.In order to avoid CVC-BSI, preventive measures have been proposed worldwide. A study that analyzed bundle care showed a reduction in AE from 32% to 19.6% and from 37.3% to 15.2% in low birth weight NBs. Thus, educational measures are able to reduce peripherally inserted CVC-BSI, however they require that the elements that make up the bundle be fulfilled by all professionals involved.A study carried out in a NICU in Australia, which used the PICC care checklist (bundle), identified significant reductions between the pre-intervention and intervention groups. The numbers show a drop in rates from 8.8 per 1,000 catheter days to 4.9 per 1,000 catheter days,15.The development of protocols, guidelines and training aimed at preventing peripherally inserted CVC-BSI are essential to guide and qualify practice, however the theory is not always transposed into the NICU team’s daily work. However, until now there is a scarcity of studies that assess the effect of educational interventions based on clinical simulations on compliance with CVC-BSI prevention practices in neonatology, which is the focus of this study. The hypothesis of this study is that the educational intervention with clinical simulation use influences the increase in compliance with peripheral insertion CVC-BSI prevention practices by the nursing team in a NICU.The set of good practices provided for in CVC-BSI prevention bundle can be complied with by the health team through educational actions. Among them, we can mention clinical simulation use, which is a dynamic experiential learning strategy that meets the needs of professionals to improve in simulated real contexts, repeatable and that adds theoretical and practical aspects to its execution, offering security to those involvedThis study is justified by obtaining elements that can support more effective educational practices in the search for greater compliance with CVC-BSI prevention measures and, consequently, patient safety (PS) in NBs using PICCs.To assess the effect of an educational intervention based on clinical simulation on the compliance of nursing professionals with peripherally inserted CVC-BSI prevention practices in NICUs.Universidade Federal de Minas Gerais and the hospital involved. The Informed Consent Form was obtained from all individuals involved in the study in writing.The study was conducted in accordance with national and international ethics guidelines and approved by the Research Ethics Committee of the This is a quasi-experimental, preand post-intervention study with a single comparison group. The SQUIRE 2.0 instrument from the EQUATOR network was used to guide this methodology.Sistema Único de Saúde) patients, which provides comprehensive care for women and NBs, in Belo Horizonte, MG, Brazil.The setting consisted of a NICU with 25 beds in a teaching and research hospital, aimed at the Brazilian Health System  month after the end of the intervention.The professionals eligible for the study were nurses qualified to insert the PICC and nursing technicians at the NICU, who are responsible for maintaining the PICC.Nurses qualified for PICC insertion and day and night shift nursing technicians who were linked to the care of newborns using a PICC, with more than 6 months of experience in the NICU, were included. Professionals who, during the preor post-intervention observation, requested to interrupt their participation in the research or who had not participated in 100% of the intervention were excluded.Among the eligible professionals, the study sample consisted of 10 nurses who provide direct patient care and who have qualifications in PICC insertion and 31 nursing technicians from the NICU, totaling 41 professionals.The research protocol was applied in three moments: pre-intervention, intervention and after intervention.In the first phase of this study, the research proposal was presented to the target population and the risks, benefits, secrecy, voluntary participation and the Informed Consent Form (ICF) were explained. Of the total number of potential participants, six nursing technicians and two nurses refused to participate in the research. Furthermore, before starting data collection, all nursing professionals were invited to individual or group meetings so that the purpose and relevance of the study could be presented. At that moment, the ICF was signed.This phase consisted of collecting data on the participants and observing the practice of inserting and/or manipulating the PICC before the intervention.The variables listed to describe the characteristics of the nursing professionals responsible for inserting and/or handling the PICC were age, time passed since graduation, time working in the NICU, weekly workload and type of job.The variables related to infection prevention practices during PICC insertion before and after the intervention were: surgical antisepsis technique of the hands of the professional in charge of PICC during insertion; Personal Protective Equipment (PPE) use by the assistant (nursing technician); PPE use by the professionals in charge of PICC during insertion; skin antisepsis with 2% chlorhexidine degermant; rubbing chlorhexidine in alcoholic solution ≥ 0.5% for 30 seconds; waiting for the time of action of alcoholic chlorhexidine of 2 minutes; hand hygiene after insertion and whether there was a breach of sterile technique during catheter insertion.To assesss the practice of preventing infection during device maintenance, the following variables were used: hand hygiene before and after handling the catheter; antisepsis with 70% ethyl alcohol solution for at least 15 seconds before opening connections; checking the validity of venous line connections; and daily review of catheter need with immediate removal of unnecessary catheters.Direct observation of PICC insertion and handling procedures by nursing professionals was carried out from March to June 2019, with the aim of providing an analysis of the care practices developed during catheter insertion and handling. A type of instrument (checklist) based on the CVC-BSI prevention actions and on the bundle was used, comprising two parts: verification items during catheter insertion and items that should be observed during PICC handling. This instrument was assessed by 6 experts in the area of safety in neonatology and infection control before its use, with the need for minor adjustments regarding assessment description. The observations were made by previously trained researchers and occurred during the day and night until 9 pm.Agência Nacional de Vigilância Sanitária), previously read, followed by simulations, debriefing and clarification of doubts regarding care practices that would be observed.Direct observation was carried out by scientific initiation students known to the team, but who did not work in the service, in a natural way so that it did not influence the behavior patterns regarding the procedure. These students participated in a previous training where two researchers of the study, through discussions of CVC-BSI prevention measures manuals of the Center for Disease Control and Prevention, World Health Organization (WHO) and Brazilian National Health Regulatory Agency , with groups of 4 to 5 people, between September 30 and October 4, 2019. The coordinator divided the professionals into groups according to shift schedule and beds. During this period, the unit had an additional nursing professional on the scale to support care during training. The intervention took place in a room attached to the NICU and used a bed in a neonatal unit with all the relevant equipment in a controlled environment and with a low fidelity dummy which are static simulators, and simulated patients, which are actors trained to act and reproduce user behaviors in different situations and health care establishments. A case was presented of a NB admitted to the NICU who would need a PICC procedure and we would have to proceed with the insertion and handling of this device. In view of this, 2 nurses were chosen, voluntarily, to perform the insertion procedure, in addition to two other nursing technicians, to provide care during the device maintenance. After simulation, debriefing was carried out with the presence of a moderator and participants, redoing the correct action when necessary and emphasizing safe practices in PICC-related infection prevention. It is noteworthy that a checklist similar to the data collection instrument was used by a moderator to monitor participants’ practical performance.Participants’ observation period was 30 days after the educational intervention, from November 21, 2019 to February 28, 2020. The same instruments used to assess the practice of PICC insertion and handling procedures by nursing professionals in first stage were used in the period after the intervention by the same researchers.The information was transferred to an Excel spreadsheet and analyzed using the IBM Statistical Package for the Social Sciences (SPSS) program, version 20.0. Qualitative variables were described using absolute and relative sequences. For the numerical values and for the inferential analysis to verify the nursing team’s compliance with prevention measures in PICC insertion and handling before and after the educational intervention, McNemar’s non-parametric test was used according to the Shapiro-Wilk test application. A significance level of 5% was adopted. The checklist items or variables were marked by means of two alternatives, being “yes” when practice was performed correctly and “no” incorrectly.Of the 10 participating nurses, all were female; 72% were between 25 and 35 years old; 80% had graduated between 10 and 20 years ago; and 78% had worked in the NICU for more than 10 years. Of the 31 nursing technicians, all were female; 82% were between 25 and 35 years old; 84% had graduated between 5 and 15 years ago; and 80% with time working in the NICU between 10 and 15 years. The workload of most participants is 30 hours, and their type of employment was public servants.Comparing the percentage of compliance in relation to PICC infection prevention practices during the device insertion by nurses before and after the educational intervention, a significant increase in compliance was observed regarding the change in attitude regarding professionals’ antisepsis during insertion, skin antisepsis with chlorhexidine, waiting for alcoholic time, hand hygiene after insertion and if there was a break in the sterile technique .Regarding the percentages of compliance with the PICC infection prevention actions during the two moments of device maintenance by nursing technicians before and after the educational intervention, there was a significant increase in compliance regarding the change of attitude towards hygiene actions of hands before handling, antisepsis before opening connections and hand hygiene after handling .The present study had the objective of assessing the effect of an educational intervention based on clinical simulation principles in relation to the preventive actions of peripherally inserted CVC-BSI during the moments of insertion and maintenance of this device by the nursing team in the NICU. The results showed the positive effect of the educational intervention in relation to compliance with peripherally inserted CVC-BSI prevention practices by the nursing team in a NICU.. In the simulation environment, the professional has the opportunity to discover gaps in their knowledge, develop new cognitive foundations and improve their intervention skills. Moreover, using simulation improves knowledge about physiology, pathophysiology, diagnostic accuracy, treatment and team role.This study revealed that most prevention actions had an effect on compliance after the intervention. In this regard, a survey points out that using educational technologies in health training optimizes the educational process and method, in addition to increasing the acquisition of technical-scientific knowledge, resulting from professionals’ experiences, providing the health team with systematization and security in care. In addition, education is a key component of infection prevention efforts, encompassing lectures, videos and fact sheets with some hands-on opportunities. Using simulation has grown in the health area, and its applicability is a complement to traditional teaching methods in preventing infections, PS and reducing costs with incidents.Simulation-based training uses artificial representation of real-world processes to enable hands-on learning-21. It is believed that the results obtained contributed to the agreement of the nursing team in seeking alternatives in peripherally inserted CVC-BSI prevention, since NBs admitted to the NICU are susceptible to these infection.Considering the increase in compliance after the educational intervention observed in the results of this study, it can be said that it is consistent with other educational interventions based on infection prevention. Thus, educational intervention based on simulation is a way to improve the processes and outcomes of patient care. Some studies reinforce that using simulation in the health area promotes some benefits, as the ability of participants to develop opportunities to examine decisions to be made, promote communication and problem-solving skills, increase interest in building improvements, and make increased learning possible-21.As an estimate of preventive actions, the systematization of care provides strategies to minimize CVC-BSIPolítica Nacional de Educação Permanente em Saúde) provides for the execution of educational actions based on the reality of services that induce transformations in work processes and reflections on professional practice, through active methodologies, such as simulation. In this sense, the National League for Nursing also emphasizes that using the simulated scenario is an opportunity for practice, learning, assessment, testing or even to gain understanding of systems or human actions. Another study also shows that simulation can favor the development of psychomotor and social skills, communication, creativity, teamwork and collaboration, critical thinking and clinical learning.The institution of the Brazilian National Policy on Permanent Education in Health  has been prioritized by the WHO since 2004, as an important and recognized measure in the fight against HAIs. The results proved to be efficient regarding global HH compliance, obtaining a significant increase from 30.9% to 69.5% after intervention. Although this study worked with an adult population, the findings showed that offering educational actions, such as simulated scenarios, is effective in contributing to increased compliance with activities based on patient care.The data obtained in this study are also similar to those of a research that sought to assess HH compliance among health professionals in an Intensive Care Unit (ICU) before and after the educational intervention. The mean density of peripherally inserted CVC-BSI, which was 21.4 episodes/1,000 days of CVC, was reduced to 9.7 episodes/1,000 days of PICC. In Brazil, a quasi-experimental study, which used the training of professionals through training as an intervention strategy, reveals that the mean density of peripherally inserted CVC-BSI in the neonatal population was reduced by 31.03 episodes/1,000 PICC days to 2.9.One of the likely explanations for the improvement in nursing professionals’ compliance with CVC-BSI prevention actions, in this study, refers to the preparation methodologies and knowledge of the PICC technique during insertion and handling. Studies indicate that interventions carried out through the training of health professionals within multidisciplinary teams, for assistance to critical patients in NICUs in hospitals in developing countries, such as El Salvador, Mexico, Philippines and Tunisia, have proved to be effectiveThese findings converge with our results, which demonstrate that the simulated scenario also as an educational tool had an influence with regard to the possibilities of reducing the rates of peripherally inserted CVC-BSI, since professionals’ compliance with HH practices was satisfactory..It is known that all nursing professionals involved in inserting the PICC must use the maximum precautionary barrier, which consists of using a long-sleeved apron, gloves, an expanded sterile field, a mask covering the nose and mouth, and a cap, which must cover all the hair. An integrative literature review, which sought to highlight the main nursing care when handling invasive devices such as the PICC in an adult ICU, showed that only 33% of 18 studies analyzed mentioned PPE use during the procedure. Despite this finding, most available evidence considers this intervention to be important, as it reduces microbiological contamination of the central catheter insertion site and, therefore, the risk of bloodstream infection.The inappropriate use of elements that make up PPE could be a harbinger of cross-infection, increased unnecessary costs for the health institution and, as a consequence, the decrease in HHGiven the above, the results showed that PPE use by assistants and professionals during insertion is consolidated among professionals, not interfering with the results before and after the intervention. The fact that the rates of compliance with PPE use did not show changes is justified by the veracity of the Hospital Infection Control Service (HICS) team of the study unit already developing in-service education actions as well as the monitoring and dissemination (feedbacks) of health professionals’ compliance with various PS components. Although the responses to this variable have not been modified, it is important to emphasize that the continuity of reinforcement actions regarding PPE use in favor of reducing peripherally inserted CVC-BSI must be maintained.. Its action is effective against Gram-positive and Gram-negative microorganisms, yeasts and some viruses, even in the presence of organic substances on the skin. In addition, it has an important residual action that prolongs its suppressive activity against microorganisms.Another important point refers to the antisepsis of the site to be punctured with 2% degerming chlorhexidine, followed by alcohol ≥ 0.5%, for 30 seconds, performed through unidirectional movements. This technique is an important measure to reduce the risk of peripherally inserted CVC-BSI, since alcoholic chlorhexidine is more effective in reducing the rates of microbial colonization on NB’s skin when compared to other antiseptics. Adequate skin preparation with using alcoholic chlorhexidine ≥ 0.5% for 30 seconds, performed through unidirectional movements, ensures the effectiveness and safety of PICC insertion site preparation and maintenance. In this sense, ANVISA recommends that, before proceeding with the puncture, one should wait for the time of action of alcoholic chlorhexidine. Using this theoretical framework in the intervention allowed us to verify that, in relation to our study, in the pre-intervention period, only 3.2% of professionals waited for the product to dry on the patient’s skin before inserting the catheter. Above all, after the educational action, there was a significant increase of 74.2% in nursing professionals’ compliance, demonstrating that the study obtained influence and safety for health professionals’ compliance in the PICC insertion site preparation and maintenance. This is reflected in the action taken by the simulated scenario, in which professionals were able to learn and practice correctly when performing the antisepsis of the site to be punctured.Applying skin preparation with alcoholic chlorhexidine for asepsis is part of the bundle of measures aimed at installing and maintaining the PICC. The inappropriate use of alcoholic chlorhexidine was 37.3%, and 27.1% of procedures had contamination. This mentioned study also converges with a descriptive American study, which showed that 22 (41.5%) who used chlorhexidine gluconate inappropriately resulted in the occurrence of burns (54.5%), redness (2.9%), dermatitis (4.5%) and other skin irritations (31.8%).One of the aspects that it was possible to perceive so that nursing professionals’ acceptance in relation to the adequate chlorhexidine use and the recommended waiting time would obtain better results, the emphasis that the incorrect use of antisepsis of the site to be punctured can lead to AE with regard to the premature skin, when the educational action through simulation took place. Thus, this emphasis is consistent, considering that a Brazilian study, which verified compliance with the PICC insertion bundle in neonatal and pediatric units, showed that, among the sample of 31 (52.5%) insertions performed, there was a technical error during degermation on patients’ skin.It is expressed that the ideal care at the time of insertion are essential measures in PICC-related infection prevention. However, risks are still present during the device’s permanence time, since the central lines at the time of catheter handling can be accessed 30 to 50 times during the day. When there is a suspicion of bloodstream infection, early PICC removal is performed through needleless connectors (NC). Its operation occurs through coupling to the catheter’s hub (cannon), where drug administration, solution infusions, blood sample withdrawal and connection of infusion equipment are performed. Infections are correlated with the presence of microorganisms on the tip of the catheter and in blood culture. A randomized clinical trial with 300 NC demonstrated that 51% of devices were contaminated by microorganisms from patients’ skin. A study published by the Royal College of Nursing showed reductions in infection rates due to using bundles as a focus to prevent infections when handling catheters. Actions such as HH, aseptic technique before opening catheter connections, changing the dressing and checking the catheter and rubbing the hub before handling the devices were performed. This reference reinforces the actions used at the time of simulation, which contributed to nursing technicians’ compliance with this practice, being 83.9% after the intervention. Likewise, the practice used shows that the need for training of the health team that performs PICC insertion, maintenance and removal can be fundamental to reduce the risks of AE for patients.With regard to catheter handling, ANVISA recommends that professionals who manipulate the device have specific qualifications and training, aiming at the safety of the care process. During routine handlings, it is considered a barrier strategy against the colonization of microorganisms, given that the opening of connections constitutes a gateway to the infusion circuit. For this reason, research considers catheter hub colonization to be the main cause of 50% of catheter-related infections after catheter insertion.This fact is in line with a descriptive study with a quantitative approach, of the systematic observation type, which aimed to identify the care strategies adopted by nursing professionals in PICC handling in children and NB. It mentions that rigorous rubbing for 5-15 seconds with 70% ethyl alcohol provides a significant reduction in PICC-related infectionsIn short, it was noticed that the simulated scenario as an educational tool helps in the compliance of health professionals responsible for PICC insertion. Furthermore, it enables the process of learning and practicing the knowledge applied to device insertion and handling techniques..Through responses to compliance with intervention practices, the continuity of professional training and permanent education of the nursing team in the NICU is essential. In this way, the risks are minimized, NB safety is guaranteed and the assistance is qualifiedThe main limitations of this study include the fact that the research was carried out in only one public institution, restricting the extrapolation or comparison of results. Also noteworthy is the reduced number of observations, since the research time was limited, thus not allowing to analyze the effect of the intervention in the long term. Therefore, what is recommended is that future studies investigate the long-term effect of the educational action on compliance with peripherally inserted CVC-BSI prevention measures, in order to monitor the sustainability of nursing team’s changes in behavior and attitudes.The findings of this study indicate that educational intervention based on simulation can help health professionals and teachers to rethink teaching strategies aimed at compliance at satisfactory levels to infection prevention measures related to the PICC. In addition, the results of this study favor evidence for clinical practice, which can help in the translation of knowledge, as it is a replicable educational strategy, in addition to encouraging researchers and professionals to develop research on this topic, especially in neonatal units, in search of a safer practice for patients.This study provided evidence that the educational intervention based on simulation positively influences nursing professionals’ compliance with peripherally inserted CVC-BSI prevention actions, both in the device insertion and maintenance. Moreover, it contributes to the dissemination of knowledge through using educational strategies that may favor scientific evidence use in clinical practice by the nursing team, in search of a more qualified and safe care.