Concerns about the management of COVID-19 cases

While front-line healthcare providers and senior management expressed their determination to offer services in these challenging times to manage COVID-19 patients, various concerns related to the treatment and management of COVID-19 cases were articulated. Dialogues with hospital senior management representatives indicated that standard operating procedures (SOPs) have been designed to manage COVID-19 cases, however, few front-line care providers believed that the presence of SOPs is fairly ambiguous. Expressing similar concerns, a pharmacist stated:

I have concerns about how to deal with patients …We need a clear procedure for dealing with them. For example, when someone comes into the pharmacy, what procedures are we meant to follow (IDI-08, Pharmacist).

During interviews, an insight into the initial practices of managing the COVID-19 crisis was also probed. Senior hospital management mentioned that the hospital was fully prepared to manage this public health emergency since its epidemic in China. Contrary to this, front-line physicians and nurses verbalised glimpses of an ad hoc management of outpatient hospital areas for COVID-19 screening and testing, during the early phase of the pandemic. Furthermore, on one hand, senior management generally exhibited their satisfaction over the availability and provision of PPEs to front-line healthcare providers. While on the other hand, shortages of PPEs were notified by few healthcare providers, alongside sanitisers while providing care to the patients.

Sometimes we face a shortage of sanitizers and other essential PPEs such as masks. I think that all the PPEs should be available at all times so that we are not worried. Sometimes doctors ask us to bring them an N95 mask and we are unable to do so because we do not have any (IDI-02, Nurse)

Although respondents appreciated the availability of negative pressure rooms during the COVID-19 pandemic, concerns about the limited capacity of the hospital were verbalised for the efficient and timely management of COVID-19 cases. Few hospital staff reported that they experienced violent behaviour by the family in case of refusal to admit new patients.

Fear of acquiring infection and transmitting to family members

Due to the highly contagious nature of the coronavirus (SARS-CoV-2) and perceived uncertainty in contracting the disease, interviews with physicians and nurses revealed their apprehension in acquiring the virus while treating patients. The front-line workers face a unique mental health challenge and several respondents experienced feeling guilty about potentially carrying the virus to their families. Highlighting this point, one respondent stated:

It is a stressful situation. By the end of the day when I am taking a break, I have many negative thoughts. I worry about carrying this infection to my family…I have a young daughter at home and nearly every day I worry about being asymptomatic and carrying this infection to my family (IDI-07, Doctor).

The increased likelihood of contracting COVID-19 is also psychologically affecting the senior management team across the hospital. Due to their exposure; their family members are also at risk of acquiring the infection.

I work in the emergency department so I always have a fear that the next patient I see will need serious treatment and I may have to resuscitate him/her. But now, I always have a fear that the next patient will be Covid-19 positive and that they may infect me. And if I get infected my family will get infected. So, this fear is a little bit different and it will last till the pandemic last (IDI-12, Doctor)

While verbalising the concerns about the healthcare providers' exposure in getting infected, respondents also voiced their concerns that front line staff is at high risk of getting infected even in non-COVID-19 areas across the hospital setting.

Overwhelmed and exhausted by the workload and exhaustive donning and doffing process

To protect front-line workers against COVID-19, the infection control policy at AKUH mandates that all staff working in areas where COVID-19 patients are suspected wear a full sleeve impervious gown, gloves, and an N95 mask. While this policy is no doubt effective and in line with the best interest of the front-line workers, it poses several challenges. For instance, our interviews revealed that several participants found the N95 mask suffocating to wear for a prolonged period of time. Commenting on the experience of wearing full PPE one front-line worker stated:

We…get tired of wearing full PPE because we have to be in the room with the patient for four hours. It gets really hot and the extra layers of protection weigh heavy on the body (IDI-11, Nurse).

Moreover, another respondent highlighted how the process of using PPE is complicated when staff is required to visit one patient to another. This occurs because the staff has to meticulously switch in and out of PPEs. Therefore, what was initially a mundane process has now become a critical aspect of infection control. This point was illustrated by a respondent who stated:

It takes around 5–7 min to put on our PPEs. We then go to the patient’s room… come back and spend the same amount of time to switch our PPEs before going to the next patient’s room. This process is a big hassle and is time-consuming. But we have to be extra careful, if this procedure is not done properly, we can pass on the infection (IDI-07, Doctor).

While this process is no doubt challenging, one respondent offered an encouraging remark stating:

Initially we felt that our workload has increased, however, with the passage of time we have become used to it and things feel normal (IDI-16, Nurse).

The stigma associated with healthcare providers working in COVID-19 wards

COVID-19 is primarily transmitted from symptomatic people to others through direct contact, or by contact with contaminated objects and surfaces. Moreover, a large portion of those infected is asymptomatic, meaning they show no overt markers of the infection. As a result of this, front-line workers face a unique mental health challenge. Since they work in high-risk environments many opt to hide details about their work-life in fear of being stigmatised by their communities.

I know that in some cases health care workers do not tell their families and communities that they are working with Covid-19 patients. They fear that this will cause unnecessary panic and people may view them differently (KII-19, Associate Professor).

It is likely that this anxiety within the families and communities of healthcare workers is propagated by the ambiguity of information available on COVID-19. It is possible that the hospital may address many of these issues by extending its outreach services. During the interviews, a front-line worker was critical of the hospital’s current outreach services:

Our services should be extended to the community. Compared to other institutions we have not done enough. Many people have criticized us in this pandemic (IDI-08, Pharmacist).

By providing more extensive services to surrounding communities, the hospital could not only alleviate the stigma faced by front-line workers but also reduce the surge of false information.

A safe and secured hospital environment

Many respondents stated that the hospital has provided a safe environment for employees and that safety measures have been improved as the hospital administration became more knowledgeable about the nature of this disease. One respondent stated the hospital’s disaster management and incident command system were ensuring adequate training and smooth communication throughout the hospital.

When the number of cases started increasing, the hospital enacted the Hospital Incident Command System, leaders from each of the different areas that is, logistics, communications, medicine, etc came together to make sure that everything was in place-. The hospital has now made smaller groups which meet regularly to go over each of the issues and an executive Operations Command Committee goes over what should be done. (KII-19, Associate Professor)

While provisions are made for the availability of PPE for the staff, many noted that implementation of proper usage of PPE and adequate hand hygiene is still a problem that requires behavioural change. It was also stated that healthcare providers that are considered vulnerable (ie, elderly and/or have serious pre-existing conditions) are not allowed to work in the COVID-19 established areas.

While several precautions are being taken, one respondent claimed that there were many places for improvement. One stated that it is complacent to feel good about any sense of safety and security and that it is important to remain vigilant in the case of new information about the disease or a high influx of patients.

There are several places where things can slip through the cracks, and cause problems, and there are several points that will fail if they come under pressure- I am not absolutely confident, but it is good so far. (KII- 16, Professor)

Adequate training and drills for dealing with COVID-19 cases

When questioned about training and drills, most respondents stated that everyone who is working for COVID-19 is trained in the usage of PPE, N95 mask, donning and doffing, and taking test samples using nasopharyngeal swabs. Many also said that regular training was being carried out on the job and at the CIME, and that master trainers were being trained to then disseminate information and train the rest of the department. Covinars (COVID-19 Webinar) sessions are being conducted to help train and provide information about the disease.

We have completed 2-day training workshops or seminars and get trained every day in new technologies and when new guidelines come (IDI-02, Nurse)

However, some specialists were concerned that very little had been done in the way of training; it was noted that besides guidance on the N95 mask fitting test, there were no opportunities to go through any drills. While communications were being carried out, it was not considered sufficient. Others said that while training were being conducted, they were not very regular. While they stated that this may be because of the social distancing measures, they insisted on more regular online training.

The strong hospital system of information sharing during the COVID-19 crisis

While the outbreak of COVID-19 has put immense pressure and stress on the hospital staff, many facilitators support the hospital staff to deal with the pandemic. Respondents stated that information was being shared through video messages and that helplines and hotlines for staff and the public were effective in screening for COVID-19 symptoms. While many stated that information sharing was difficult at first, it was claimed that this was due to the changing information coming about the disease from international agencies It was reported that the hospital leadership holds weekly meetings with senior management, who then circulate that within their respective departments.

I think we have a reasonably good system built for disaster and we have a very defined chair of command… There have been different working groups formed for Covid-19 and they all have specialized tasks for information sharing, and there is a Covid-19 hotline for employees and the public and that is adequate. (KII-16, Professor)

In addition, university-wide town hall meetings were held regularly. It was suggested that more town halls should be carried out and that regular memos should be sent with information about caring for those with the disease.

Town halls boosted the morale of the health care providers, and this communication was very good. (KII-3, Professor)

Supportive management and leadership

Most IDI participants mentioned that senior management and institutional leadership is providing immense support by ensuring appropriate PPE in the COVID-19 and non-COVID-19 wards to ensure the safety of front-line healthcare providers. In addition, few participants mentioned that the institutional leadership regularly visits COVID-19 units for staff appreciation and encouragement. Besides, the senior management responds to healthcare providers’ concerns in a timely manner through a WhatsApp group.

Initially, we were supposed to remain inside the patient room consecutively for 4 hours. This was very exhausting for bedside nurses especially since we have to wear three layers of PPE. We raised these concerns and senior management has now permitted us to exit the room when the patient’s condition gets stable … we now observe the patients from the mirrored door. This has given us a huge relief (IDI-11, Nurse)

While front-line providers appreciated the support received from management and institutional leadership, they also recognised the efforts of all other support departments who are working together for the safety of front-line hospital staff. These support departments include finance, design office, construction, laundry, purchase and supply chain management, safety and security, human resource, information, and technology department, nutrition and food services, marketing and communications, travel services, etc.

All the support departments are contributing in the same manner as our frontline healthcare providers (KII-01, Professor)

In addition, the few IDI participants mentioned that institutional leadership has arranged accommodation facilities for the front-line staff who are working in COVID-19 wards but the hospital staff is not availing those services because they have their families and children back home. Few respondents further stated that the senior management has also ensured the provision of shower facilities for the front-line hospital staff; however, due to time limitations, nurses are unable to make effective use of those facilities.

Prepare and train backup health workforce

Both IDI and KII participants mentioned that they have been experiencing staff shortages in COVID-19 wards because many of the front-line healthcare providers have been either quarantined or isolated due to exposure. When asked about recommendations to support the front-line health workforce, most IDI respondents suggested that healthcare providers (doctors and nurses) of other sub-specialties (neurology, cardiac, surgery, orthopaedic) need to be trained as a backup to mitigate situations when entire internal medicine teams may be placed in self-quarantine due to COVID-19 exposure. In addition, a few key informants recommended that there should be a central backup plan for staff coverage in both COVID-19 and routine wards.

Currently, only the healthcare providers of Covid-19 wards have received specialized training on ventilator code, BIPAP management, and handling body of expired Covid-19 patient. However, these training should be given to all healthcare staff across the institution to prepare a central backup. (IDI-03, Nurse)

Ensuring motivation for front-line health workforce

To ensure enthusiasm among front liners, study respondents highlighted the need of appreciating and motivating front-line providers for their countless efforts in this pandemic battle.

Most IDIs including front-line nurses suggested that risk allowance should be given to all front-line healthcare providers involved in the treatment and management of COVID-19 patients. Healthcare providers suggested that instead of giving extra time off, hospital staff should be compensated for taking additional risks while caring for COVID-19 cases.

As you know the world is very materialistic and people always need motivation. While we are being encouraged by senior management, this form of verbal motivation will only work for a time period. If the current situation is going to go on, we will need to give people an added incentive in the form of material compensation. This can either be more money or additional days off (IDI-04, Nurse).

In addition, respondents verbalised that some activities for staff entertainment should also be thought-about to alleviate stress and anxiety associated with this crisis situation among healthcare providers.

Anticipate and address the mental health needs of the health workforce

IDI and KII respondents mentioned that there is no formal platform established where front liners' voices are being heard. Such a platform could provide an opportunity to anticipate and address the mental health needs of the front-line health workforce.

Everyone is very stressed. I see it every time one of my staff has to take care of a suspected patient, they are hesitant and scared. Sometimes, I feel the same way myself. We need an integrated counseling program. People should not just come for counseling when they are mentally struggling. Similar to how we have guidelines for PPE and social distancing we should have small group talks on ZOOM so that we can dispel our anxieties before they build up (KII 06, Associate Professor).

Few study participants particularly KIs appreciated the motivation sessions organised by psychiatric fellows on stress and coping. However, study respondents highlighted the need of arranging more psychiatric sessions for healthcare staff on a daily basis to cope with the stress. More specifically, participants stated that currently there is a blanket approach around mental health; however, more is needed to address varied concerns of the health workforce.

There was a zoom session arranged on stress management, but I was unable to attend it due to my duties. I think we need more of these sessions. We can even add more innovative things such as breathing exercises, mindfulness, and yoga. There is so much anxiety relating to Covid-19 both at work and in our homes. Everyone is so panicked and there is so much hype going around. These types of innovative sessions would really help (IDI-05, Doctor)