Theme 1. Minimise the spread of disease at all times.

Combatting the COVID-19 pandemic requires caring for patients who contract the virus, while adopting infection control policies and procedures to protect the healthcare professionals who are enabling and administering care.

1. 1(a) At the centre of staff concerns was the potential unavailability of PPE and uncertainties about the appropriate type and use of masks.

The contention around the mask … seemed to cause a lot of anxiety. (P11)

The introduction of a centralised and managed PPE stock addressed multiple problems including staff stockpiling on wards, expired stock and escalating demands on the clinical product personnel to meet individual needs.

…and I think that [centralisation] worked well. You just made sure that you got what you needed for the week. (P14)

1. 1(b) The pandemic resulted in some participants advocating for aspects of infection control to be accommodated alongside Work Health & Safety (WH&S) practices that would keep staff and their patients safe year-round.

When it comes to keeping staff safe, you need to have a WH&S mindset, not an infection control mindset … Infection control relies on behaviours … WH&S has a much more precautionary approach; it develops systems that, in my view, stop people from making mistakes. (P06)

Conscious of the importance of PPE, staff demands for training/refresher sessions in donning and doffing created heavy workloads for nurse educators and led to innovations to address demands. Personnel were needed to organise the extensive implementation, including venues and schedules.

Part of infection control is education … [through] Grand Rounds [also]… on-the-spot PPE training on the ward. Anyone new coming on had to have a competency [assessment] done, … a lot of education [occurred] with individual departments, like radiology, the cleaners, ICU … (P36)

1. 1(c) Equipping the COVID ward with a permanent nurse unit manager and staff eliminated the daily task of training nurses from a temporary pool, and reduced time pressures on clinicians as well as the anxiety of patients whose questions previously went unanswered at best. Permanent staffing fostered teamwork and increased competency, valued in a highly stressful environment.

And so, you train someone up, and they’ll be gone the next day, you train someone else up, and they’ll be gone the next day … The patients they were helping would ask them questions, and they wouldn’t know the answers. Sometimes they just make answers up. And that’s when the shortcuts get made… (P01)

1. 1(d) The social isolation of patients who were already experiencing limited physical contact was distressing for all involved. Staff described the moral dilemma as they struggled to abide by the ‘no visitor’ policy, particularly for patients who were at the end of their life. Acknowledging the unnatural caring situation, equipment and technology facilitated patient contact with family and loved ones. Staff struggled with, but appreciated, the need to limit visitor numbers.

Things like reducing visitor [numbers] and not allowing visitors … [entailed] big negotiation in the COVID ward. We were very firm about a lot of that stuff, no visitors, minimal people. (P03)

1. 1(e) Suitable physical infrastructure necessary for isolation such as reconstructing physical space to establish ‘hot zones’ for patients undergoing COVID testing was lacking initially. Challenges staff experienced in attempting to provide usual care included concerns about airborne transmission, the sanitising of equipment and staff’s restricted capacity while donned in full PPE.

It’s important that there are certain designated isolated areas for the different wards [for] patients who develop any symptoms which might be suspicious … cleaning equipment for the scanners if they need imaging, and the right workflows to ensure … imaging if needed. Having the right spaces to keep the patient so that clinicians and nursing staff feel comfortable treating them and reviewing them, examining them and providing plans and updates in person. (P07)

1. 1 (f) Throughout the pandemic, minimising the risk of airborne transmission has been a priority. Risky procedures such as the use of nebulisers and non-invasive ventilation were stopped, and alternative or new procedures were introduced.

Simple things, like the use of PPE, avoiding nebulisers, the process of intubating people, …non-invasive ventilation [NIV] have changed forever. The processes of cohorting people and risk stratifying at triage, that’s something that’s going to change forever. A lot of practice has changed … those changes will be permanent. (P31)

Theme 2. Maintain a sense of collegiality and promote informed decision-making.

Effective management enabling a quick pace of change across the facility, most consequential during the initial uncertainties such as virus-host interaction and length of period of transmissibility, was dependent on the leadership of and collaboration among staff and fit-for-purpose communication methods, channels and communicators. The majority of participants, including the Heads of Departments, spoke passionately about frequent and productive inter-department and department-executive interactions that permitted ‘on-tap’ problem solving for the continuation of a range of routine services employing innovative approaches. A critical facilitator was the creation of three hierarchical committees, one of which was the Clinical Expert Advisory Group (CEAG), which met as frequently as the situation required, daily or more often, and continues to meet more than a year and a half on from its inception.

1. 2(a) Leadership and the teamwork it supported were essential for timely decision-making and the continuation of health care delivery during the pandemic.

The strength of our response has been the camaraderie and goodwill between clinical services. …teams have really pulled together wonderfully well. Never had any pushback about COVID and who’s taking what responsibility. I think everyone stepped up remarkably. (P10)

Leadership and strong collaboration evident in the CEAG meetings were widely acknowledged and enabled timely solutions and directives to address critical issues.

I think maintaining some of those meetings, where there is a broad input from clinicians to executives in an open format, would be helpful. (P06)

1. 2(b) The pandemic placed urgent and extensive demands on staff, the majority of whom stepped up to the challenges. A recurring theme was unscheduled work hours with demanding workloads. Unsurprising were calls for acknowledgment of outstanding contributions of staff.

I feel like there’s a lot of unsung heroes. (P12)

1. 2(c) Information overload from numerous local and international sources, and traditional and social media, often exacerbated staff anxiety and created an onerous task for those responsible for policies and guidelines. Conflicting information, for example about the appropriate type of and circumstances for wearing a mask, was challenging for most.

We had WHO guidance, we had advice from the federal government, from the AHPPC [Australian Health Protection Principal Committee], from the Ministry [of Health], who had advice from the Community of Practice. So much advice, so many documents being drafted and redrafted and redrafted. (P18)

Managers had a burdensome task to justify the reason for inconsistent policies across the state and among Local Health Districts (LHDs). The consequence was heightened fears that inhibited optimum health care and, in some circumstances, led to deficient patient care.

I think we were really challenged because the different LHDs did things differently. And some people who worked both, say, here and the LHD2, would come back from LHD2 going, ‘Oh, they’re doing this?’ And I [would say] ‘Well, you know, we are very clear that we will do….’ I think that was really challenging, having variation between LHDs. So I think at a state level that should be done differently. (P29)

1. 2(d) Transparency, credibility and accountability of timely directives were noticeably absent. The initial lack of identified channel(s) of trusted information resulted in misinformation, anxiety and inconsistent practices. Participants voiced concern about operational decision-making that sometimes lacked input from staff at the coalface.

One of the things that was potentially lacking was transparency with what was happening at the state level, or within the Ministry of Health level, that appeared to be almost like a black box. (P06)

Missing from state directives was an appreciation that health facilities were not equal pandemic responders and therefore directives needed to be specific and detailed.

They did have an intensivist from [Hospital1], who was part of the advisory group … But [Hospital1] really didn’t have much direct input into the day-to-day management of COVID. It was really [Hospital2] managing that…there was a lack of input of [Hospital2] within the Ministry’s decision-making, representing essential intensive care. (P06)

Timely dissemination of information via the Chief Executive’s Broadcasts to all HCWs gave credibility to the rapidly changing workplace requirements. Open forums such as Q&As and Grand Rounds were valued because they allowed staff to seek answers and have further clarity. Some departments also employed additional mechanisms to keep staff informed.

I think the communication was a way of relieving staff anxiety …the Chief Executive’s daily broadcast was quite helpful … Grand Rounds initially was very effective. The Infectious Diseases team was so articulate, and they gave such measured responses, and gave people the information that they needed. (P03)

Theme 3: Plan for future crises.

The ambiguity surrounding appropriate procedures and directives for the provision of care in a safe environment fuelled feelings of stress and anxiety. Participants described the benefits of a multidisciplinary team armed with the expertise, experience and resources capable of providing an immediate response and ongoing governance and capacity for the wide-ranging components integral to a comprehensive pandemic response.

1. 3(a) COVID-19 demanded an urgent review of usual health care activities. Delays were counterproductive to efforts to keep staff engaged. A taskforce that could be activated at a moment’s notice would minimise delays, staff anxiety and the accompanying risks to staff and patient well-being.

Having an emergency taskforce at the hospital where, say, if anything like this happened—Ebola, some sort of pandemic, a fire—you have ten designated nurses that you would pull out of different departments … a mobilised taskforce with consistent nurses… already from different wards that had already been designated. … And these are the [taskforce] doctors. (P01)

1. 3(b) A pandemic plan detailing components for a comprehensive response would minimise delays and uncertainties. Details would support a proactive response and identify designated spaces appropriate for isolating and caring for suspected or infected patients.

We should have had a pandemic plan. We have for influenza; we’ve had these plans … at an executive level probably sitting on a shelf somewhere…. But it’s not just about having a document as to how you do these things … we’ve learned …we were doing things very reactively. But now, part of our mandate with the biocontainment centre is that we’re going to be thinking very proactively about pandemic planning, and at every level… (P10)

1. 3(c) The criteria and a plan for modifications to clinical operations, including escalation and de-escalation of procedures, would enable staff to be prepared and act in unison.

We probably need to have a better consideration of how to stage our transition from a team-based or ward-based system without going from one to the other extreme immediately. (P30)

1. 3(d) Clarity around roles, responsibilities and lines of reporting were blurred or absent during the height of the pandemic, deleterious to patient care and staff well-being. Long hours were spent developing solutions for working at the coalface that were superseded by less fit-for-purpose directives from higher levels of the health sector. A multidisciplinary central control committee could efficiently create expert groups with the authority and responsibility to action urgent and ongoing change.

I think there has been a very strong case for us to have some sort of strong national, multidisciplinary communicable disease centre, where you incorporate all the leaders from these various groups into one entity that could then share their information and make sure that all the information that they’re sharing with their groups is consistent. (P10)

Theme 4: Promote corporate and clinical agility.

Staff and patient safety and well-being are paramount concerns for any health system. Circumstances during the pandemic fashioned unique responses to the provision of health care and staff’s ways of working.

1. 4(a) Individual staff/patient characteristics and needs were foremost in the minds of those determining the day-to-day operations in the facility. Staff’s age, personal circumstances and physical and mental status were key considerations in determining their vulnerability, and simultaneously, their capacity to contribute to the facility’s pandemic response. Similarly, confidence in staff enabled flexibility in caring and advocating for patients.

The majority of the time [visiting rules] were followed. There were a few exceptions, though, where families did try and do their own thing…. The hospital staff did the best they could under the circumstances…. Sometimes it’s not possible though, especially if you have someone who’s very sick or dying … that’s the hardest bit. (P16)

1. 4(b) Perspectives on adopting a ward-based model of care, while diverse, were predominantly positive. Concerns were voiced about staff in training achieving required competencies and the immediacy with which the model was introduced. Conversely, the medical staff were more easily accessible and shifts that accompanied the ward-based care minimised un-rostered and overtime schedules.

Changes from the medical staff model to your ward-based group, they should try and hang on to that, but that’s going to take some investment of resources. … That really made a difference. … But that’s completely changing the delivery of medical care…. (P20)

1. 4(c) Technology offered the organisation an avenue to sustain aspects of workplace requirements, as staff could remotely attend meetings, engage in educational sessions, review medical notes and communicate with patients. The remote work culture was welcomed by most, despite its sudden and widespread application.

It was a significant cultural shift for the entire organisation to realise that you don’t need to physically be in the building to be able to contribute. There’s a role for physically walking around and seeing the lie of the land. But there are also certain advantages, not spending hours travelling to and from an office … you can be equally productive in this sort of setting. (P06)

1. 4(d) Technologies such as telehealth to enhance patient care were welcomed by most clinicians, with some advocating for continued or greater use. Telehealth supported self-isolation, reducing risk of exposure and spread of COVID-19. Senior clinical staff touted the value of a permanent virtual ED.

I’ve found telehealth really useful. I do everything by telehealth now. (P17)

I think telehealth could have been done better, to be honest. I think we could have had [a] virtual emergency department for patients who were suffering conditions where they needed to see a doctor … to be in an emergency department, but they couldn’t because of COVID. … And then they could have had a more planned approach. (P34)

For certain conditions, such as those requiring a physical examination or patient observation, telehealth was deemed unsuitable.

We decided that there were very few visits that we could cut out, or that we could move to video. …we needed to keep doing most of these visits as face to face visits, because to do otherwise was going to potentially make things unsafe. (P38)

Minimise risk of infection.

Health care organisations around the world are reassessing how to safely provide essential care for patients in times of crisis [31]. The pandemic elevated the importance of staff safety and prevention of transmission to the community comparable to patient safety [32, 33]. Heightened anxiety–stemming from the unknowns of the virus, [3] inconsistent guidelines, and inadequate PPE stocks and directives–was not unique to Australia [34]. Sudden and extensive demands for training stretched the resources of Infection Control and nurse educators. Establishment of a centralised managed stock enabled transparency and ready access, thereby reducing individual hoarding and stockpiling.

The utmost priority given to infection control positively affected WH&S aspects of the healthcare system. Posited as the way forward, infection control practices could be effectively incorporated into routine activities if perceived as a WH&S issue, a concept previously reported [35]. One such example, initiated by the ED, saw staff assigned designated workstations and computers and required to declutter and regularly clean surfaces to reduce contamination and sources of infection. Restricting visits, employed as an early infection control strategy, caused moral injury, [36] particularly for staff unable to apply their professional judgement. Guidelines enabling patients to safely receive visitors [37] reflect an appreciation for the benefits of visitors to patients [38] as well as the need for regulation [39, 40].

Efforts directed towards procedural changes and staffing may have relevance to non-pandemic operations [41]. Staff agility enabled the adoption of rapid changes, some temporary as was an innovative process for intubating patients, and others long-term such as avoidance of nebulisers, cohorting patients suffering from infectious diseases and use of suitable physical infrastructure. Work is already underway to review regulations and standards on hospital buildings and the guidelines that govern their operations [42, 43]. Minimising the contact between infected and non-infected patients and staff using ‘shelter hospitals’ [44] would enable non-pandemic operations to continue, thereby minimising the de-escalation of services.

Early designation of a separate testing clinic and ward, the latter equipped with permanent staff and a Nurse Unit Manager (NUM), would support operations, staff and patient safety, and work demands of assigned medical practitioners. Pool staff increased the likelihood of shortcuts of various procedures, unauthorised staff providing directives, PPE breaches, and anxiety and unabated fear among both poorly informed staff and patients.

Maintain a sense of collegiality and informed decision-making.

The general motivation of staff to be involved early in the pandemic might have stemmed from feelings of obligation in the presence of facilitators such as the provision of accommodation, and at a local level, transparent information sharing and a sense of inclusion in decision-making, [45, 46] which would have alleviated feelings of distress that were common among HCWs [47]. The collaboration participants experienced, desirous across occupational and professional groups, [18] was underpinned by multipronged communication strategies between staff at the coalface and the leadership groups, and was particularly valuable in the periods of rapid change, as noted elsewhere [48]. Recounts of everyone having the same agenda were as common as those of un-rostered hours worked–both warranting recognition.

Plan for future crises.

Despite SARS-CoV-2 being the third coronavirus to emerge in the past 20 years and experts’ previous warnings of impending deadly epi/pandemics [49–51], the world was unprepared for COVID-19. In addition to ‘a detailed operational blueprint’ [51] for an effective response, participants expressed the importance of the retention of a skilled multidisciplinary emergency taskforce and, for sustained analytical and operational capacities, a multidisciplinary central control group. A taskforce would prove invaluable particularly in situations when there is an extended period before the infectious agent is identified such as those presented by COVID-19, compared to the SARS outbreak when researchers quickly identified the infectious agent as SARS-CoV-1.

Up-to-date information, education and training are not only prerequisites for quality patient care but are important for reducing HCWs’ risk of psychological distress [52, 53], from which full recovery may be challenging [11]. Integrated in the control centre, designated individuals in core response areas such as ICU [40] could establish information channels on the current status of operations that would strengthen collaboration and coordination across diverse but relevant groups. Hand-in-hand with information sharing and having what has been referred to as a transparent strategy [54], is acknowledging uncertainty [55] to abate confusion and panic. Transparency alongside tailored information from trusted spokespeople are similarly relevant to achieving optimal vaccine uptake, which itself is vulnerable to a number of factors including, at any point in time, the public’s perception of risk [56, 57] and vaccine safety, efficacy and side-effects [58].

An effective control centre would: engage frontline staff and experts across disciplines and levels of governance [59] in decision-making and the development of evidence-based policies and protocols [44], avoiding duplication of processes; prioritise infection control, protection and safety measures ahead of knowledge of disease transmission; [47] create central stocking and stockpiling of equipment to avoid resource strain; [60] and deploy standardised frameworks to keep all staff abreast of updated protocols, guidelines and policies. Acknowledged as a key component of a preparedness plan is a scalable emergency system capable of responding to a surge in demand for resources and patient care [21, 61]. Such undertakings of a control centre could fall within the remit of the long anticipated and now imminent Australian Centre for Disease Control [62, 63], to address experiences of HCWs that are detrimental to their well-being and mental health [64–67].

Promoting corporate and clinical agility.

Participants extoled the agility of staff as they reflected on efforts to achieve essential elements for a responsive health care environment that provides quality patient care while simultaneously mitigating the spread of the virus amid rapid and frequent change. Similarly, leaders acted swiftly to mitigate risk, introducing a ward-based model of care aimed at minimising the movement and interacting of staff at work, and offering assistance to staff identified as vulnerable–the latter a known effective measure [68]. Risk management included staff taking leave, working remotely and being redeployed. Working remotely, a practice previously considered impractical [69], especially in health care related jobs, became a reality for many in the pandemic [70]. However, still lacking are appropriate guidelines for individual sectors [69] and assessment of its benefits.

Telemedicine proved effective in filling some health care gaps, enabling healthcare services to infected and non-infected people during the pandemic [71]. In our study clinicians had mixed reactions to its sustainability, citing situations when a traditional physical examination is necessary. Nonetheless, most appreciated that remote working has the potential to be cost-effective, extend access to specialist care [72], and increase productivity and job performance [73, 74].