The role of leadership and effective engagement in multi-level coordination
Based on the facilitators highlighted by participants, including staff input, feedback and engagement, the role of leadership, organizational readiness, the development of guidelines and protocols, and teamwork across the organization, it is clear that multi-level coordination can act as a facilitator of initiatives. Multi-level coordination and preparedness, which we define as the range of actions undertaken simultaneously and with input from a range of stakeholders that are required to prepare the organization for a pandemic situation, facilitates frontline healthcare providers in developing, rolling out and managing initiatives to improve the health and wellbeing of staff.
Effective coordination within organizations, as well as with external partners, regional and national government, and in line with guidance from the World Health Organization, is a critical element of managing HCWs health and wellbeing during a pandemic situation. As developing and maintaining good multi-level coordination is a complex and challenging task, when organizations are confronted with a range of competing priorities, the importance of forward planning for a pandemic situation is critical. Human and financial resources should be made available to organizations to work towards this goal. Policies and guidelines should be in place to ensure both mental and physical safety of HCWs before a pandemic and updated based on emerging local and international guidance following the onset of the pandemic.
The most published coordination challenges through the COVID-19 outbreak thus far have focused on the provision of personal protective equipment (PPE) and guidance on how it should be used by HCWs. A variety of challenges have been outlined in the literature [9, 39, 40], as well as by respondents of the study, covering procurement, including price regulation and shortages, PPE quality, distribution, provision, and guidelines on use. One respondent summed up the multi-level challenges.
“It was unclear if supply chains of medical equipment (including PPE) would be disrupted. This potential threat to [organization’s] supply of equipment was compounded by early national epidemic curve projections predicting a surge in COVID-19 admissions to hospitals, which would have driven up healthcare demand and use of medical equipment. With potential PPE supply disruptions and increased PPE needs in mind, PPE use by staff had to be judicious yet adequate enough to confer protection.”
Early research into the health and wellbeing of HCWs during the COVID-19 pandemic has linked access to adequate PPE with better psychological outcomes. Gold (2020) notes that their findings highlight the adverse effects that lack of PPE also have on mental health . They add that insufficient PPE provision can be seen as institutional betrayal, described as “when trusted and powerful institutions act in ways that can harm those dependent on them for safety and wellbeing”, compounding trauma .
Another aspect of the multi-level coordination challenge, seen through the lens of PPE during the COVID-19 pandemic, is effective evidence translation and the challenges associated with rapidly changing national, regional, and organizational guidelines. Healthcare governing bodies in several countries including China, UK and USA altered official guidelines through 2020, impacting guidelines at regional and organizational levels [41,42,43]. In the USA, the Centers for Disease Control and Prevention (CDC) changed guidance on the use of N95 respirators on 11th March 2020, outlining that HCWs could use a facemask where N95 respirators were not available. This guidance was contrary to previous CDC guidance that outlined the need for all HCWs to wear N95 respirators . Similarly, in the UK, guidelines surrounding different aspects of PPE changed several times between March and April 2020 .
In our research, several respondents noted confusion around the correct PPE equipment for different areas of the hospital and for different staff. One respondent explained that staff within the organization were outright distrustful of organizational PPE guidelines, accusing the organization of trying to save money. This example outlines a challenge in knowledge translation in healthcare, but also the importance of trust in the organization and health system. In implementation science, the involvement of stakeholders (e.g., patients, providers, payers) in the design and introduction of initiatives is now seen as the ‘holy grail’ of healthcare improvement. However, such methods, including integrated knowledge translation, have not yet been well validated . As such, tools to facilitate knowledge translation in this context will require greater attention to the understanding and matching of appropriate communication methods relevant for different stakeholders and audiences. Several tools developed by Knowledge Translation Canada’s Knowledge Translation Program, for example, can offer organizations guidance on communicating complex and simple information . In the context of the COVID-19 pandemic and potential future pandemics where evidence generation and the need for knowledge translation moves at a particularly fast pace, healthcare organizations will benefit from having knowledge translation strategies in place ahead of time.
Similarly, effective staff engagement can aid knowledge translation and the build-up of trust between organization and staff, encouraging greater utilization of initiatives to improve HCWs health and wellbeing. Multiple respondents noted the importance of staff engagement in facilitating new initiatives, one noted.
“Our collective wisdom, at all levels of the organization, is huge. In giving voice to this, we not only find innovative and creative solutions, we also value and engage our workforce.”
The importance of staff input, feedback, and engagement across all levels of the organization was discussed frequently by participants who felt strongly that engagement between senior level managers and other staff had a two-fold value. As well as allowing the dissemination of the latest findings and COVID-19 guidelines, this engagement also offered staff the opportunity to raise ideas and concerns at the highest level, with the hope of making them feel valued and listened to.
Mental health, stressors, and the role of fear
The prominence of mental health initiatives mentioned by the respondent group was somewhat unprecedented, given the infectious nature of the virus and the physical repercussions. However, it is possible that the wording of the case study questions, which requested information on either/both physical and mental health initiatives, encouraged participants to discuss mental health initiatives specifically. It may also point to an increasing awareness among the global health community of the far-reaching mental health implications of working and living through a global pandemic.
The role of fear as a barrier to the implementation of health and wellbeing initiatives for HCWs was a recurring theme among participants. They noted fear in the context of personal exposure, exposing family members to the virus should they transmit COVID-19 in their homes. One participant explained.
“Especially earlier on in the realization of the pandemic, [the] majority of the healthcare workers in my facility were fearful and concerned about their personal safety and the safety of their families. They didn’t trust that the organization had their interest at heart every day that they went to work and took care of patients (regardless of whether the patients were positive for COVID-19).”
Fear posed a particular challenge to the implementation of initiatives to adapt the healthcare facility to reduce transmission, as many participants noted that staff were hesitant to volunteer. Heads of Department were also hesitant to volunteer their staff for redeployment to higher demand services and units. Similarly, fear was noted as a challenge in duty rostering during the pandemic period as staff were concerned about undertaking higher risk activities. However, participants noted that such challenges were overcome through direct engagement with departments and staff, where concerns and fears were addressed, and with better training and assurance from peer groups.
In the pandemic situation, burnout is a real and tangible risk of increased pressure on healthcare services and on the health workforce. This is exacerbated due to the infectious nature of the disease, which reduces the capacity of the health workforce due to illness. Burnout is described as a “response to prolonged exposure to occupational stressors”, which may have serious consequences for healthcare professionals and the organizations in which they work . Burnout is associated with sleep deprivation, medical errors, poor quality and safety of care, and low ratings of patient satisfaction . Several of the respondents in the study reported burnout among multiple professional groups since the onset of the COVID-19 pandemic, with one suggesting that initiatives targeting HCWs health and wellbeing may struggle to reach those who need it most as a result of a lack of time and willingness to engage with the support on offer.
The importance of engaging with HCWs who are under extreme stress and pressure in a pandemic may pose a particular challenge, but it is nonetheless important to encourage uptake of mental health initiatives designed to improve their health and wellbeing. One participant noted that.
“Attention to emotional and mental well-being along with psychological support from immediate senior management and peer groups, managed to boost up the morale amongst the junior doctors. Continuous monitoring of the health and well-being of the staff in COVID-19 unit was done. Monitoring of the workload demands, personnel health and safety, resource needs and safe documentation practices was done.”
Such an example outlines that the range of actions and initiatives that must be employed simultaneously to ensure the mental health of HCWs is a critical consideration, while also considering how the very conditions that may be causing stress and burnout (e.g., workload demands) can be reduced to improve take up of additional initiatives. A consideration of these two elements together creates a positive cycle, where initiatives to reduce the stress burden on HCWs also free up time and energy for HCWs to better engage with the additional support on offer to improve mental health and wellbeing.
Challenging the impact of misinformation
Conflicting information, misinformation and disinformation during the COVID-19 pandemic has been a novel challenge given it is the first pandemic in history in which technology and social media are being used on a massive scale as a means of keeping people connected and informed . Respondents in this study largely highlighted both misinformation and disinformation as major challenges to facilitating initiatives for HCWs health and wellbeing, but some also noted the role of conflicting information in challenging implementation. One explained.
“The spread of misinformation via social media presented challenges to the implementation of both physical and psychological categories of welfare measures for staff, not just for the practice of IPC measures.”
Such is the importance of tackling misinformation and disinformation to aid the COVID-19 response globally, WHO Member States passed Resolution WHA73.1 at the World Health Assembly in May 2020 . The Resolution recognizes that managing the infodemic is a critical part of controlling the COVID-19 pandemic: it calls on Member States to provide reliable COVID-19 content, take measures to counter mis- and disinformation and leverage digital technologies across the response. The Resolution also calls on international organizations to address mis- and disinformation in the digital sphere, work to prevent harmful cyber activities undermining the health response and support the provision of science-based data to the public [47, 48]. So too must health organizations consider the role that misinformation and disinformation may have in their COVID-19 response and on the health and wellbeing of their staff. One participant in the study noted that.
“Effective communication between senior staff/ leaders and staff is one way to address this issue. This involves timely dissemination of accurate and evidence-based information to staff, frequent engagement of staff by leaders to allay fears and address concerns, and two-way communication to ensure staff have avenues to provide feedback to leaders.”
Once again, addressing mis- and disinformation requires multi-level collaboration within healthcare organizations, clear preplanning, and engaging staff while respecting their ideas and thoughts. The provision of education and training for staff may also offer healthcare organizations the opportunity to counter mis- and dis-information with targeted scientifically-backed information on the origins, nature and symptoms of the virus, transmission and preventing transmission. This would benefit from including information on essential IPC within the healthcare setting, the role of testing, including available testing facilities for staff, and other common misconceptions. Providing clear information on where staff can find out more reliable information, speak to a dedicated helpline, or seek additional assistance within the organization also offers the opportunity to address mis- and dis-information on an ongoing basis. As the role of technology in day-to-day life and in healthcare continues to expand, more time must be invested in ensuring staff are able to access up-to-date and trusted information about the virus, the pandemic, and the national and local pandemic response.
Developing new ways of working
The COVID-19 pandemic has shown HCWs and patients, their families, and carers the power of data and digital technology in tracking and containing the virus, and in developing new adapted ways of delivering healthcare . There are a range of examples of telehealth being introduced for primary care in countries around the world, offering greater flexibility for patients and better reaching those in geographically challenging areas [50,51,52]. Similarly, in-person/telemedicine hybrid approaches to critical care have also been shown to be feasible and effective in addressing cross-cultural public health emergencies . At the organizational level, several of our study participants developed new ways of working through the course of the pandemic. One participant explained.
“We had to close some of our clinics because of the pandemic of course, but then [had] to really think about how [we could] still serve our patients and encourage them to seek care if they need it. We had to do a lot of telemedicine, you know, on video, which worked really well, but that took a while to put the infrastructure in place.”
Changes to ways of working were largely designed to reduce the risk of transmission and optimize workflow given the increased pressure on resources. However, the development of new ways of working need not stop as the pandemic winds down. One respondent noted.
“As contingency spaces and capacities are gradually used to support the growth and development of the hospital, periodic reviews and re-investment efforts are critical to re-establishing such buffers. This would help to ensure that the hospital retains the capability and capacity to cope with future crises.”
It is notable that a lack of resources was a commonly highlighted barrier by participants in this research. Developing new, more efficient ways of working offers the opportunity for healthcare leadership to maximize the available resources. Of course, these advances must be closely monitored and evaluated to ensure standards are maintained or surpassed, the health and wellbeing of both patients and HCWs remain a priority, and that patient safety is a core consideration in any actions towards more efficient ways of working.
The COVID-19 pandemic has provided healthcare organizations around the world the opportunity to assess the present state of their ways of working, including the provisions on offer that seek to improve the health and wellbeing of their HCWs. As health systems around the world continue to address the pandemic, with an eye towards post-pandemic health system preparedness and planning, these considerations must remain at the heart of healthcare delivery and development.
The findings of the research offer insights into the facilitators and barriers to implementation only at one point in time. Findings therefore do not account for experiences of implementation after December 2020 and do not offer information on whether facilitators and barriers changed with time after initiatives were first introduced, nor whether additional facilitators and barriers have emerged in implementing new initiatives post-2020. However, the research offers valuable insight into facilitators and barriers in the beginning of the COVID-19 pandemic across a range of contexts that may be valuable through the course of the COVID-19 pandemic and for future pandemics and other prolonged crises. A further limitation of the study is the representativeness of the cases outlined. While the authors aimed to collect case studies from a range of geographic regions and types of healthcare organization (N = 13), the case study approach may have led to selection bias and so it is important to note that the findings are not necessarily representative of the experience of all healthcare organizations of that type/geography. Case study research has sometimes been criticized for lacking scientific precision in which to make a generalisation . Nonetheless, the collective case study better facilitates studying multiple cases simultaneously to generate a broader appreciation of a particular issue . As such, the research team designed the research to collect case studies and information from a range of organizations and health systems around the world to better assess trends ahead of generalization, while being cognizant of the limitations in representativeness of the case studies.