The COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? I asked a variety of practitioners to give a short answer – whatever came to mind. Many have kindly responded so far, and more are expected (scroll the the bottom of this post, where new entries are dated).
What might we draw from the learnings below? You will draw your own insights, no doubt. For me, the themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisatonal hierarchy, problem solving and innovation, and – generally – change. In fact, many of the themes of recent issues of HindSight magazine are reflected.
Thanks to those who kindly responded and to those to who plan to, despite high workloads. If you are willing to contribute as a healthcare practitioner, or as a patient or family member, please scroll to the bottom of this post.
“Why not the psychology of human high performance?”
We understand a great deal about the impact of stress, long hours, tiredness and fatigue on our performance. We just ignore this in healthcare! What we don’t really understand is the impact of long periods of time away from work. Time away from work is not uncommon, for example when a professional has a lengthy sickness absence. Yet some people bounce back with minimal assistance, whilst others struggle to “get back in the saddle”. Achieving peak performance for sports people is a whole scientific discipline. Why not the psychology of human high performance in safety critical industries?
Martin Bromiley OBE, Founder Clinical Human Factors Group
“Frontline workers are the solution to most problems“
During COVID19 I learned that the need for change is the only thing we can reliably predict about the future. Fortunately, frontline workers are the solution to most problems that will inevitably arise. They are the most valuable resource in healthcare, both for delivering the care and for designing how to do it. Locally, we have seen rapid, successful innovation of work practices through the marriage of simulation and human-centred design principles. Sadly, though the safety of our workforce is paramount, it has been threatened worldwide. We still haven’t learned how to put humans at the centre of healthcare.
Chris Nickson, Intensivist, Australia @precordialthump
“The pandemic has required groups to leave their silos“
High trust relationships are critical to safety. Strong bonds within groups develop organically over time. This social capital has many advantages particularly during a crisis, but can have the unintended consequence of excluding others. The pandemic has required groups to leave their silos and to collaborate rapidly on high-stakes issues. I have learned that we need to call on those who have not previously routinely been included in healthcare teams – such as aerodynamic scientists and occupational hygienists – to keep workers and patients safe. Many of these experts are accessible on social media, primarily twitter, and have been generously sharing their expertise for the benefit of all.
Tanya Selak, Anaesthetist, Australia @GongGasGirl
“Team learning is needed”
Individual adaptations are necessary to cope with goal conflicts, but team learning is needed to maximise the impact and ensure the safety of such adaptations. In my GP practice, daily ‘huddles’ (short meetings) were used to discuss how we implemented rapidly changing guidance while coping with varying conditions (e.g., demand and capacity) and competing goals (e.g., reducing hospital admissions while maintaining patient safety). Huddles encouraged sharing of innovative practice and increased understanding of why decisions were made and how decisions affected other parts of the system. It also supported those making difficult decisions and ensured people did not drift into unsafe practices.
Duncan McNab, General Practitioner, Scotland @Duncansmcnab
“It is essential to foster good relational coordination”
I have learnt the importance of emotional contagion. It is essential to foster good relational coordination amongst colleagues particularly during a time of great uncertainty and constant change. Although this pandemic has brought lots of new concepts and working conditions, it’s imperative that we maintain our usual high standards and not be tempted to try new techniques and alter our usual routine safe practice.
Caoimhe Duffy, Anaesthesiologist, USA @CaoiDuffy
“Diverse views were brought together”
The potential impacts of COVID-19 required a rapid reconfiguration of the intensive care unit. This required many different teams: ICU clinicians, infection control nurses, biomedical engineers, builders, ventilation engineers and quality improvement specialists. These diverse views were brought together for the complex, dynamic problems we faced. This work leaned heavily on the pre-existing relationships built up during a recent volcanic burns disaster. Additionally, the redesign of clinical work was based on four requirements: to be SAFE, SIMPLE, SUSTAINABLE and ADAPTABLE. The ability to anticipate potential challenges required imagination and a deep understanding of the realities of everyday work.
Carl Horsley, Intensivist, New Zealand @HorsleyCarl
“Systemic inequity has become apparent”
New Zealand was fortunate to have very few cases of COVID. Preparation involved a high level of adaptability and dizzying pace of change where everything seemed possible. As the situation calmed, the true cost of these adaptations has become apparent. Major systemic inequity has become apparent for those whose care was compromised by prioritisation on others. Important perspectives came to light, which had not been heard in the rush to respond based on traditional institutional hierarchies and values. The lesson for us has been the need to consider unintended consequences by truly listening to those who have different perspectives and to focus on flattening hierarchies. Addressing inequity is now a major target of our health response.
Fiona Miles, Paediatric Intensivist, New Zealand @fionam_miles
“I witnessed enormous willingness and motivation”
The pandemic provided me with an opportunity to work locally in my hospital and elsewhere at a major new hospital, ‘Nightingale’. I witnessed enormous willingness and motivation amongst practitioners and managers to respond to the need for rapid change. This felt like a big contrast from previous ‘norms’ of organisational behaviour in healthcare. I also observed and experienced significant challenges to redesigning clinical services when facing considerable resource constraints such as workforce availability, skill mix and preparedness for redeployment; creating and adapting new clinical environments; accessing critical specialised equipment and supplies quickly and reliably. This was confounded by multiple channels and frequent shifts in emphasis of central guidance and policy, that did not always seem to match scientific evidence or the wider public narrative.
Bryn Baxendale, Anaesthetist & Health Education England Simulation Lead, England @gasmanbax
“Working in PPE is hot, tiring and difficult to both hear and see”
With the arrival of PPE – the sort you see on television – came the notion that it alone ensured staff and patient safety. Thus the assumption evolved that the more PPE, the more safety, without considering the downsides. Working in PPE is hot, tiring and difficult to both hear and see. Staff avoid drinking to reduce bathroom visits, all of which affects their ability to work. Extra time is taken from patient care to put on and take off the PPE. Thus the measures to reduce a single source of danger – Covid – indirectly affected patient safety in many other ways.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“Pay attention to human and organisational factors”
The COVID19 outbreak has been thunder on a sunny day. Surprise, ignorance, fear for our relatives. The need for more ICU beds required us to work outside our comfort zone. Equipment wasn’t designed for ICU, nor were newly formed teams used to working together in this stressful environment. So, what could we do? The only answer that came to my mind was to pay attention to human and organisational factors. Those were the skills needed to tackle this disease. The use of collective intelligence via inclusive collaboration and open communication was very effective in preventing harmful events for both patients and healthcare workers.
Frédéric Martin, Anesthesiologist, France @drmartinfred
“It is critical that ‘work-as-prescribed’ reflects ‘work-as-done’”
Healthcare has a reputation for resistance to change, particularly top-down initiated change, with limited consultation with clinicians. During the pandemic, many frontline clinicians experienced change done ‘to’ them, instituted by administrators, particularly rationing personal protective equipment. Other organisations have initiated clinician-lead processes, resulting in durable models of care but uncovering ‘wicked problems’. COVID-19 has taught me that engaging clinicians doing the work increases short-term complexity, but doing otherwise risks failure in the long term, losing trust on the way. It is critical that ‘work-as-prescribed’ reflects ‘work-as-done’ to prevent depletion of the workforce through infection and exhaustion.
Kara Allen, Anaesthetist, Australia @ergopropterdoc
“What differs from country to country is dependent on leadership”
It’s confronting, working in an industry that conditions staff to risk their own lives unnecessarily instead of speaking up with sufficient impact to deliver the safety initiatives we need. COVID19 has bared the healthcare issue for all to see. Dreadful administration in top down hierarchical frameworks is registering in different countries as a death rate. What differs from country to country is dependent on leadership. Those countries with great leadership – overcoming siloed thinking behaviours, overcoming ‘airborne deniers’ and responding appropriately with early hard lockdowns, mandatory mask wearing and adequate Personal Protective Equipment – have fared so much better.
Rob Hackett, Anaesthetist, Australia @patientsafe3
“It has shone a light on how we work”
The COVID-19 pandemic has been an acid test of the quality of health care, standard of governance and social capital across countries. The pandemic certainly has exposed the limitations in healthcare systems and existing health inequities. It has shone a light on how we work, and the dichotomy between ‘work-as-imagined and work-as-done’. Well-resourced and supported teams that perform regular reviews using a ‘systems approach’ for the purpose of collective learning has been critical in bridging this gap and achieving good outcomes. Teams were able to confidently balance efficiency and thoroughness safely when faced with the challenge of multiple uncertainties.
Manoj Kumar, Surgeon, Scotland @Manoj_K_Kumar
“For the first time, work and its goals were shared”
“I know what I’m doing, I don’t need to be told how to do it” … these are words I haven’t heard during these months of COVID19. This whole experience was new for everyone. For many professionals, it has created a touching sense of humility, both among frontline actors and managers. I believe that this humility has facilitated communication and the emergence of a shared governance between caregivers and administrators where I’ve been working. For the first time, work and its goals were shared and the gap between work-as-imagined and work-as-done was almost zero.
François Jaulin, Anesthesiologist-Intensivist, France @Francois_JAULIN
“Looking back, local practice is not ‘work-as-prescribed’”
Despite 25 years in the specialty, the COVID19 pandemic was my first introduction to Personal Protective Equipment (PPE) and a FFP3 mask. Fit testing achieved and training in PPE donning and doffing undertaken was great preparation to prevent catching a deadly viral disease. However, this was no preparation for the daily challenges of working in PPE exacerbated by concerns around PPE availability and changes in doffing station practice. The impact of heat, the need for good hydration, and the communication challenges became stressors – recognised and managed by great team working through adaptations in how we worked. Looking back, local practice is not ‘work-as-prescribed’.
Alastair Williamson, Anaesthetist, UK @dr_alwilliamson
“Work-as-done can be close to work-as-imagined”
I have learned that some types of ambulance service work systems that would previously have been considered very difficult to change, can actually be reconfigured at pace and new ways of working can be introduced, which lead to significantly different system performance. Work-as-done can be close to work-as-imagined with changes up to a certain size. With larger groups of workforce, it can be very difficult to influence multiple, often subtle, changes in work-as-done to match with the more easily changeable work-as-prescribed (and work-as-imagined). This was particularly evident in the early stages of the response phase when clinical, logistical and PPE criteria were becoming established.
Gary Rutherford, Ambulance Service Patient Safety Manager, Scotland @garyrutherford2
“A completely flattened hierarchy is also a barrier to effective communication”
We often hear about ‘flattened hierarchy’ and how hierarchy can be a barrier to effective communication. I found that a completely flattened hierarchy is also a barrier to effective communication. For example, everyone is wearing the same outfits, no name badges are shown and no one recognises anyone. So who is the leader? Being involved in a medical emergency with no leadership evident is a scary place to be. The role of a leader in any critical situation is required. The role of a decisive leader has also been critical during the pandemic. Being led by a leader that is decisive has given me comfort and guidance when I have felt as if I was floundering.
Claire Cox, Critical Care Outreach Nurse, England @safetynurse999
“Let user-centred and data-driven design lead us in rebuilding”
COVID-19 has shone a light on our lack of insight into complex system design. Healthcare is a precarious thing, balancing on the backs individual and team resourcefulness and resilience. Emergency medicine, in particular, suffers from ‘ad hoc-itis’. Our ability to improvise solutions in the face of massive systemic limitations and inefficiencies is practically a professional badge of honour. But it doesn’t have to be this way. We can build systems that make sense. We can use simulation-informed design, prototype testing, multi-source feedback and hazard analysis to help manage complexity rather than compel us to work against it. The pandemic has compelled us to tear down and begin again, and therein lies a massive challenge and unprecedented opportunity: let user-centred and data-driven design lead us in rebuilding.
Christopher Hicks, Emergency Physician, Trauma Team Leader, and Simulation Educator, Canada @HumanFact0rz
“Work-as-imagined and work-as-done might well apply to how patients ‘work'”
Hollnagel’s descriptions of work-as-imagined (WAI) and work-as-done (WAD) might well apply to how patients ‘work’ as well as staff. Initially we asked our patients to self-isolate for 14 days prior to elective surgery, and (as we knew the reasons), we imagined that they would do that unquestioningly. We ‘prescribed’ that to them, without explanation, and then anyone who proceeded to surgery had to ‘disclose’ that they had completed this. Only the patient ever knew whether they had done so. It took a period of time to identify the gap between WAI / WAD and is taking longer yet to close this gap.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“By starting to address problems iteratively we could create a network of actions”
The biggest problem we faced at the start was the uncertainty and a stream of unfiltered information. We had tentative ideas of what needed to be done and what might happen. What we learned subsequently was that by starting to address problems iteratively we could create a network of actions that we could knit together. We rapidly developed a tolerance of failures, using them, with active feedback, to modify our processes and facilities adaptively, alongside the new information that became available. This made it much easier to try and keep pace with a rapidly evolving situation.
Alex Kazemi, Intensivist, New Zealand @KazemiAlex
“A significant issue…has been effective communication”
A significant issue for health professionals during the coronavirus pandemic has been effective communication while wearing PPE, especially for aerosol generating procedures. Voices are muffled, hearing is compromised and implicit communication through facial expression is lost. This is especially a problem for resuscitation teams working under pressure. We provided our staff with 5 tools (PRESS) to improve communication using PPE:
P – Pre-transmission pause. Think before you speak
R – Read back – close the loop
E – Eye contact – ensure focussed attention
S – Say again – repeat critical information.
S – Shared team mental model with a team rally point
Stephen Hearns, Consultant in Emergency and Retrieval Medicine @StephenHearns1
“Simulation is a great tool for training”
I learned three things in particular: 1. Simulation is a great tool for training; but it is much more effective to establish a shared mental model (understanding) and then simulate it, than use a simulation to establish a shared mental model. 2. Complex teamwork tasks with sequential critical actions are easier to develop in medical subcultures which have already established the role of expert team-leader as being separate from expert technical operator. 3. Maintaining buy-in to a different way of working is difficult when in a prolonged high-vigilance, low-activity state (such as here in NSW).
Tom Evens, Emergency Physician, Australia @DocTomEvens
“We were finding solutions from the ground up”
During the start of the pandemic, the rules and guidance we had normally been following were gone. Sometimes, rules set out by people that don’t ‘do the work’ are not the way that the work happens. These rules end up being a barrier to do the right thing. For example, filling a 35-page safety booklet about a newly admitted patient takes us away from practical tasks such as personal care or administering medication. Now, no-one knew the best way to do things. There was no evidence base to draw from, and no exemplars to follow. This led to a more collaborative approach. Everyone came up with ideas, and many more came from social media. We openly learned from each other. We were finding solutions from the ground up and the senior leadership team listened.
Claire Cox, Former Critical Care Outreach Nurse, England @safetynurse999
“COVID appears to have acted as a powerful inductor for team building”
I’ve discovered through the different cases reported on the Patient Safety Database how strongly empathetic and benevolent leadership can have a positive impact on patient safety, work organisation, coping and caregivers’ well-being. COVID appears to have acted as a powerful inductor for team building. On the other hand, where human and organisational factors did not seem to be considered, it reinforced the cleavages, created tragic situations for both patients and caregivers and increased workers’ ‘ill-being’. Empathy and benevolence were overused words that we no longer knew the meaning of. I believe it is now much clearer.
François Jaulin, Anesthesiologist-Intensivist, France @Francois_JAULIN
“The ability of staff to innovate and adapt was remarkable”
Without timely clear guidance arriving down the traditional lines, the ability of staff to innovate and adapt was remarkable. The constraint of normal change bureaucracy was temporarily suspended and essential new ways of working arrived in a rapid and remarkably effective way, significantly prior to written SOPs. Front-line staff absorbed the principles and developed them in appropriate ways for their own local work, often utilising the skillset of their staff, e.g., military nurses who had significant experience with PPE and Ebola. Staff needed guidance in underlying principles, but then excelled at translating them into their own working environment.
Pip Fabb, Consultant Anaesthetist, England @PipCassford
“You end up counting on good people to do everything they can”
During the pandemic, I learned that no matter how well organised the healthcare system is, you end up counting on good people to do everything they can to overcome and minimise effects of hopefully rare but inevitable system flaws.
Filip Płużański, Orthopaedic Resident, Poland @filip_pluzanski
“My colleagues and I could adapt rapidly to these new conditions”
Overnight, my job changed from in-person clinical care to online telemedicine. Our telemedicine urgent care started seeing hundreds of COVID patients a day, a disease and volume that were totally new to us. I learned that my colleagues and I could adapt rapidly to these new conditions. The tradeoffs between in person care and online care were challenging for everyone, as patients feared contracting COVID at the hospital. Communicating clearly with one another and with our patients about uncertainty and risk were essential, as conditions changed rapidly.
Shannon McNamara, Emergency Physician, USA @ShannonOMac
“Design and processes affect the normal functioning of a team”
Preparing a new ‘COVID operating theatre’ has highlighted the importance of how design and processes affect the normal functioning of a team. To minimise risk, the negative air pressure of a dedicated COVID theatre needs maintaining and non-essential equipment and personnel removed from the ‘hot-zone’. Limiting opening of doors and wearing of masks and face shields results in markedly difficult communication – even when that communication is critical. Cameras, microphones, patching of monitors and hand signals are valuable but inadequate. There is certainly greater appreciation for shared mental models and planning for complications with pre-operative briefings than before the pandemic.
Stu Marshall, Anaesthesiologist, Australia @hypoxicchicken
“I’ve learned about ethnography and how contextual narratives can yield a theme”
I’m part of a research team looking at organizational responses to COVID-19. Using special federal funding, the team we’ve assembled includes Ethnographers, Human Factors (HF) experts and Infection Prevention & Control (IPC) specialists. For one major project, three team members visit and review COVID-19 in-patient units, looking at HF aspects of Personal Protective Equipment (PPE). We conduct observations from all three perspectives, weighing what is done against what should and what could be done. We present suggestions and thus help co-design workable solutions. I’ve learned about ethnography and how contextual narratives can yield a theme that helps illuminate a problem.
Jan Davies, Anesthesiologist (clinically-retired), Canada @JanMDavies
“Lessons from Europe don’t necessarily translate well in LMIC’s”
As a country the pandemic reached us later than Europe, and we were able to learn from them. Strong decisive measures from government limited the impact on the healthcare system initially. However it soon descended into information overload, inconsistent messages and departure from plain common sense. It reiterated the inequalities of access and availability to healthcare. One unanticipated factor was the effect of fear and stigma of the illness in the community and in healthcare workers, and the negative impact it has had on patient care. Lessons from Europe don’t necessarily translate well in LMIC’s where the cultural context is different.
Ellen, Critical Care Nurse, South Africa (added 18/09/20)
“A focus on leadership over management is required”
The need for sincerity and genuine characteristics is essential. A focus on leadership over management is required. Midwifery managers/consultants need to be able to utilise their clinical skills they started off with to enable support and understanding of their units in today’s world. Point scoring is no good in a pandemic, any holes will just grow bigger. Never underestimate what a major stress relief it is to begin a shift without busy traffic and being able to park close to your work.
Suzanne, Midwife, England (added 18/09/20)
“Let departments organise themselves”
Let departments organise themselves. Radiologists were split into two groups – one at home, one in department. Radiographers worked out their own rotas. Radiographers and nursing staff worked on SOPs for imaging COVID positive patients. No top down orders. Homeworking was sorted in short time after years of dragging feet (helped by already having screens and laptops in hospital, but not set up). We found that if IT sorted this out we could be appreciative and positive people, rather than grumpy and negative about IT (we even nominated the IT staff who sorted this out for a ‘GREATix’ excellence report).
James, Radiologist, England (added 18/09/20)
“Where you draw the system boundary matters”
Where you draw the system boundary matters. I started chairing a theatre COVID preparedness group in March. We quickly transformed the theatre complex to handle a surge in patients with COVID, while keeping staff safe. We liaised with ED, ICU and the wards which are upstream/downstream of theatres. The teamwork, dynamism and psychological safety of the working group were excellent. There were times on the fringes of this system when we found other systems which benefitted from our input. Our system boundary did not include the whole hospital system and that was appropriate, other people were focusing on this. Looking back now I wonder about the care homes. They were not within my system and I didn’t give them a second’s thought within my planning. Whose system boundary included care homes? What were their working conditions, demands and constraints? How could we do better next time?
Michael Moneypenny, Anaesthetist, Scotland (added 17/09/20)
“It’s like a slow moving major incident”
Mass redeployment, degrading staff by giving one set of technical skills primacy and devaluing primary work which still needs doing causes distress. I have also learnt a lot about the structural and cultural barriers to leveraging talent in surge demand. It’s like a slow moving major incident without the implementation of the major incident plan.
Alison Leary, Professor of Healthcare, U.K. (added 28/09/20)
Please feel free to add or adjust if you’re happy for me to add!
What have you learned about work during the COVID-19 pandemic as a front-line healthcare professional, patient or family member? Please add your answer, preferably in 100 words or fewer, via the comment function at the bottom of this page, and I will integrate these also into the text (please also add your name, role, and country).
N.B. Collecting these insights was partly to inform an article for a forthcoming HindSight magazine, reflecting on lessons on work from the COVID-19 pandemic in healthcare and aviation. Not all healthcare roles are well eflected – of course – and I’m still waiting for some reponses. The aim was not a comprehensive survey, and I was asking people at a time of very high workload. However, as there were more healthcare responses than I expected – and more than is possible to print in a magazine article – I thought most benefit would be gained by publishing them all here. As is quite typical of healthcare staff, many have dual roles in front-line work and education, simulation, quality, improvement human factors, safety, etc. And of course healthcare staff tend to have many post-nominals. I have simplified all of this down to name, primary clinical role, and country. For more information, check out their twitter profile.
A unique opportunity to do things differently
The rapid implementation of a new temporary critical care unit in response to the first surge meant that many aspects of standard WAI and WAP in critical care became irrelevant. Bringing together an unknown, unestablished team released the cultural and siloed shackles we are so often bound by in healthcare and allowed us to learn as we did the work. This allowed us to iteratively develop systems and processes that helped us adapt to the emergent situation. This included delivering daily onsite ‘just in time’ training and bedside educational support to redeployed staff, implementing a coloured hat system to identify skills and improve escalation (airway and critical care) and develop new roles (bedside practitioner) and allocations that suited skills without causing excessive cognitive overload. By breaking down previous social/professional boundaries and using some non-critical care junior doctors in a bedside practitioner role, we were able to have right people, in the right place, at the right time. This nuanced way of doing things helped build collaboration, improved relationships and was seen by the majority of staff and professions as a positive intervention. We have taken this learning and are trying to implement this again for wave two.
The WAI storm has returned
Five months on things don’t feel as innovative as both national and local level government WAI rules, interpreted by Trusts into WAP around social distancing within education, workspaces and restrooms, often result in staff becoming more and more restricted in how well they can work. Many rules are simply unachievable in a chronically under resourced healthcare system and have to be broken daily in order for staff to work, eat, rest, communicate and learn. Therefore as staff on the frontline are the ones ‘breaking the rules’ who will be blamed when there is a negative outcome???