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Implementation of initiatives designed to improve healthcare worker health and wellbeing during the COVID-19 pandemic: comparative case studies from 13 healthcare provider organisations globally

Implementation of initiatives designed to improve healthcare worker health and wellbeing during... Background: Healthcare workers are at a disproportionate risk of contracting COVID-19. The physical and mental repercussions of such risk have an impact on the wellbeing of healthcare workers around the world. Healthcare workers are the foundation of all well-functioning health systems capable of responding to the ongoing pandemic; initiatives to address and reduce such risk are critical. Since the onset of the pandemic healthcare organizations have embarked on the implementation of a range of initiatives designed to improve healthcare worker health and wellbeing. Methods: Through a qualitative collective case study approach where participants responded to a longform survey, the facilitators, and barriers to implementing such initiatives were explored, offering global insights into the chal- lenges faced at the organizational level. 13 healthcare organizations were surveyed across 13 countries. Of these 13 participants, 5 subsequently provided missing information through longform interviews or written clarifications. Results: 13 case studies were received from healthcare provider organizations. Mental health initiatives were the most commonly described health and wellbeing initiatives among respondents. Physical health and health and safety focused initiatives, such as the adaption of workspaces, were also described. Strong institutional level direction, including engaged leadership, and the input, feedback, and engagement of frontline staff were the two main facilita- tors in implementing initiatives. The most common barrier was HCWs’ fear of contracting COVID-19 / fear of passing COVID-19 to family members. In organizations who discussed infection prevention and control initiatives, inadequate personal protective equipment and supply chain disruption were highlighted by respondents. Conclusions: Common themes emerge globally in exploring the enablers and barriers to implementing initiatives to improve healthcare workers health and wellbeing through the COVID-19 pandemic. Consideration of the themes outlined in the paper by healthcare organizations could help influence the design and deployment of future initia- tives ahead of implementation. Keywords: Global institutions/organizations, Human resources for health, Healthcare workers, Health care planning, COVID-19, Outbreaks, Communicable disease, Psychosocial impacts *Correspondence: n.obrien@imperial.ac.uk Institute of Global Health Innovation, Imperial College London, London, United Kingdom © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. O’Brien et al. Globalization and Health (2022) 18:24 Page 2 of 13 service. Non explicit support services are services or Background initiatives set up without mental health support as the Severe acute respiratory syndrome coronavirus (SARS- primary goal, but do have a positive impact on mental CoV-2), henceforth described as COVID-19, was first health. Examples include the provision and use of PPE, identified in Wuhan, China in December 2019 and has which can reduce HCWs concerns over their health and since spread to more than 200 countries [1]. Healthcare spreading infections to their families [2]. Non-explicit workers (HCWs) at the frontline of the COVID-19 pan- initiatives may seek to ease caregiver or childcare bur- demic are at a disproportionate risk of adverse physical den or lessen financial stressors, such as hazard pay, for and psychological outcomes [2]. The true scale of COV - example, to mitigate negative mental health outcomes ID-19’s impact on health and wellbeing is not yet known, [2]. however Amnesty International found that at least 17,000 The importance of HCWs to a well-functioning health healthcare workers around the world died in the first system is not always acknowledged or backed up with year of the pandemic, a substantial increase from more appropriate responses from systems or leaders. Devel- than 3,000 deaths reported in research published in July oping and launching initiatives designed to address and 2020 [3, 4]. Data from surveys around the world admin- reduce health and wellbeing challenges whilst under time, istered during the COVID-19 pandemic, as well as other human resource and financial pressures is a key challenge pandemics and epidemics, also found that HCWs experi- for many health systems and institutions globally. Our enced concerns about their own health and fear of trans- study addresses a research gap by unpacking the facilita- mitting the virus to family, as well as increased levels of tors and barriers to the implementation of initiatives to depression, anxiety, distress and insomnia [5–8]. Nurses, improve the health and wellbeing of HCWs through the female workers, frontline workers, younger medical staff, COVID-19 pandemic. While initiatives have been rolled and workers in areas with higher infection rates have out globally, the health and wellbeing of HCWs continues been identified as the groups most likely to suffer severe to be a major concern in healthcare organizations around adverse psychological outcomes [7]. the world and so we need to better understand how best Protecting HCWs requires a comprehensive approach to support them [10, 11]. This paper presents a series of to address multiple aspects of health and wellbeing. findings on the facilitators and barriers to implement - Healthcare facilities must develop infection prevention ing health and wellbeing initiatives, based on case stud- and control as part of protecting physical health and ies from health systems globally, to inform and generate wellbeing, engineering changes to workflow and admin - transferable lessons and facilitate shared learning. istrative systems [5]. Infection prevention and control (IPC) are measures or initiatives that aim to protect Methodology healthcare workers, patients and visitors from aquiring Design and Theoretical Approach an infection in a healthcare organization, and to control A collective case study approach was selected as the infection transmission when identified. Examples include research method as it allows in-depth, multi-faceted the provision and use of personal protective equipment explorations of complex issues in their real-life settings (PPE), safe injection practices, and the promotion of [12]. The case study approach is an established research hand hygiene. However, such initiatives are not neces- design and is sometimes referred to as a "naturalistic" sarily simple to implement given financial and human design as it explores an event or phenomenon in depth resource constraints, among other challenges. Notably, and in its natural context. This contrasts with an "experi - many countries have struggled to secure PPE for their mental" design, where investigators seek to exert control health workers, partly because of shortages on the inter- over and manipulate the variable(s) of interest[12]. The national market [5]. However, there are also instances of collective case study involves studying multiple cases corruption and misuse of funds, including for contracts simultaneously to generate a broader appreciation of for the procurement of PPE [5]. a particular issue [12]. Gilson et  al. (2011) note that in Initiatives to support physical health must be under- studies with multiple cases, systematic and deliberate pinned by strong leadership and appropriate psychologi- cross-case comparison supports analytic generalization, cal support for staff [9]. Mental health support services not to draw conclusions that can be statistically general- are services or initiatives that aim to support the mental ized to a wider study population, or that will hold across health of healthcare workers. Workplace initiatives can time and place, but rather towards “general conclusions improve the working lives of HCWs as well as mental that, although derived from a limited number of particu- wellbeing [2]. Explicit support services designed to sup- lar experiences, provide theoretical insights that can be port mental health can include a staff support telephone put forward for consideration, and testing, in other, simi- hotline, the availability of wellbeing resources such as lar situations [13]. apps or mindfulness videos, and a peer to peer  listening O ’Brien et al. Globalization and Health (2022) 18:24 Page 3 of 13 The research was grounded in implementation of the research and the study protocol before informed research, which refers to “the application of effective consent was obtained from those who agreed to take part and evidence‐based interventions, in targeted settings, (N  = 13). The case studies were collected via a survey to improve the health and well‐being of specific popu - developed in Qualtrics. The questions were developed lation groups” [14]. Within implementation research, and tested internally by the research team. Questions “implementation science” describes the scientific study were focused on recently implemented initiatives and of methods that take findings into practice, while “effec - facilitators and barriers to their implementation, offering tive implementation” refers to the process whereby an participants the opportunity to write free text responses. intervention is appropriately and successfully executed Specific follow up questions were sent via email to each [15]. Considering initiatives to improve HCWs health of the participants and online calls were held on Micro- and wellbeing during the COVID-19 pandemic through soft Teams where required. Questions asked during the the lens of implementation research encourages ques- calls focused on clarifying the responses to the initial tions to be asked about whether, and if so how, initiatives survey. Ethical approval was provided by the Imperial can make a difference to HCWs and patients. Questions College Research Ethics Committee (ICREC reference: are also raised about the practice of a healthcare delivery 20IC6277). The research was conducted online between team, and whether bringing new knowledge into one set- 22nd September 2020 and 22nd December 2020. ting automatically, or with effort, enables its applicabil - ity in another. Answers to such questions will encourage Data analysis better, more targeted service provision and policy devel- The NVivo 1.0 (QSR International) qualitative data analy - opment, closely linking HCWs health and wellbeing and sis computer software package was used to systematically the delivery of healthcare in a pandemic situation with code the data and assist analysis, especially in cataloguing rigorous evidence. codes to develop and connect codes into wider themes. The research team used a “ground up” approach, devel - Methods oping codes derived from the primary data, and linked Data collection and facility/participant selection concepts and codes to specific themes. The four theme The research participants comprised of representatives nodes that formed the starting point of the analysis were: from 13 healthcare provider organizations from 13 coun- initiatives, facilitators, barriers, and lessons learned. NO tries. The selection of participants was done through the (author 1) and OB (author 2) independently coded the following criteria: individuals who have oversight of the data and met to review and address discrepancies. Dur- management of healthcare provision within a healthcare ing the meeting to review discrepancies, each author (1 institution and have permission from the relevant insti- and 2) presented their justification for coding the data in tution to share information about initiatives developed/ question and subsequently discussed and came to agree- implemented for healthcare workers in response to the ment on the codes most appropriate for data with dis- COVID-19 pandemic. The identification and recruitment crepancies. AS (author 3) reviewed the final analysis to of participants was initiated through the Imperial Col- enhance internal validity, focusing particularly on the lege London Leading Health Systems Network (LHSN), final coding of discrepancies by authors 1 and 2. Finally, the NIHR Imperial Patient Safety Translational Research as part of the analysis process, ‘word frequency queries’ Centre (PSTRC), and through the networks of the were run on NVivo to identify words that occurred most research team. The research team initially approached 20 often in the dataset, as well as their relative and absolute contacts based on their assessment of their existing con- frequency to determine the most mentioned aspects of tacts in healthcare organisations around the world. The the research topic. assessment process towards contact selection focused on identifying contacts to approach that were 1) geo- Results graphically diverse to facilitate international comparisons We received a range of responses from 13 participant between health systems (e.g. equal numbers where pos- organizations, outlining one or several initiatives at the sible from Africa, East Asia and Pacific, Europe and Cen - facility level. In three cases responses focused on initia- tral Asia, Latin America and the Caribbean, Middle East tives at the systems level from the perspective of a World and North Africa, and South Asia), 2) at the healthcare Health Organization (WHO) Regional Office, a national provider level to examine local level decision making, ministry of health and a national patient safety institute. and 3) from diverse healthcare provider organizations to Of the remaining local healthcare organizations, 6 were examine differences between types of provider (e.g. pub - public sector institutions and 4 were private sector. The lic, private, faith-based, parastatal). The research team participant countries are outlined in Fig.  1. Table  1 out- provided potential participants information on the aims lines a summary of the national O’Brien et al. Globalization and Health (2022) 18:24 Page 4 of 13 Fig. 1 Participants by country health system, the date of the first reported case, and mental health initiatives highlighted by respondents estimated total COVID-19 cases and deaths in each of included: peer-to-peer support programs, support hot- the participant countries. lines and psychological first aid. Table  2 outlines the types of initiatives reported at the Physical health initiatives were captured via several country level, as well as the associated facilitators and different types of initiative described. Initiatives that barriers generalized across the initiatives in each country adapted the workplace, such as actions towards health context. and safety compliance in the COVID-19 environment Across the countries, initiatives focused on physi- and actions to reduce the transmission risk to HCWs cal health, including infection prevention and control were commonly noted by respondents. The implemen - (IPC), and mental health. Mental health initiatives were tation of initiatives involving the use of PPE were high- most commonly described among the respondents, with lighted by more than half of respondents as a key element various initiatives designed to combat mental health as a of health and wellbeing addressed by the organization standalone concern or as part of a more holistic approach following the onset of the COVID-19 pandemic. PPE to health and wellbeing, such as the management of staff initiatives were often closely related to wider IPC and rota to balance increasing staffing demands while seeking surveillance. Respondents across a range of geographic to reduce burnout. Respondents noted that mental health areas, types of health system, and public/private org- initiatives developed by their institutions were designed naizations noted PPE challenges as a barrier to imple- to address burnout, compassion fatigue, stress, and mentation of initiatives, highlighting the universality of trauma. Fear of infection, both individually and bring- this barrier during the study period. Similarly, training ing COVID-19 home to family members, was commonly and awareness raising initiatives and guidance for staff cited as a major driver of mental ill health among staff. were outlined in several subject areas, including IPC. Notably, fear as a barrier was exclusively mentioned by Initiatives focused on administration, management healthcare organisations in low- or middle-income coun- and adapted workplace, and health and safety largely tries (LMICs), perhaps due to the resource constraints overlapped with the physical and mental health initia- (e.g. fewer human resources to treat patients, PPE and tives to support the health and wellbeing of HCWs. For equipment challenges) more acutely found in LMICs. example, the set-up of “hot and cold” wards, wards for However, additional research is required to better under- COVID-19 positive patients and wards without COVID- stand the role of fear in different organizational, health 19 positive patients, with different rules and PPE require - system, and geographic contexts. Examples of standalone ments to reduce infection transmission among patients O ’Brien et al. Globalization and Health (2022) 18:24 Page 5 of 13 Table 1 Details of the COVID-19 pandemic in participant countries Country Summary of health system Date of first case (2020) Estimated total cumulative Estimated total culmative COVID-19 Cases per 1 million COVID-19 Deaths per 1 a a population [16] million population [16] th Canada Decentralized, universal, publi- 26 January [18] 4,310 249 cally funded health system [17]. th Chad Mix of severely limited public 19 March [20] 74 5 and private healthcare provid- ers [19]. th Colombia Mix of parallel public and 6 March 30] 16,539 519 private insurers and healthcare providers [21]. th Egypt Mix of public, parastatal and 13 February [23] 1,012 58 private insurers and healthcare providers [22]. th January [18] 4,746 74 India Mixed financing system, with 30 decentralized, universal, publi- cally funded health system and private sector [24]. th Kenya Mix of public and private, 13 March [27] 724 13 for-profit and nonprofit, and faith-based healthcare provid- ers [25, 26]. nd Malawi Mix of public and private, 2 April [29] 302 9 for-profit and nonprofit, and faith-based healthcare provider [28]. th Mexico Mixed financing system, with 28 February [18] 5,814 609 employment-based social insurance schemes, public system for the uninsured, and a private sector [30]. th New Zealand Universal, publically funded 28 February [32] 311 5 health system, delivery system regionally administered [31]. th Pakistan Mix of parallel public and pri- 26 February [34] 1,424 29 vate healthcare providers [33]. rd Singapore Mixed financing system, with 23 January [36] 9,880 5 public statutory insurance system [35]. st Spain Universal, publically funded 1 February [18] 16,895 686 health system, delivery system regionally administered [37]. nd United States of America Mix of public and private, for- 22 January [18] 21,922 626 profit and nonprofit insurers and healthcare providers [38]. a th Figures on 4 October 2020 and staff was designed to reduce the risk of physical ill Facilitators to implementation health among HCWs, but also reassure HCWs work- Several facilitators of implementation were described ing in the wards that safety was a priority. Leadership by the respondents (see Table  3). The two main facilita - engagement initiatives, including the introduction of tors noted were staff input, feedback, and engagement COVID-19 information ward rounds and designated (N = 7) and commitment from leadership (N = 6). Other COVID-19 leadership liaisons were described commonly common facilitators were communication across the by respondents, as was the development of awards to rec- organization (N  = 5), government/national engagement ognize outstanding performance and to boost morale. with the organization and/or intervention(s) (N  = 4) and adequate financial resources (N  = 3). At the facility level, organizational readiness (N = 2), teamwork across O’Brien et al. Globalization and Health (2022) 18:24 Page 6 of 13 Table 2 Types of initiatives implemented, and facilitators/barriers identified Country Intervention(s) reported Facilitators Barriers Canada Support programs for psychological and Organizational readiness Challenges in engaging staff on the uptake mental health. of initiatives Inadequate external knowledge translation / changing national guidelines Chad IPC surveillance, training, and PPE provision Government/national engagement with HCWs fear of contracting COVID-19 / fear of the organization and/or intervention(s) passing COVID-19 to family members Communication across the organization Colombia Health and safety at work initiatives, includ- Adequate financial resources Lack of adequate education and training for ing adaptation of workplaces. Commitment from leadership staff / Misinformation IPC surveillance, training, and PPE provi- Staff input, feedback, and engagement HCWs fear of contracting COVID-19 / fear of sion. Teamwork across the organization passing COVID-19 to family members The wider political and public health context Egypt Active surveillance of psychological and Commitment from leadership HCWs fear of contracting COVID-19 / fear of mental health of staff. Organizational readiness passing COVID-19 to family members Health and safety at work initiatives, includ- Staff input, feedback, and engagement Lack of human resources within the organi- ing adaptation of workplaces. zation India Health and safety at work initiatives, includ- Commitment from leadership Inadequate knowledge translation / chang- ing adaptation of workplaces. Communication across the organization ing guidelines IPC surveillance, training, and PPE provi- Development of guidelines and protocols HCWs fear of contracting COVID-19 / fear of sion. Government/national engagement with passing COVID-19 to family members Support programs for psychological and the organization and/or intervention(s) Lack of human resources within the organi- mental health. zation Redeployment and workload re-distribu- tion. Kenya Health and safety at work initiatives, includ- Adequate financial resources PPE challenges ing adaptation of workplaces. Government/national engagement with IPC surveillance, training, and PPE provision the organization and/or intervention(s) Support programs for psychological and mental health. Malawi IPC surveillance, training, and PPE provision Staff input, feedback, and engagement Challenges in engaging staff on the uptake Support programs for psychological and of initiatives mental health. HCWs fear of contracting COVID-19 / fear of Recognition and awards for staff. passing COVID-19 to family members PPE challenges The wider political and public health context Mexico Health and safety at work initiatives, includ- Adequate financial resources PPE challenges ing adaptation of workplaces. Communication across the organization IPC surveillance, training, and PPE provision Staff input, feedback, and engagement New Zealand Creation of new role for staff support Commitment from leadership Challenges in engaging staff on the uptake Communication across the organization of initiatives Staff input, feedback, and engagement Staff exhaustion Teamwork across the organization The wider political and public health content Pakistan Health and safety at work initiatives, includ- Staff input, feedback, and engagement ing adaptation of workplaces. IPC training and PPE provision. Support programs for psychological and mental health. Singapore Health and safety at work initiatives, includ- Commitment from leadership “Fake news” and misinformation circulating ing adaptation of workplaces. Communication across the organization on social media IPC surveillance, training, and PPE provi- Government/national engagement with PPE challenges sion. the organization and/or intervention(s) Redeployment and workload re-distribu- tion. Spain Support programs for psychological and Pressure of the media to address HCWs Challenges in engaging staff on the uptake mental health. health and wellbeing of initiatives Lack of focus on teams and organizations in developing initiatives O ’Brien et al. Globalization and Health (2022) 18:24 Page 7 of 13 Table 2 (continued) Country Intervention(s) reported Facilitators Barriers United States IPC surveillance, training, and PPE provision Commitment from leadership “Fake news” and misinformation circulating Support programs for psychological and Eec ff tive infection prevention and control on social media mental health. Staff input, feedback, and engagement Inadequate external knowledge translation / Recognition and awards for staff. changing national guidelines Redeployment and workload re-distribu- Lack of human resources within the organi- tion. zation The wider political and public health context Trust in the organization or health system Table 3 Summary of facilitators and barriers to intervention implementation Facilitators Barriers Internal Commitment from leadership Engaging staff on the uptake of initiatives Communication across the organization HCWs’ fear of contracting COVID-19 Development of guidelines and protocols Lack of adequate education and training for staff / Eec ff tive infection prevention and control Lack of focus on teams and organizations in developing initiatives Organizational readiness Lack of human resources within the organization Staff input, feedback, and engagement Staff exhaustion Teamwork across the organization External Government/national engagement with the organization and/or The wider political and public health context intervention(s) Pressure from the media to address HCWs health and wellbeing The wider political and public health context Internal and external Adequate financial resources Inadequate knowledge translation / changing guidelines Fear of passing COVID-19 to family members “Fake news” and misinformation circulating on social media PPE challenges Lack of trust in the organization or health system to exhaustion and burnout, stigma around the need to the organization (N  = 2), effective infection prevention utilize initiatives, or cynicism on the value of utilizing and control (N = 1), and the development of guidelines initiatives (N  = 4), PPE challenges (N  = 4), a lack of and protocols (N  = 1) were also considered enablers in human resources (N  = 3), inadequate external knowl- implementing initiatives to improve HCWs health and edge translation / changing national guidelines (N = 3), wellbeing in the pandemic context. Respondents also and the wider political and public health context, such noted pressure from the media to address HCWs health as political priorities, the balance between economic and wellbeing (N = 1), and the wider political and public prosperity and public health decision-making, and health context (N = 1), such as low infection rates in the non-COVID-19 clinical demands and priorities (N  = community, as external facilitators to implementation. 3). At the facility level, lack of adequate education and training for staff / misinformation (N  = 1), exhaustion Barriers to implementation (N = 1), and a lack of focus on teams and organizations Several barriers to implementation were described by in developing initiatives (N  = 1) were also considered the respondents (see Table  3). The most noted bar - barriers in implementing initiatives to improve the rier was HCWs’ fear of contracting COVID-19 / fear health and wellbeing of HCWs in the pandemic con- of passing COVID-19 to family members (N  = 5). text. Respondents also noted “Fake news” and misinfor- Similarly, respondents commonly noted challenges in mation circulating on social media (N = 2), and lack of engaging staff on the uptake of initiatives, largely due trust in the organization or health system (N  = 1) as O’Brien et al. Globalization and Health (2022) 18:24 Page 8 of 13 barriers to implementation that are both internal and ment. With potential PPE supply disruptions and external to the organisation. increased PPE needs in mind, PPE use by staff had to be judicious yet adequate enough to confer pro- Discussion tection.” The role of leadership and effective engagement Early research into the health and wellbeing of HCWs in multi-level coordination during the COVID-19 pandemic has linked access to Based on the facilitators highlighted by participants, adequate PPE with better psychological outcomes. including staff input, feedback and engagement, the Gold (2020) notes that their findings highlight the role of leadership, organizational readiness, the devel- adverse effects that lack of PPE also have on mental opment of guidelines and protocols, and teamwork health [2]. They add that insufficient PPE provision can across the organization, it is clear that multi-level coor- be seen as institutional betrayal, described as “when dination can act as a facilitator of initiatives. Multi-level trusted and powerful institutions act in ways that can coordination and preparedness, which we define as the harm those dependent on them for safety and wellbe- range of actions undertaken simultaneously and with ing”, compounding trauma [2]. input from a range of stakeholders that are required Another aspect of the multi-level coordination chal- to prepare the organization for a pandemic situation, lenge, seen through the lens of PPE during the COVID- facilitates frontline healthcare providers in develop- 19 pandemic, is effective evidence translation and the ing, rolling out and managing initiatives to improve the challenges associated with rapidly changing national, health and wellbeing of staff. regional, and organizational guidelines. Healthcare Effective coordination within organizations, as well governing bodies in several countries including China, as with external partners, regional and national gov- UK and USA altered official guidelines through 2020, ernment, and in line with guidance from the World impacting guidelines at regional and organizational lev- Health Organization, is a critical element of managing els [41–43]. In the USA, the Centers for Disease Con- HCWs health and wellbeing during a pandemic situa- trol and Prevention (CDC) changed guidance on the tion. As developing and maintaining good multi-level th use of N95 respirators on 11 March 2020, outlining coordination is a complex and challenging task, when that HCWs could use a facemask where N95 respira- organizations are confronted with a range of compet- tors were not available. This guidance was contrary to ing priorities, the importance of forward planning for previous CDC guidance that outlined the need for all a pandemic situation is critical. Human and financial HCWs to wear N95 respirators [43]. Similarly, in the resources should be made available to organizations to UK, guidelines surrounding different aspects of PPE work towards this goal. Policies and guidelines should changed several times between March and April 2020 be in place to ensure both mental and physical safety [42]. of HCWs before a pandemic and updated based on In our research, several respondents noted confusion emerging local and international guidance following around the correct PPE equipment for different areas the onset of the pandemic. of the hospital and for different staff. One respond - The most published coordination challenges through ent explained that staff within the organization were the COVID-19 outbreak thus far have focused on the outright distrustful of organizational PPE guidelines, provision of personal protective equipment (PPE) and accusing the organization of trying to save money. This guidance on how it should be used by HCWs. A vari- example outlines a challenge in knowledge translation ety of challenges have been outlined in the literature [9, in healthcare, but also the importance of trust in the 39, 40], as well as by respondents of the study, covering organization and health system. In implementation sci- procurement, including price regulation and shortages, ence, the involvement of stakeholders (e.g., patients, PPE quality, distribution, provision, and guidelines providers, payers) in the design and introduction of on use. One respondent summed up the multi-level initiatives is now seen as the ‘holy grail’ of healthcare challenges. improvement. However, such methods, including inte- “It was unclear if supply chains of medical equip- grated knowledge translation, have not yet been well ment (including PPE) would be disrupted. This validated [44]. As such, tools to facilitate knowledge potential threat to [organization’s] supply of equip- translation in this context will require greater attention ment was compounded by early national epidemic to the understanding and matching of appropriate com- curve projections predicting a surge in COVID-19 munication methods relevant for different stakeholders admissions to hospitals, which would have driven and audiences. Several tools developed by Knowledge up healthcare demand and use of medical equip- Translation Canada’s Knowledge Translation Program, O ’Brien et al. Globalization and Health (2022) 18:24 Page 9 of 13 for example, can offer organizations guidance on com - at heart every day that they went to work and took municating complex and simple information [45]. In care of patients (regardless of whether the patients the context of the COVID-19 pandemic and potential were positive for COVID-19).” future pandemics where evidence generation and the Fear posed a particular challenge to the implemen- need for knowledge translation moves at a particularly tation of initiatives to adapt the healthcare facility to fast pace, healthcare organizations will benefit from reduce transmission, as many participants noted that having knowledge translation strategies in place ahead staff were hesitant to volunteer. Heads of Department of time. were also hesitant to volunteer their staff for redeploy - Similarly, effective staff engagement can aid knowledge ment to higher demand services and units. Similarly, translation and the build-up of trust between organiza- fear was noted as a challenge in duty rostering dur- tion and staff, encouraging greater utilization of initia - ing the pandemic period as staff were concerned about tives to improve HCWs health and wellbeing. Multiple undertaking higher risk activities. However, participants respondents noted the importance of staff engagement in noted that such challenges were overcome through direct facilitating new initiatives, one noted. engagement with departments and staff, where concerns “Our collective wisdom, at all levels of the organiza- and fears were addressed, and with better training and tion, is huge. In giving voice to this, we not only nd fi assurance from peer groups. innovative and creative solutions, we also value and In the pandemic situation, burnout is a real and tan- engage our workforce.” gible risk of increased pressure on healthcare services and on the health workforce. This is exacerbated due to The importance of staff input, feedback, and engage - the infectious nature of the disease, which reduces the ment across all levels of the organization was discussed capacity of the health workforce due to illness. Burnout frequently by participants who felt strongly that engage- is described as a “response to prolonged exposure to ment between senior level managers and other staff had occupational stressors”, which may have serious conse- a two-fold value. As well as allowing the dissemination quences for healthcare professionals and the organiza- of the latest findings and COVID-19 guidelines, this tions in which they work [46]. Burnout is associated with engagement also offered staff the opportunity to raise sleep deprivation, medical errors, poor quality and safety ideas and concerns at the highest level, with the hope of of care, and low ratings of patient satisfaction [46]. Sev- making them feel valued and listened to. eral of the respondents in the study reported burnout among multiple professional groups since the onset of the COVID-19 pandemic, with one suggesting that initia- Mental health, stressors, and the role of fear tives targeting HCWs health and wellbeing may struggle The prominence of mental health initiatives mentioned to reach those who need it most as a result of a lack of by the respondent group was somewhat unprecedented, time and willingness to engage with the support on offer. given the infectious nature of the virus and the physical The importance of engaging with HCWs who are under repercussions. However, it is possible that the wording extreme stress and pressure in a pandemic may pose a of the case study questions, which requested informa- particular challenge, but it is nonetheless important to tion on either/both physical and mental health initia- encourage uptake of mental health initiatives designed tives, encouraged participants to discuss mental health to improve their health and wellbeing. One participant initiatives specifically. It may also point to an increasing noted that. awareness among the global health community of the far- reaching mental health implications of working and liv- “Attention to emotional and mental well-being along ing through a global pandemic. with psychological support from immediate senior The role of fear as a barrier to the implementation of management and peer groups, managed to boost health and wellbeing initiatives for HCWs was a recur- up the morale amongst the junior doctors. Continu- ring theme among participants. They noted fear in the ous monitoring of the health and well-being of the context of personal exposure, exposing family members staff in COVID-19 unit was done. Monitoring of the to the virus should they transmit COVID-19 in their workload demands, personnel health and safety, homes. One participant explained. resource needs and safe documentation practices was done.” “Especially earlier on in the realization of the pan- demic, [the] majority of the healthcare workers in Such an example outlines that the range of actions my facility were fearful and concerned about their and initiatives that must be employed simultane- personal safety and the safety of their families. They ously to ensure the mental health of HCWs is a critical didn’t trust that the organization had their interest O’Brien et al. Globalization and Health (2022) 18:24 Page 10 of 13 consideration, while also considering how the very con- staff have avenues to provide feedback to leaders.” ditions that may be causing stress and burnout (e.g., Once again, addressing mis- and disinformation workload demands) can be reduced to improve take up requires multi-level collaboration within healthcare of additional initiatives. A consideration of these two ele- organizations, clear preplanning, and engaging staff ments together creates a positive cycle, where initiatives while respecting their ideas and thoughts. The provision to reduce the stress burden on HCWs also free up time of education and training for staff may also offer health - and energy for HCWs to better engage with the addi- care organizations the opportunity to counter mis- and tional support on offer to improve mental health and dis-information with targeted scientifically-backed infor - wellbeing. mation on the origins, nature and symptoms of the virus, transmission and preventing transmission. This would Challenging the impact of misinformation benefit from including information on essential IPC Conflicting information, misinformation and disinforma - within the healthcare setting, the role of testing, includ- tion during the COVID-19 pandemic has been a novel ing available testing facilities for staff, and other common challenge given it is the first pandemic in history in which misconceptions. Providing clear information on where technology and social media are being used on a mas- staff can find out more reliable information, speak to a sive scale as a means of keeping people connected and dedicated helpline, or seek additional assistance within informed [47]. Respondents in this study largely high- the organization also offers the opportunity to address lighted both misinformation and disinformation as major mis- and dis-information on an ongoing basis. As the role challenges to facilitating initiatives for HCWs health of technology in day-to-day life and in healthcare contin- and wellbeing, but some also noted the role of conflict - ues to expand, more time must be invested in ensuring ing information in challenging implementation. One staff are able to access up-to-date and trusted informa - explained. tion about the virus, the pandemic, and the national and local pandemic response. “The spread of misinformation via social media presented challenges to the implementation of both physical and psychological categories of welfare Developing new ways of working measures for staff, not just for the practice of IPC The COVID-19 pandemic has shown HCWs and measures.” patients, their families, and carers the power of data Such is the importance of tackling misinformation and and digital technology in tracking and containing the disinformation to aid the COVID-19 response globally, virus, and in developing new adapted ways of deliver- WHO Member States passed Resolution WHA73.1 at the ing healthcare [49]. There are a range of examples of tel - World Health Assembly in May 2020 [48]. The Resolution ehealth being introduced for primary care in countries recognizes that managing the infodemic is a critical part around the world, offering greater flexibility for patients of controlling the COVID-19 pandemic: it calls on Mem- and better reaching those in geographically challenging ber States to provide reliable COVID-19 content, take areas [50–52]. Similarly, in-person/telemedicine hybrid measures to counter mis- and disinformation and lever- approaches to critical care have also been shown to be age digital technologies across the response. The Resolu - feasible and effective in addressing cross-cultural pub - tion also calls on international organizations to address lic health emergencies [53]. At the organizational level, mis- and disinformation in the digital sphere, work to several of our study participants developed new ways of prevent harmful cyber activities undermining the health working through the course of the pandemic. One par- response and support the provision of science-based data ticipant explained. to the public [47, 48]. So too must health organizations “We had to close some of our clinics because of the consider the role that misinformation and disinformation pandemic of course, but then [had] to really think may have in their COVID-19 response and on the health about how [we could] still serve our patients and and wellbeing of their staff. One participant in the study encourage them to seek care if they need it. We had noted that. to do a lot of telemedicine, you know, on video, which “Effective communication between senior staff/ lead - worked really well, but that took a while to put the ers and staff is one way to address this issue. This infrastructure in place.” involves timely dissemination of accurate and evi- Changes to ways of working were largely designed to dence-based information to staff, frequent engage - reduce the risk of transmission and optimize workflow ment of staff by leaders to allay fears and address given the increased pressure on resources. However, the concerns, and two-way communication to ensure O ’Brien et al. Globalization and Health (2022) 18:24 Page 11 of 13 development of new ways of working need not stop as research has sometimes been criticized for lacking sci- the pandemic winds down. One respondent noted. entific precision in which to make a generalisation [11]. Nonetheless, the collective case study better facilitates “As contingency spaces and capacities are gradually studying multiple cases simultaneously to generate a used to support the growth and development of the broader appreciation of a particular issue [11]. As such, hospital, periodic reviews and re-investment efforts the research team designed the research to collect case are critical to re-establishing such buffers. This studies and information from a range of organizations would help to ensure that the hospital retains the and health systems around the world to better assess capability and capacity to cope with future crises.” trends ahead of generalization, while being cognizant of It is notable that a lack of resources was a commonly the limitations in representativeness of the case studies. highlighted barrier by participants in this research. Developing new, more efficient ways of working offers the opportunity for healthcare leadership to maximize Conclusions the available resources. Of course, these advances must HCWs at the frontline of the COVID-19 pandemic are be closely monitored and evaluated to ensure standards at a disproportionate risk of adverse physical and psy- are maintained or surpassed, the health and wellbe- chological outcomes and so protecting HCWs requires ing of both patients and HCWs remain a priority, and a comprehensive and multi-modal approach to address that patient safety is a core consideration in any actions multiple aspects of health and wellbeing. Through a towards more efficient ways of working. case study approach, we demonstrate the facilitators The COVID-19 pandemic has provided healthcare and barriers to implementing such initiatives across organizations around the world the opportunity to assess healthcare organizations globally. Our findings, based the present state of their ways of working, including the on the experiences of 13 healthcare organizations, provisions on offer that seek to improve the health and show multi-level coordination and preparedness is a wellbeing of their HCWs. As health systems around the critical starting point to ensure initiatives for HCW world continue to address the pandemic, with an eye health and wellbeing can be implemented in a condu- towards post-pandemic health system preparedness and cive environment, but it remains vital that the role of planning, these considerations must remain at the heart fear and misinformation must also be managed as the of healthcare delivery and development. pandemic progresses. Health systems and healthcare organizations should now consider these findings at the system and organizational level as part of their efforts Limitations to design and implement smart and agile solutions for The findings of the research offer insights into the facil - the physical and mental wellbeing of HCWs. Stakehold- itators and barriers to implementation only at one point ers must also recognize that the health and wellbeing in time. Findings therefore do not account for experi- needs of HCWs will continue well beyond the ‘end’ ences of implementation after December 2020 and do of the pandemic due to the prolonged impact of their not offer information on whether facilitators and barri - experiences. ers changed with time after initiatives were first intro - duced, nor whether additional facilitators and barriers Abbreviations have emerged in implementing new initiatives post- COVID-19: Severe acute respiratory syndrome coronavirus (SARS-CoV-2); 2020. However, the research offers valuable insight into CDC: Centers for Disease Control and Prevention; IPC: Infection preven- tion and control; HCWs: Healthcare workers; LHSN: Leading Health Systems facilitators and barriers in the beginning of the COVID- Network; LMICs: Low- and middle-income countries; PPE: Personal protective 19 pandemic across a range of contexts that may be val- equipment; PSTRC : NIHR Imperial Patient Safety Translational Research Centre; uable through the course of the COVID-19 pandemic WHO: World Health Organization. and for future pandemics and other prolonged crises. Acknowledgements A further limitation of the study is the representative- This work was supported by the NIHR Imperial Patient Safety Translational ness of the cases outlined. While the authors aimed to Research Centre (PSTRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. collect case studies from a range of geographic regions and types of healthcare organization (N = 13), the case Authors’ contributions study approach may have led to selection bias and so NO, KF and MD conceptualized the manuscript. NO, OB and AS completed the data analysis. NO lead on the administration and writing of the original draft it is important to note that the findings are not nec - with support from KF. All authors equally contributed to the writing, reviewing, essarily representative of the experience of all health- and editing. MD supervised the work. The author(s) read and approved the care organizations of that type/geography. Case study final manuscript. O’Brien et al. Globalization and Health (2022) 18:24 Page 12 of 13 Funding 14. Lobb R, Colditz GA. Implementation science and its application to popu- This work was supported by the NIHR Imperial Patient Safety Translational lation health. Annu Rev Public Health. 2013;34:235–51. Research Centre (PSTRC). The views expressed are those of the authors and 15. Rapport F, Clay-Williams R, Churruca K, et al. The struggle of translating not necessarily those of the NIHR or the Department of Health and Social Care. science into action: Foundational concepts of implementation science. J NIHR Imperial Patient Safety Translational Research Centre. Eval Clin Pract. 2018;24(1):117–26. 16. WHO. Coronavirus Disease (COVID-19) Situation Report: October 4 2020 Availability of data and materials [online]. World Health Organization; 2021. Available from: https:// www. Not applicable.who. int/ docs/ defau lt- source/ coron aviru se/ situa tion- repor ts/ 20201 005- weekly- epi- update- 8. pdf. Accessed 9 Dec 2021. 17. Tikkanen R, Osborn R, Mossialos E, et al. 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Accessed 4 May Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : 50. Centers for Medicare & Medicaid Services. Trump Administration Makes fast, convenient online submission Sweeping Regulatory Changes to Help U.S. Healthcare System Address thorough peer review by experienced researchers in your field COVID-19 Patient Surge [online]. 2020. Available from: https:// www. cms. gov/ newsr oom/ press- relea ses/ trump- admin istra tion- makes- sweep rapid publication on acceptance ing- regul atory- chang es- help- us- healt hcare- system- addre ss- covid- 19. support for research data, including large and complex data types Accessed 4 May 2021. • gold Open Access which fosters wider collaboration and increased citations 51. Hoeksma, J & Downey, A. NHS England issues 48-hour tender for online primary care consultations [online]. Digital Health. 2020 Mar 19. Available maximum visibility for your research: over 100M website views per year from: https:// www. digit alhea lth. net/ 2020/ 03/ nhs- engla nd- issues- 48- hour- tender- for- online- prima ry- care- consu ltati ons/. Accessed 4 May At BMC, research is always in progress. Learn more biomedcentral.com/submissions 52. Ministère des Solidarités et de la Santé. Tableau récapitulatif des profes- sions autorisées à exercer a distance dans le cadre de la gestion de crise http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Globalization and Health Springer Journals

Implementation of initiatives designed to improve healthcare worker health and wellbeing during the COVID-19 pandemic: comparative case studies from 13 healthcare provider organisations globally

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Abstract

Background: Healthcare workers are at a disproportionate risk of contracting COVID-19. The physical and mental repercussions of such risk have an impact on the wellbeing of healthcare workers around the world. Healthcare workers are the foundation of all well-functioning health systems capable of responding to the ongoing pandemic; initiatives to address and reduce such risk are critical. Since the onset of the pandemic healthcare organizations have embarked on the implementation of a range of initiatives designed to improve healthcare worker health and wellbeing. Methods: Through a qualitative collective case study approach where participants responded to a longform survey, the facilitators, and barriers to implementing such initiatives were explored, offering global insights into the chal- lenges faced at the organizational level. 13 healthcare organizations were surveyed across 13 countries. Of these 13 participants, 5 subsequently provided missing information through longform interviews or written clarifications. Results: 13 case studies were received from healthcare provider organizations. Mental health initiatives were the most commonly described health and wellbeing initiatives among respondents. Physical health and health and safety focused initiatives, such as the adaption of workspaces, were also described. Strong institutional level direction, including engaged leadership, and the input, feedback, and engagement of frontline staff were the two main facilita- tors in implementing initiatives. The most common barrier was HCWs’ fear of contracting COVID-19 / fear of passing COVID-19 to family members. In organizations who discussed infection prevention and control initiatives, inadequate personal protective equipment and supply chain disruption were highlighted by respondents. Conclusions: Common themes emerge globally in exploring the enablers and barriers to implementing initiatives to improve healthcare workers health and wellbeing through the COVID-19 pandemic. Consideration of the themes outlined in the paper by healthcare organizations could help influence the design and deployment of future initia- tives ahead of implementation. Keywords: Global institutions/organizations, Human resources for health, Healthcare workers, Health care planning, COVID-19, Outbreaks, Communicable disease, Psychosocial impacts *Correspondence: n.obrien@imperial.ac.uk Institute of Global Health Innovation, Imperial College London, London, United Kingdom © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. O’Brien et al. Globalization and Health (2022) 18:24 Page 2 of 13 service. Non explicit support services are services or Background initiatives set up without mental health support as the Severe acute respiratory syndrome coronavirus (SARS- primary goal, but do have a positive impact on mental CoV-2), henceforth described as COVID-19, was first health. Examples include the provision and use of PPE, identified in Wuhan, China in December 2019 and has which can reduce HCWs concerns over their health and since spread to more than 200 countries [1]. Healthcare spreading infections to their families [2]. Non-explicit workers (HCWs) at the frontline of the COVID-19 pan- initiatives may seek to ease caregiver or childcare bur- demic are at a disproportionate risk of adverse physical den or lessen financial stressors, such as hazard pay, for and psychological outcomes [2]. The true scale of COV - example, to mitigate negative mental health outcomes ID-19’s impact on health and wellbeing is not yet known, [2]. however Amnesty International found that at least 17,000 The importance of HCWs to a well-functioning health healthcare workers around the world died in the first system is not always acknowledged or backed up with year of the pandemic, a substantial increase from more appropriate responses from systems or leaders. Devel- than 3,000 deaths reported in research published in July oping and launching initiatives designed to address and 2020 [3, 4]. Data from surveys around the world admin- reduce health and wellbeing challenges whilst under time, istered during the COVID-19 pandemic, as well as other human resource and financial pressures is a key challenge pandemics and epidemics, also found that HCWs experi- for many health systems and institutions globally. Our enced concerns about their own health and fear of trans- study addresses a research gap by unpacking the facilita- mitting the virus to family, as well as increased levels of tors and barriers to the implementation of initiatives to depression, anxiety, distress and insomnia [5–8]. Nurses, improve the health and wellbeing of HCWs through the female workers, frontline workers, younger medical staff, COVID-19 pandemic. While initiatives have been rolled and workers in areas with higher infection rates have out globally, the health and wellbeing of HCWs continues been identified as the groups most likely to suffer severe to be a major concern in healthcare organizations around adverse psychological outcomes [7]. the world and so we need to better understand how best Protecting HCWs requires a comprehensive approach to support them [10, 11]. This paper presents a series of to address multiple aspects of health and wellbeing. findings on the facilitators and barriers to implement - Healthcare facilities must develop infection prevention ing health and wellbeing initiatives, based on case stud- and control as part of protecting physical health and ies from health systems globally, to inform and generate wellbeing, engineering changes to workflow and admin - transferable lessons and facilitate shared learning. istrative systems [5]. Infection prevention and control (IPC) are measures or initiatives that aim to protect Methodology healthcare workers, patients and visitors from aquiring Design and Theoretical Approach an infection in a healthcare organization, and to control A collective case study approach was selected as the infection transmission when identified. Examples include research method as it allows in-depth, multi-faceted the provision and use of personal protective equipment explorations of complex issues in their real-life settings (PPE), safe injection practices, and the promotion of [12]. The case study approach is an established research hand hygiene. However, such initiatives are not neces- design and is sometimes referred to as a "naturalistic" sarily simple to implement given financial and human design as it explores an event or phenomenon in depth resource constraints, among other challenges. Notably, and in its natural context. This contrasts with an "experi - many countries have struggled to secure PPE for their mental" design, where investigators seek to exert control health workers, partly because of shortages on the inter- over and manipulate the variable(s) of interest[12]. The national market [5]. However, there are also instances of collective case study involves studying multiple cases corruption and misuse of funds, including for contracts simultaneously to generate a broader appreciation of for the procurement of PPE [5]. a particular issue [12]. Gilson et  al. (2011) note that in Initiatives to support physical health must be under- studies with multiple cases, systematic and deliberate pinned by strong leadership and appropriate psychologi- cross-case comparison supports analytic generalization, cal support for staff [9]. Mental health support services not to draw conclusions that can be statistically general- are services or initiatives that aim to support the mental ized to a wider study population, or that will hold across health of healthcare workers. Workplace initiatives can time and place, but rather towards “general conclusions improve the working lives of HCWs as well as mental that, although derived from a limited number of particu- wellbeing [2]. Explicit support services designed to sup- lar experiences, provide theoretical insights that can be port mental health can include a staff support telephone put forward for consideration, and testing, in other, simi- hotline, the availability of wellbeing resources such as lar situations [13]. apps or mindfulness videos, and a peer to peer  listening O ’Brien et al. Globalization and Health (2022) 18:24 Page 3 of 13 The research was grounded in implementation of the research and the study protocol before informed research, which refers to “the application of effective consent was obtained from those who agreed to take part and evidence‐based interventions, in targeted settings, (N  = 13). The case studies were collected via a survey to improve the health and well‐being of specific popu - developed in Qualtrics. The questions were developed lation groups” [14]. Within implementation research, and tested internally by the research team. Questions “implementation science” describes the scientific study were focused on recently implemented initiatives and of methods that take findings into practice, while “effec - facilitators and barriers to their implementation, offering tive implementation” refers to the process whereby an participants the opportunity to write free text responses. intervention is appropriately and successfully executed Specific follow up questions were sent via email to each [15]. Considering initiatives to improve HCWs health of the participants and online calls were held on Micro- and wellbeing during the COVID-19 pandemic through soft Teams where required. Questions asked during the the lens of implementation research encourages ques- calls focused on clarifying the responses to the initial tions to be asked about whether, and if so how, initiatives survey. Ethical approval was provided by the Imperial can make a difference to HCWs and patients. Questions College Research Ethics Committee (ICREC reference: are also raised about the practice of a healthcare delivery 20IC6277). The research was conducted online between team, and whether bringing new knowledge into one set- 22nd September 2020 and 22nd December 2020. ting automatically, or with effort, enables its applicabil - ity in another. Answers to such questions will encourage Data analysis better, more targeted service provision and policy devel- The NVivo 1.0 (QSR International) qualitative data analy - opment, closely linking HCWs health and wellbeing and sis computer software package was used to systematically the delivery of healthcare in a pandemic situation with code the data and assist analysis, especially in cataloguing rigorous evidence. codes to develop and connect codes into wider themes. The research team used a “ground up” approach, devel - Methods oping codes derived from the primary data, and linked Data collection and facility/participant selection concepts and codes to specific themes. The four theme The research participants comprised of representatives nodes that formed the starting point of the analysis were: from 13 healthcare provider organizations from 13 coun- initiatives, facilitators, barriers, and lessons learned. NO tries. The selection of participants was done through the (author 1) and OB (author 2) independently coded the following criteria: individuals who have oversight of the data and met to review and address discrepancies. Dur- management of healthcare provision within a healthcare ing the meeting to review discrepancies, each author (1 institution and have permission from the relevant insti- and 2) presented their justification for coding the data in tution to share information about initiatives developed/ question and subsequently discussed and came to agree- implemented for healthcare workers in response to the ment on the codes most appropriate for data with dis- COVID-19 pandemic. The identification and recruitment crepancies. AS (author 3) reviewed the final analysis to of participants was initiated through the Imperial Col- enhance internal validity, focusing particularly on the lege London Leading Health Systems Network (LHSN), final coding of discrepancies by authors 1 and 2. Finally, the NIHR Imperial Patient Safety Translational Research as part of the analysis process, ‘word frequency queries’ Centre (PSTRC), and through the networks of the were run on NVivo to identify words that occurred most research team. The research team initially approached 20 often in the dataset, as well as their relative and absolute contacts based on their assessment of their existing con- frequency to determine the most mentioned aspects of tacts in healthcare organisations around the world. The the research topic. assessment process towards contact selection focused on identifying contacts to approach that were 1) geo- Results graphically diverse to facilitate international comparisons We received a range of responses from 13 participant between health systems (e.g. equal numbers where pos- organizations, outlining one or several initiatives at the sible from Africa, East Asia and Pacific, Europe and Cen - facility level. In three cases responses focused on initia- tral Asia, Latin America and the Caribbean, Middle East tives at the systems level from the perspective of a World and North Africa, and South Asia), 2) at the healthcare Health Organization (WHO) Regional Office, a national provider level to examine local level decision making, ministry of health and a national patient safety institute. and 3) from diverse healthcare provider organizations to Of the remaining local healthcare organizations, 6 were examine differences between types of provider (e.g. pub - public sector institutions and 4 were private sector. The lic, private, faith-based, parastatal). The research team participant countries are outlined in Fig.  1. Table  1 out- provided potential participants information on the aims lines a summary of the national O’Brien et al. Globalization and Health (2022) 18:24 Page 4 of 13 Fig. 1 Participants by country health system, the date of the first reported case, and mental health initiatives highlighted by respondents estimated total COVID-19 cases and deaths in each of included: peer-to-peer support programs, support hot- the participant countries. lines and psychological first aid. Table  2 outlines the types of initiatives reported at the Physical health initiatives were captured via several country level, as well as the associated facilitators and different types of initiative described. Initiatives that barriers generalized across the initiatives in each country adapted the workplace, such as actions towards health context. and safety compliance in the COVID-19 environment Across the countries, initiatives focused on physi- and actions to reduce the transmission risk to HCWs cal health, including infection prevention and control were commonly noted by respondents. The implemen - (IPC), and mental health. Mental health initiatives were tation of initiatives involving the use of PPE were high- most commonly described among the respondents, with lighted by more than half of respondents as a key element various initiatives designed to combat mental health as a of health and wellbeing addressed by the organization standalone concern or as part of a more holistic approach following the onset of the COVID-19 pandemic. PPE to health and wellbeing, such as the management of staff initiatives were often closely related to wider IPC and rota to balance increasing staffing demands while seeking surveillance. Respondents across a range of geographic to reduce burnout. Respondents noted that mental health areas, types of health system, and public/private org- initiatives developed by their institutions were designed naizations noted PPE challenges as a barrier to imple- to address burnout, compassion fatigue, stress, and mentation of initiatives, highlighting the universality of trauma. Fear of infection, both individually and bring- this barrier during the study period. Similarly, training ing COVID-19 home to family members, was commonly and awareness raising initiatives and guidance for staff cited as a major driver of mental ill health among staff. were outlined in several subject areas, including IPC. Notably, fear as a barrier was exclusively mentioned by Initiatives focused on administration, management healthcare organisations in low- or middle-income coun- and adapted workplace, and health and safety largely tries (LMICs), perhaps due to the resource constraints overlapped with the physical and mental health initia- (e.g. fewer human resources to treat patients, PPE and tives to support the health and wellbeing of HCWs. For equipment challenges) more acutely found in LMICs. example, the set-up of “hot and cold” wards, wards for However, additional research is required to better under- COVID-19 positive patients and wards without COVID- stand the role of fear in different organizational, health 19 positive patients, with different rules and PPE require - system, and geographic contexts. Examples of standalone ments to reduce infection transmission among patients O ’Brien et al. Globalization and Health (2022) 18:24 Page 5 of 13 Table 1 Details of the COVID-19 pandemic in participant countries Country Summary of health system Date of first case (2020) Estimated total cumulative Estimated total culmative COVID-19 Cases per 1 million COVID-19 Deaths per 1 a a population [16] million population [16] th Canada Decentralized, universal, publi- 26 January [18] 4,310 249 cally funded health system [17]. th Chad Mix of severely limited public 19 March [20] 74 5 and private healthcare provid- ers [19]. th Colombia Mix of parallel public and 6 March 30] 16,539 519 private insurers and healthcare providers [21]. th Egypt Mix of public, parastatal and 13 February [23] 1,012 58 private insurers and healthcare providers [22]. th January [18] 4,746 74 India Mixed financing system, with 30 decentralized, universal, publi- cally funded health system and private sector [24]. th Kenya Mix of public and private, 13 March [27] 724 13 for-profit and nonprofit, and faith-based healthcare provid- ers [25, 26]. nd Malawi Mix of public and private, 2 April [29] 302 9 for-profit and nonprofit, and faith-based healthcare provider [28]. th Mexico Mixed financing system, with 28 February [18] 5,814 609 employment-based social insurance schemes, public system for the uninsured, and a private sector [30]. th New Zealand Universal, publically funded 28 February [32] 311 5 health system, delivery system regionally administered [31]. th Pakistan Mix of parallel public and pri- 26 February [34] 1,424 29 vate healthcare providers [33]. rd Singapore Mixed financing system, with 23 January [36] 9,880 5 public statutory insurance system [35]. st Spain Universal, publically funded 1 February [18] 16,895 686 health system, delivery system regionally administered [37]. nd United States of America Mix of public and private, for- 22 January [18] 21,922 626 profit and nonprofit insurers and healthcare providers [38]. a th Figures on 4 October 2020 and staff was designed to reduce the risk of physical ill Facilitators to implementation health among HCWs, but also reassure HCWs work- Several facilitators of implementation were described ing in the wards that safety was a priority. Leadership by the respondents (see Table  3). The two main facilita - engagement initiatives, including the introduction of tors noted were staff input, feedback, and engagement COVID-19 information ward rounds and designated (N = 7) and commitment from leadership (N = 6). Other COVID-19 leadership liaisons were described commonly common facilitators were communication across the by respondents, as was the development of awards to rec- organization (N  = 5), government/national engagement ognize outstanding performance and to boost morale. with the organization and/or intervention(s) (N  = 4) and adequate financial resources (N  = 3). At the facility level, organizational readiness (N = 2), teamwork across O’Brien et al. Globalization and Health (2022) 18:24 Page 6 of 13 Table 2 Types of initiatives implemented, and facilitators/barriers identified Country Intervention(s) reported Facilitators Barriers Canada Support programs for psychological and Organizational readiness Challenges in engaging staff on the uptake mental health. of initiatives Inadequate external knowledge translation / changing national guidelines Chad IPC surveillance, training, and PPE provision Government/national engagement with HCWs fear of contracting COVID-19 / fear of the organization and/or intervention(s) passing COVID-19 to family members Communication across the organization Colombia Health and safety at work initiatives, includ- Adequate financial resources Lack of adequate education and training for ing adaptation of workplaces. Commitment from leadership staff / Misinformation IPC surveillance, training, and PPE provi- Staff input, feedback, and engagement HCWs fear of contracting COVID-19 / fear of sion. Teamwork across the organization passing COVID-19 to family members The wider political and public health context Egypt Active surveillance of psychological and Commitment from leadership HCWs fear of contracting COVID-19 / fear of mental health of staff. Organizational readiness passing COVID-19 to family members Health and safety at work initiatives, includ- Staff input, feedback, and engagement Lack of human resources within the organi- ing adaptation of workplaces. zation India Health and safety at work initiatives, includ- Commitment from leadership Inadequate knowledge translation / chang- ing adaptation of workplaces. Communication across the organization ing guidelines IPC surveillance, training, and PPE provi- Development of guidelines and protocols HCWs fear of contracting COVID-19 / fear of sion. Government/national engagement with passing COVID-19 to family members Support programs for psychological and the organization and/or intervention(s) Lack of human resources within the organi- mental health. zation Redeployment and workload re-distribu- tion. Kenya Health and safety at work initiatives, includ- Adequate financial resources PPE challenges ing adaptation of workplaces. Government/national engagement with IPC surveillance, training, and PPE provision the organization and/or intervention(s) Support programs for psychological and mental health. Malawi IPC surveillance, training, and PPE provision Staff input, feedback, and engagement Challenges in engaging staff on the uptake Support programs for psychological and of initiatives mental health. HCWs fear of contracting COVID-19 / fear of Recognition and awards for staff. passing COVID-19 to family members PPE challenges The wider political and public health context Mexico Health and safety at work initiatives, includ- Adequate financial resources PPE challenges ing adaptation of workplaces. Communication across the organization IPC surveillance, training, and PPE provision Staff input, feedback, and engagement New Zealand Creation of new role for staff support Commitment from leadership Challenges in engaging staff on the uptake Communication across the organization of initiatives Staff input, feedback, and engagement Staff exhaustion Teamwork across the organization The wider political and public health content Pakistan Health and safety at work initiatives, includ- Staff input, feedback, and engagement ing adaptation of workplaces. IPC training and PPE provision. Support programs for psychological and mental health. Singapore Health and safety at work initiatives, includ- Commitment from leadership “Fake news” and misinformation circulating ing adaptation of workplaces. Communication across the organization on social media IPC surveillance, training, and PPE provi- Government/national engagement with PPE challenges sion. the organization and/or intervention(s) Redeployment and workload re-distribu- tion. Spain Support programs for psychological and Pressure of the media to address HCWs Challenges in engaging staff on the uptake mental health. health and wellbeing of initiatives Lack of focus on teams and organizations in developing initiatives O ’Brien et al. Globalization and Health (2022) 18:24 Page 7 of 13 Table 2 (continued) Country Intervention(s) reported Facilitators Barriers United States IPC surveillance, training, and PPE provision Commitment from leadership “Fake news” and misinformation circulating Support programs for psychological and Eec ff tive infection prevention and control on social media mental health. Staff input, feedback, and engagement Inadequate external knowledge translation / Recognition and awards for staff. changing national guidelines Redeployment and workload re-distribu- Lack of human resources within the organi- tion. zation The wider political and public health context Trust in the organization or health system Table 3 Summary of facilitators and barriers to intervention implementation Facilitators Barriers Internal Commitment from leadership Engaging staff on the uptake of initiatives Communication across the organization HCWs’ fear of contracting COVID-19 Development of guidelines and protocols Lack of adequate education and training for staff / Eec ff tive infection prevention and control Lack of focus on teams and organizations in developing initiatives Organizational readiness Lack of human resources within the organization Staff input, feedback, and engagement Staff exhaustion Teamwork across the organization External Government/national engagement with the organization and/or The wider political and public health context intervention(s) Pressure from the media to address HCWs health and wellbeing The wider political and public health context Internal and external Adequate financial resources Inadequate knowledge translation / changing guidelines Fear of passing COVID-19 to family members “Fake news” and misinformation circulating on social media PPE challenges Lack of trust in the organization or health system to exhaustion and burnout, stigma around the need to the organization (N  = 2), effective infection prevention utilize initiatives, or cynicism on the value of utilizing and control (N = 1), and the development of guidelines initiatives (N  = 4), PPE challenges (N  = 4), a lack of and protocols (N  = 1) were also considered enablers in human resources (N  = 3), inadequate external knowl- implementing initiatives to improve HCWs health and edge translation / changing national guidelines (N = 3), wellbeing in the pandemic context. Respondents also and the wider political and public health context, such noted pressure from the media to address HCWs health as political priorities, the balance between economic and wellbeing (N = 1), and the wider political and public prosperity and public health decision-making, and health context (N = 1), such as low infection rates in the non-COVID-19 clinical demands and priorities (N  = community, as external facilitators to implementation. 3). At the facility level, lack of adequate education and training for staff / misinformation (N  = 1), exhaustion Barriers to implementation (N = 1), and a lack of focus on teams and organizations Several barriers to implementation were described by in developing initiatives (N  = 1) were also considered the respondents (see Table  3). The most noted bar - barriers in implementing initiatives to improve the rier was HCWs’ fear of contracting COVID-19 / fear health and wellbeing of HCWs in the pandemic con- of passing COVID-19 to family members (N  = 5). text. Respondents also noted “Fake news” and misinfor- Similarly, respondents commonly noted challenges in mation circulating on social media (N = 2), and lack of engaging staff on the uptake of initiatives, largely due trust in the organization or health system (N  = 1) as O’Brien et al. Globalization and Health (2022) 18:24 Page 8 of 13 barriers to implementation that are both internal and ment. With potential PPE supply disruptions and external to the organisation. increased PPE needs in mind, PPE use by staff had to be judicious yet adequate enough to confer pro- Discussion tection.” The role of leadership and effective engagement Early research into the health and wellbeing of HCWs in multi-level coordination during the COVID-19 pandemic has linked access to Based on the facilitators highlighted by participants, adequate PPE with better psychological outcomes. including staff input, feedback and engagement, the Gold (2020) notes that their findings highlight the role of leadership, organizational readiness, the devel- adverse effects that lack of PPE also have on mental opment of guidelines and protocols, and teamwork health [2]. They add that insufficient PPE provision can across the organization, it is clear that multi-level coor- be seen as institutional betrayal, described as “when dination can act as a facilitator of initiatives. Multi-level trusted and powerful institutions act in ways that can coordination and preparedness, which we define as the harm those dependent on them for safety and wellbe- range of actions undertaken simultaneously and with ing”, compounding trauma [2]. input from a range of stakeholders that are required Another aspect of the multi-level coordination chal- to prepare the organization for a pandemic situation, lenge, seen through the lens of PPE during the COVID- facilitates frontline healthcare providers in develop- 19 pandemic, is effective evidence translation and the ing, rolling out and managing initiatives to improve the challenges associated with rapidly changing national, health and wellbeing of staff. regional, and organizational guidelines. Healthcare Effective coordination within organizations, as well governing bodies in several countries including China, as with external partners, regional and national gov- UK and USA altered official guidelines through 2020, ernment, and in line with guidance from the World impacting guidelines at regional and organizational lev- Health Organization, is a critical element of managing els [41–43]. In the USA, the Centers for Disease Con- HCWs health and wellbeing during a pandemic situa- trol and Prevention (CDC) changed guidance on the tion. As developing and maintaining good multi-level th use of N95 respirators on 11 March 2020, outlining coordination is a complex and challenging task, when that HCWs could use a facemask where N95 respira- organizations are confronted with a range of compet- tors were not available. This guidance was contrary to ing priorities, the importance of forward planning for previous CDC guidance that outlined the need for all a pandemic situation is critical. Human and financial HCWs to wear N95 respirators [43]. Similarly, in the resources should be made available to organizations to UK, guidelines surrounding different aspects of PPE work towards this goal. Policies and guidelines should changed several times between March and April 2020 be in place to ensure both mental and physical safety [42]. of HCWs before a pandemic and updated based on In our research, several respondents noted confusion emerging local and international guidance following around the correct PPE equipment for different areas the onset of the pandemic. of the hospital and for different staff. One respond - The most published coordination challenges through ent explained that staff within the organization were the COVID-19 outbreak thus far have focused on the outright distrustful of organizational PPE guidelines, provision of personal protective equipment (PPE) and accusing the organization of trying to save money. This guidance on how it should be used by HCWs. A vari- example outlines a challenge in knowledge translation ety of challenges have been outlined in the literature [9, in healthcare, but also the importance of trust in the 39, 40], as well as by respondents of the study, covering organization and health system. In implementation sci- procurement, including price regulation and shortages, ence, the involvement of stakeholders (e.g., patients, PPE quality, distribution, provision, and guidelines providers, payers) in the design and introduction of on use. One respondent summed up the multi-level initiatives is now seen as the ‘holy grail’ of healthcare challenges. improvement. However, such methods, including inte- “It was unclear if supply chains of medical equip- grated knowledge translation, have not yet been well ment (including PPE) would be disrupted. This validated [44]. As such, tools to facilitate knowledge potential threat to [organization’s] supply of equip- translation in this context will require greater attention ment was compounded by early national epidemic to the understanding and matching of appropriate com- curve projections predicting a surge in COVID-19 munication methods relevant for different stakeholders admissions to hospitals, which would have driven and audiences. Several tools developed by Knowledge up healthcare demand and use of medical equip- Translation Canada’s Knowledge Translation Program, O ’Brien et al. Globalization and Health (2022) 18:24 Page 9 of 13 for example, can offer organizations guidance on com - at heart every day that they went to work and took municating complex and simple information [45]. In care of patients (regardless of whether the patients the context of the COVID-19 pandemic and potential were positive for COVID-19).” future pandemics where evidence generation and the Fear posed a particular challenge to the implemen- need for knowledge translation moves at a particularly tation of initiatives to adapt the healthcare facility to fast pace, healthcare organizations will benefit from reduce transmission, as many participants noted that having knowledge translation strategies in place ahead staff were hesitant to volunteer. Heads of Department of time. were also hesitant to volunteer their staff for redeploy - Similarly, effective staff engagement can aid knowledge ment to higher demand services and units. Similarly, translation and the build-up of trust between organiza- fear was noted as a challenge in duty rostering dur- tion and staff, encouraging greater utilization of initia - ing the pandemic period as staff were concerned about tives to improve HCWs health and wellbeing. Multiple undertaking higher risk activities. However, participants respondents noted the importance of staff engagement in noted that such challenges were overcome through direct facilitating new initiatives, one noted. engagement with departments and staff, where concerns “Our collective wisdom, at all levels of the organiza- and fears were addressed, and with better training and tion, is huge. In giving voice to this, we not only nd fi assurance from peer groups. innovative and creative solutions, we also value and In the pandemic situation, burnout is a real and tan- engage our workforce.” gible risk of increased pressure on healthcare services and on the health workforce. This is exacerbated due to The importance of staff input, feedback, and engage - the infectious nature of the disease, which reduces the ment across all levels of the organization was discussed capacity of the health workforce due to illness. Burnout frequently by participants who felt strongly that engage- is described as a “response to prolonged exposure to ment between senior level managers and other staff had occupational stressors”, which may have serious conse- a two-fold value. As well as allowing the dissemination quences for healthcare professionals and the organiza- of the latest findings and COVID-19 guidelines, this tions in which they work [46]. Burnout is associated with engagement also offered staff the opportunity to raise sleep deprivation, medical errors, poor quality and safety ideas and concerns at the highest level, with the hope of of care, and low ratings of patient satisfaction [46]. Sev- making them feel valued and listened to. eral of the respondents in the study reported burnout among multiple professional groups since the onset of the COVID-19 pandemic, with one suggesting that initia- Mental health, stressors, and the role of fear tives targeting HCWs health and wellbeing may struggle The prominence of mental health initiatives mentioned to reach those who need it most as a result of a lack of by the respondent group was somewhat unprecedented, time and willingness to engage with the support on offer. given the infectious nature of the virus and the physical The importance of engaging with HCWs who are under repercussions. However, it is possible that the wording extreme stress and pressure in a pandemic may pose a of the case study questions, which requested informa- particular challenge, but it is nonetheless important to tion on either/both physical and mental health initia- encourage uptake of mental health initiatives designed tives, encouraged participants to discuss mental health to improve their health and wellbeing. One participant initiatives specifically. It may also point to an increasing noted that. awareness among the global health community of the far- reaching mental health implications of working and liv- “Attention to emotional and mental well-being along ing through a global pandemic. with psychological support from immediate senior The role of fear as a barrier to the implementation of management and peer groups, managed to boost health and wellbeing initiatives for HCWs was a recur- up the morale amongst the junior doctors. Continu- ring theme among participants. They noted fear in the ous monitoring of the health and well-being of the context of personal exposure, exposing family members staff in COVID-19 unit was done. Monitoring of the to the virus should they transmit COVID-19 in their workload demands, personnel health and safety, homes. One participant explained. resource needs and safe documentation practices was done.” “Especially earlier on in the realization of the pan- demic, [the] majority of the healthcare workers in Such an example outlines that the range of actions my facility were fearful and concerned about their and initiatives that must be employed simultane- personal safety and the safety of their families. They ously to ensure the mental health of HCWs is a critical didn’t trust that the organization had their interest O’Brien et al. Globalization and Health (2022) 18:24 Page 10 of 13 consideration, while also considering how the very con- staff have avenues to provide feedback to leaders.” ditions that may be causing stress and burnout (e.g., Once again, addressing mis- and disinformation workload demands) can be reduced to improve take up requires multi-level collaboration within healthcare of additional initiatives. A consideration of these two ele- organizations, clear preplanning, and engaging staff ments together creates a positive cycle, where initiatives while respecting their ideas and thoughts. The provision to reduce the stress burden on HCWs also free up time of education and training for staff may also offer health - and energy for HCWs to better engage with the addi- care organizations the opportunity to counter mis- and tional support on offer to improve mental health and dis-information with targeted scientifically-backed infor - wellbeing. mation on the origins, nature and symptoms of the virus, transmission and preventing transmission. This would Challenging the impact of misinformation benefit from including information on essential IPC Conflicting information, misinformation and disinforma - within the healthcare setting, the role of testing, includ- tion during the COVID-19 pandemic has been a novel ing available testing facilities for staff, and other common challenge given it is the first pandemic in history in which misconceptions. Providing clear information on where technology and social media are being used on a mas- staff can find out more reliable information, speak to a sive scale as a means of keeping people connected and dedicated helpline, or seek additional assistance within informed [47]. Respondents in this study largely high- the organization also offers the opportunity to address lighted both misinformation and disinformation as major mis- and dis-information on an ongoing basis. As the role challenges to facilitating initiatives for HCWs health of technology in day-to-day life and in healthcare contin- and wellbeing, but some also noted the role of conflict - ues to expand, more time must be invested in ensuring ing information in challenging implementation. One staff are able to access up-to-date and trusted informa - explained. tion about the virus, the pandemic, and the national and local pandemic response. “The spread of misinformation via social media presented challenges to the implementation of both physical and psychological categories of welfare Developing new ways of working measures for staff, not just for the practice of IPC The COVID-19 pandemic has shown HCWs and measures.” patients, their families, and carers the power of data Such is the importance of tackling misinformation and and digital technology in tracking and containing the disinformation to aid the COVID-19 response globally, virus, and in developing new adapted ways of deliver- WHO Member States passed Resolution WHA73.1 at the ing healthcare [49]. There are a range of examples of tel - World Health Assembly in May 2020 [48]. The Resolution ehealth being introduced for primary care in countries recognizes that managing the infodemic is a critical part around the world, offering greater flexibility for patients of controlling the COVID-19 pandemic: it calls on Mem- and better reaching those in geographically challenging ber States to provide reliable COVID-19 content, take areas [50–52]. Similarly, in-person/telemedicine hybrid measures to counter mis- and disinformation and lever- approaches to critical care have also been shown to be age digital technologies across the response. The Resolu - feasible and effective in addressing cross-cultural pub - tion also calls on international organizations to address lic health emergencies [53]. At the organizational level, mis- and disinformation in the digital sphere, work to several of our study participants developed new ways of prevent harmful cyber activities undermining the health working through the course of the pandemic. One par- response and support the provision of science-based data ticipant explained. to the public [47, 48]. So too must health organizations “We had to close some of our clinics because of the consider the role that misinformation and disinformation pandemic of course, but then [had] to really think may have in their COVID-19 response and on the health about how [we could] still serve our patients and and wellbeing of their staff. One participant in the study encourage them to seek care if they need it. We had noted that. to do a lot of telemedicine, you know, on video, which “Effective communication between senior staff/ lead - worked really well, but that took a while to put the ers and staff is one way to address this issue. This infrastructure in place.” involves timely dissemination of accurate and evi- Changes to ways of working were largely designed to dence-based information to staff, frequent engage - reduce the risk of transmission and optimize workflow ment of staff by leaders to allay fears and address given the increased pressure on resources. However, the concerns, and two-way communication to ensure O ’Brien et al. Globalization and Health (2022) 18:24 Page 11 of 13 development of new ways of working need not stop as research has sometimes been criticized for lacking sci- the pandemic winds down. One respondent noted. entific precision in which to make a generalisation [11]. Nonetheless, the collective case study better facilitates “As contingency spaces and capacities are gradually studying multiple cases simultaneously to generate a used to support the growth and development of the broader appreciation of a particular issue [11]. As such, hospital, periodic reviews and re-investment efforts the research team designed the research to collect case are critical to re-establishing such buffers. This studies and information from a range of organizations would help to ensure that the hospital retains the and health systems around the world to better assess capability and capacity to cope with future crises.” trends ahead of generalization, while being cognizant of It is notable that a lack of resources was a commonly the limitations in representativeness of the case studies. highlighted barrier by participants in this research. Developing new, more efficient ways of working offers the opportunity for healthcare leadership to maximize Conclusions the available resources. Of course, these advances must HCWs at the frontline of the COVID-19 pandemic are be closely monitored and evaluated to ensure standards at a disproportionate risk of adverse physical and psy- are maintained or surpassed, the health and wellbe- chological outcomes and so protecting HCWs requires ing of both patients and HCWs remain a priority, and a comprehensive and multi-modal approach to address that patient safety is a core consideration in any actions multiple aspects of health and wellbeing. Through a towards more efficient ways of working. case study approach, we demonstrate the facilitators The COVID-19 pandemic has provided healthcare and barriers to implementing such initiatives across organizations around the world the opportunity to assess healthcare organizations globally. Our findings, based the present state of their ways of working, including the on the experiences of 13 healthcare organizations, provisions on offer that seek to improve the health and show multi-level coordination and preparedness is a wellbeing of their HCWs. As health systems around the critical starting point to ensure initiatives for HCW world continue to address the pandemic, with an eye health and wellbeing can be implemented in a condu- towards post-pandemic health system preparedness and cive environment, but it remains vital that the role of planning, these considerations must remain at the heart fear and misinformation must also be managed as the of healthcare delivery and development. pandemic progresses. Health systems and healthcare organizations should now consider these findings at the system and organizational level as part of their efforts Limitations to design and implement smart and agile solutions for The findings of the research offer insights into the facil - the physical and mental wellbeing of HCWs. Stakehold- itators and barriers to implementation only at one point ers must also recognize that the health and wellbeing in time. Findings therefore do not account for experi- needs of HCWs will continue well beyond the ‘end’ ences of implementation after December 2020 and do of the pandemic due to the prolonged impact of their not offer information on whether facilitators and barri - experiences. ers changed with time after initiatives were first intro - duced, nor whether additional facilitators and barriers Abbreviations have emerged in implementing new initiatives post- COVID-19: Severe acute respiratory syndrome coronavirus (SARS-CoV-2); 2020. However, the research offers valuable insight into CDC: Centers for Disease Control and Prevention; IPC: Infection preven- tion and control; HCWs: Healthcare workers; LHSN: Leading Health Systems facilitators and barriers in the beginning of the COVID- Network; LMICs: Low- and middle-income countries; PPE: Personal protective 19 pandemic across a range of contexts that may be val- equipment; PSTRC : NIHR Imperial Patient Safety Translational Research Centre; uable through the course of the COVID-19 pandemic WHO: World Health Organization. and for future pandemics and other prolonged crises. Acknowledgements A further limitation of the study is the representative- This work was supported by the NIHR Imperial Patient Safety Translational ness of the cases outlined. While the authors aimed to Research Centre (PSTRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. collect case studies from a range of geographic regions and types of healthcare organization (N = 13), the case Authors’ contributions study approach may have led to selection bias and so NO, KF and MD conceptualized the manuscript. NO, OB and AS completed the data analysis. NO lead on the administration and writing of the original draft it is important to note that the findings are not nec - with support from KF. All authors equally contributed to the writing, reviewing, essarily representative of the experience of all health- and editing. MD supervised the work. The author(s) read and approved the care organizations of that type/geography. Case study final manuscript. O’Brien et al. Globalization and Health (2022) 18:24 Page 12 of 13 Funding 14. Lobb R, Colditz GA. Implementation science and its application to popu- This work was supported by the NIHR Imperial Patient Safety Translational lation health. Annu Rev Public Health. 2013;34:235–51. Research Centre (PSTRC). The views expressed are those of the authors and 15. Rapport F, Clay-Williams R, Churruca K, et al. The struggle of translating not necessarily those of the NIHR or the Department of Health and Social Care. science into action: Foundational concepts of implementation science. J NIHR Imperial Patient Safety Translational Research Centre. Eval Clin Pract. 2018;24(1):117–26. 16. WHO. Coronavirus Disease (COVID-19) Situation Report: October 4 2020 Availability of data and materials [online]. World Health Organization; 2021. Available from: https:// www. Not applicable.who. int/ docs/ defau lt- source/ coron aviru se/ situa tion- repor ts/ 20201 005- weekly- epi- update- 8. pdf. Accessed 9 Dec 2021. 17. Tikkanen R, Osborn R, Mossialos E, et al. 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Journal

Globalization and Health – Springer Journals

Published: Feb 22, 2022

Keywords: Global institutions/organizations; Human resources for health; Healthcare workers; Health care planning; COVID-19; Outbreaks; Communicable disease; Psychosocial impacts

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