“Building the plane while flying it” Reflections on pandemic preparedness and response; an organisational case study
BMC Health Services Research volume 23, Article number: 940 (2023)
The COVID-19 pandemic provided a unique opportunity to learn about acute health organisations experiences implementing a pandemic response plan in real-time. This study was conducted to explore organisational leader’s perspectives and experience activating a COVID-19 pandemic response plan in their health service and the impact of this on service provision, clinicians, and consumers.
This study was conducted at a large metropolitan health service in Australia that provides acute, subacute, and residential aged care services. Semi-structured interviews were conducted with 12 key participants from the COVID-19 leadership team between November-January 2021/2022. A semi-structured interview guide was developed to explore how the health service developed a clinical governance structure, policy and procedures and experience when operationalising each element within the Hierarchy of Controls Framework. Thematic analysis was used to code data and identify themes. A cross-sectional survey of frontline healthcare workers on the impacts and perceptions of infection control practices during the COVID-19 pandemic, was also completed in 2021 with 559 responses.
Twelve organisational leaders completed the semi-structured interviews. Key themes that emerged were: (1) Building the plane while flying it, (2) A unified communications strategy, (3) Clinicians fear ‘my job is going to kill me’, (4) Personal Protective Equipment (PPE) supply and demand, and (5) Maintaining a workforce. When surveyed, front-line healthcare workers responded positively overall about the health services pandemic response, in terms of communication, access to PPE, education, training, and availability of resources to provide a safe environment.
Health service organisations were required to respond rapidly to meet service needs, including implementing a pandemic plan, developing a command structure and strategies to communicate and address the workforce needs. This study provides important insights for consideration when health service leaders are responding to future pandemics. Future pandemic plans should include detailed guidance for acute and long-term care providers in relation to organisational responsibilities, supply chain logistics and workforce preparation.
The Coronavirus Disease (COVID-19) pandemic has had an unprecedented impact on both the population and health service providers around the world. Understanding of the transmission modes of SARS-CoV-2 has evolved over time, and has at times, been considered controversial with much debate around droplet versus aerosol transmission. In early 2020, the World Health Organization (WHO) identified the transmission of SARs-CoV-2 occurred primarily through droplet and contact transmission . The debate raged on throughout the pandemic and in 2021 the scientific community was reporting on the aerosol transmission of SARs-CoV-2, which was later acknowledged by the WHO .
Health service providers were faced with unique challenges influenced by the suite of services they provide, the needs of the population accessing those services, and the dynamic nature of the pandemic that resulted in localised outbreaks and surges in demand for health care resources. Patients, frontline healthcare workers, managers and leaders have all had suddenly and dramatically adapt their services in response to this public health threat while maintaining the safety of staff and services .
In January 2020 the Australian federal government COVID-19 pandemic response was implemented to target zero cases, and involved a nation-wide lockdown, travel restrictions on select countries before evolving to all countries, and a two week mandatory quarantine for returning travellers . By May 2020 COVID-19 cases of local transmission and international arrivals were low, with new cases less than 20 per day . However, by June 2020 a second wave of COVID-19 had begun, and localised clusters of cases had appeared throughout Melbourne, Victoria, these clusters were linked to hotel quarantine breaches and were spreading rapidly before public health authorities could contain them . During this second wave of infections the total number of cases more than doubled within a month . Increasing stages of restrictions were imposed on the residents of Victoria to contain the cases, including stay at home orders, mandatory face coverings, curfews, and five kilometres travel and exercise restrictions . Tough border restrictions were also imposed by other States in Australia . By September 2020 a roadmap to ease restrictions was released, and by November 2020 no local transmission of cases was reported . During the second wave of COVID-19 in Victoria the healthcare system faced significant impact, of the 20,000 cases nearly 20% were health care workers, a third of which were nurses and nearly half were aged-care workers .
The Australian healthcare system operates through a publicly funded universal healthcare system Medicare, that provides all Australian and permanent residents with access to health and hospital services . Each State and Territory, however, has primary responsibility for providing residents with public health care services within their jurisdiction, including hospitals, public health and emergency management during the pandemic . In March 2020 the Victorian State Government released the COVID 19 pandemic plan for the health sector, in an effort to act decisively and limit the spread of disease . Health services were required to implement a response to the pandemic that executed the government directives, maintain a workforce, and remain operational while minimising the incidence of COVID-19 within their service.
Scientific insights into the nature of the novel SARS-CoV-2 virus developed throughout the early stages of the pandemic and led to the inevitable evolution of evidence about the disease process and viral transmission, and subsequently the government directives were rapidly changing. In response, health services endeavoured to develop and implement a structured emergency response plan that was flexible and dynamic, enabling modification of health service policies, practice guidelines and models of care in real-time, as the pandemic evolved .
The aim of this research was to explore the health service organisational response to the COVID-19 pandemic, using a single organisational case study approach. Key factors that were explored were: clinical governance structures, organisational communication, infrastructure requirements, service provision requirements and experiences of front-line health care providers. The pandemic provides a unique opportunity to learn from the strategic response of organisations, by obtaining leadership and clinical staff perspectives on how the organisational response was implemented and the impact of this on service provision, staff members and consumers at a local level. The findings of this study will provide guidance to inform development and implementation of strategies in the event of a future large-scale outbreak of COVID-19 or other pandemics.
The case for this research is a Melbourne tertiary health service provider. The health service network was selected as the case for this research as it is unique in that it includes a network of hospitals and provides care to the population in both the public and private sectors, and across primary, residential aged care, subacute ambulatory care and acute health service delivery.
During the COVID-19 pandemic, clinical and non-clinical staff and organisational leaders faced considerable challenges continuing to provide care to the communities they service. One hospital within the network faced particular challenges as it provides general acute, subacute and mental services to a population that saw an increase in community transmission and increased cases during the second wave of cases, with 2,248 cases in a population of 270,487 residents . In contrast the specialist nature of another hospital within the network, meant that the health service experienced challenges providing specialist services to women and children during the pandemic as rapid changes in service delivery models needed to be implemented.
Study design and data collection
A mixed-methods study design was used that included both qualitative interviews with organisational leaders and a cross sectional survey of front-line staff. Semi-structured interviews were conducted with 12 organisational leaders working at the health service during the pandemic. The leaders were selected based on their role within the COVID pandemic response team and were representative of both clinical and operational services across the health service. The organisational structure meant that key leaders had responsibility for programs across all the hospitals within the health service.
A cross-sectional survey was also used to explore clinical and non-clinical healthcare workers’ experiences as part of the organisational response to the COVID-19 pandemic in 2020. Data related to the participants evaluation of the organisational response; staff training and the availability of Personal Protective Equipment (PPE) are reported. The responses relating to side-effects of PPE will be reported separately.
Purposive sampling was used to obtain a representative sample of organisational leaders from across the health service who had key leadership roles during the pandemic. Leaders were invited to participate in the interviews and were provided with a written informed consent form for study participation. The interviews were conducted over the Zoom® online video platform. Each interview took approximately 30–45 min and was recorded. Inclusion criteria were: Organisational leaders who provided consent for study participation and exclusion criteria were: leaders who were not employed at the health service in 2020 and were therefore not involved in operationalising the COVID-19 pandemic response.
Participants recruited for the cross-sectional survey were front-line clinicians (nurses, midwives, medical and allied health staff) and non-clinical healthcare workers (cleaners, ward-clerks) working across the health service. Exclusion criteria were individuals who did not provide informed consent by completing the online survey, and staff who were not permanent employees.
Leadership semi-structured interview tool
The semi-structured organisational leadership interview guide was designed to explore how the health service developed a clinical governance structure, policy and procedures and experience when operationalising each element in the Hierarchy of Controls Framework.
There were 12 organisational leaders that participated in the interviews conducted between November and January 2021/2022. The organisational leaders interviewed were; the Executive Director of Nursing and Midwifery and Aged Care Clinical Practice, the Executive Director of Nursing, the Chief Operating Officer, the acting Chief Medical Officer/Program Director Medical Sub-Acute and Palliative Care Program, the Clinical Services Director Perioperative Program, the Program Director Perioperative Program, the Program Director Women’s and Children’s Program, the Program Director Mental Health Program, the Infectious Diseases COVID Consultant, the Group Manager Work Health Safety, the Procurement Supply Manager, the Manager COVID Response. An invitation to participate was extended to the Allied Health program director who was unable to participate due to time constraints.
Cross-sectional survey tool
At the time of the study, there was no validated survey tool in the literature, so the survey data collection tool was developed with an expert panel of international Infection prevention leaders and was informed by a rapid review of the current literature around issues and side-effects surrounding the widespread use of PPE during the COVID-19 pandemic response internationally and previous outbreaks of respiratory infections . The survey tool was developed through the completion of a series of meetings between the members of the research team, and international experts, including clinical Infection Prevention leads from Singapore General Hospital and the United Kingdom London region, and members of the Australasian College for Infection Prevention and Control . The survey tool was structured in 3 sections, and included a mix of yes/no questions, open ended questions, and a Likert scale with responses ranging from strongly disagree (1) to strongly agree (5), and rating responses on a scale of 1–10 with 1 being very poor and 10 excellent. The survey tool was used to undertake concurrent research at an acute care hospital in Singapore . Demographic data was collected including age, gender, occupation, employment status and work location. The survey questions were based on issues related to PPE that were topical throughout the pandemic.
The video recordings and field notes of the interviews were transcribed by the researcher who conducted the interviews and checked against the recordings for accuracy. Qualitative thematic analysis was used to identify, analyse, and report the themes identified within the data set. Braun and Clarke’s  six phases for data analysis were used as the framework for the analysis. Quantitative content analysis was used to measure the proportion of participants who discussed each theme.
The cross-sectional survey was made accessible to participants via a QR code. The survey responses were analysed using descriptive statistics, including frequencies and percentages. As this was an online survey, we were unable to measure the reach of the survey, however 627 respondents commenced the survey and 559 completed at least one section and were included in the analysis, providing a survey completion rate of 89%. Majority of the respondents were female (83.7%) and aged between 31–45 years (33.6%). Most respondents were Nurses/Midwives (66%), followed by Allied Health (5%). However, 87 respondents (15.6%) did not specify their occupation.
Data triangulation was used to evaluate and validate the responses of the front-line health care workers who completed the cross-sectional survey, and the organisational leader interviews. The cross-sectional survey questions were reviewed, and the questions identified as relevant to the identified themes from the analysis of the leadership interviews were included in this analysis.
Ethics approvals were obtained from the institutional Human Research Ethics Committee (HREC) and Deakin University.
The organisational leaders were asked to consider the response to the pandemic and the challenges faced by the organisation throughout the pandemic, considering both the preparation and response phases. The themes that emerged from the data were: (1) Building the plane while flying it, (2) A unified communications strategy, (3) Clinicians fear ‘my job is going to kill me’, (4) PPE supply and demand, and (5) Maintaining a workforce.
Theme 1 Building the plane while flying it
One of the significant themes identified by the organisational leaders was the concept of building the plane while flying it, effectively developing the pandemic response at the same time as executing it. Subthemes identified within this major theme were (1.1) the organisations existing pandemic plan was not fit for purpose, (1.2) a lack of command and control versus egalitarianism, (1.3) a lack of guidance from the health department, (1.3) the volume, velocity, and source of information, (1.4) craft groups implemented independent plans and practices and (1.5) differing tolerance for risk.
1.1 The organisation’s existing pandemic plan was not fit for purpose
There was a consistent observation throughout the participants’ interviews (6, 50%) that the organisations existing pandemic plans was not fit for purpose for a large-scale response to a novel respiratory pathogen. The pandemic plan was noted to be related to pandemic influenza-like events and was considered too abstract with a lack of specific detail (Table 1, Q1 P3). Participants also commented that there was not a direct transference between the influenza pandemic plan and how to respond to an unknown respiratory virus (Table 1, Q1 P3, Q4 P11, Q5 P5). One respondent noted that they were unaware of a pandemic plan existing prior to the pandemic, and the challenges that presented to a large health service in having to develop a pandemic plan while simultaneously implementing it (Table 1, Q2 P2).
1.2 Lack of command and control versus egalitarianism
The perceived lack of a centralised command and control model within the Victorian Department of Health during the pandemic was identified by five (42%) participants as a barrier to implementing an efficient response. The participants noted the difference in the Victorian response compared to other States in Australia where a command and control model was in place (Table 1, Q8 P8, Q9 P3). Three (25%) participants identified the information received from the Victorian Department of Health response came in the form of guidelines requiring interpretation, and the subsequent lack of coordinated responses between health services leading to redundant work, inequality, and conflict between health services (Table 1, Q6 P2, Q10 P3).
1.3 Lack of guidance from the health department
There were consistent responses from 50% (6) of the participants that the guidance and information from the Health Department to the health service was a set of principles rather than specific directives, requiring interpretation and translation into usable resources for implementation (Table 1, Q14 P3, Q17 P9, Q18, P10). It was also identified that the guidance differed between States and the Federal health departments, creating challenges for organisations providing services, (such as residential aged care facilities), in more than one state (Table 1, Q13 P1).
1.4 Volume, velocity, and sources of information
There was a consistent perception from 50% (6) participants that the information, advice, and guidelines were changing so frequently that there were significant challenges in controlling the dissemination of information throughout the organisation, resulting in confusion within the workforce (Table 1, Q20 P4, Q22 P10, Q23 P11). The need for a clearly structured communication plan was identified by one participant who noted that at the beginning of the pandemic when information was slow to come from the Department of Health, the wide distribution of information by the workforce from varied sources including the media, different professional bodies, and observations from the earlier European response, was creating a sense of panic (Table 1, Q26 P1).
1.5 Craft groups implemented independent plans and practices
Five (42%) participants identified the challenges of working with different craft groups, who would use the lack of clear directives as an opportunity to produce their own documents in response to clinical issues (Table 1, Q27 P2, Q29 P3). While there were positive elements to this practice, in that staff were actively looking at their own workflows and planning, it also created conflict between different craft groups and at times a lack of governance, (Table 1, Q30 P10).
1.6 Differing tolerance for risk
A differing tolerance for risk was identified as a subtheme across individuals and craft groups by 6 (50%) participants. Two of the participants identified within their own clinical practice that they had accepted that they would be exposed to infectious diseases as clinicians and had developed a philosophy around their practice to address that risk (Table 1, Q35 P3, Q36 P2).
One of the participants identified different craft groups had differences in tolerance for risk, and this was a barrier to streamlining the implementation of the organisations pandemic response (Table 1 Q37 P3). Challenges appeared to stem from a lack of understanding by clinicians of the emergency pandemic response (Table 1, Q41 P1), and the need to move quickly with decisions therefore bypassing the consultation process normally required within the governance structure (Table 1, Q38 P2, Q41 P1).
Theme 2 A unified communications strategy
The second major theme identified was the need for a clear and consistent communication strategy throughout the organisation. Sub themes that were identified within this theme were (2.1) consistent communication within the leadership group, (2.2) discovering the need for a structured communications strategy, (2.3) changing goalposts.
2.1 Consistent communication within the leadership group
Five (42%) of the interviewed participants identified the cohesive communication between the leadership group, and the frequent meeting of the group as being an important element to a successful and unified response. As well as ensuring all the right people were in the same room getting the same message, disseminating this throughout the organisation to make sure everyone was on the same page (Table 2, Q38 P2, Q41 P1).
2.2 Discovering the need for a structured communications strategy
The participants (6, 50%) identified the challenges in implementing a unified communications strategy across a large health service, with both positive and negative outcomes identified. Positive outcomes of the communication response were having a consistent strategy that was centrally driven and used multiple platforms to reach different audiences, including the use of electronic meeting platforms, and posters and messaging that could be refreshed and updated regularly (Table 2, Q5 P5, Q7 P1, Q9 P4, Q23, P8). Negative outcomes of the communication response included the challenges associated with identifying the frequency of communicating with staff and finding the balance between providing the workforce with enough information to provide guidance but not too much that it was overwhelming and confusing (Table 2, Q8 P1, Q14 P4).
Timeliness of communications to staff within the organisation was identified as an important aspect of the communication strategy, the frequency of this was contested with some leaders reporting positive outcomes and some reporting negative outcomes. Four (33%) participants identified that timely and responsive communications were an important strategy, but there were delays and issues with getting this information down to the clinical workforce (Table 2, Q13 P11, Q17 P9). And the delays in communications down to the workforce led to the local areas developing their own messaging, which resulted in inconsistencies in messaging, and resources sitting in multiple places (Table 2, Q5 P5, Q16 P5, Q17 P9).
2.3 Changing goalposts
There was consensus among five (42%) of the participants that the frequency of changes to the guidelines created barriers in establishing a consistent unified communications strategy. Communicating the frequent changes in the guidelines across a large organisation rapidly, was difficult and created frustration within the workforce (Table 2 Q24 P6, Q25 P6, Q27 P5).
Cross-sectional survey response
When surveyed, the front-line healthcare workers responded positively about the communication from the health service during the pandemic. The respondents were asked to rate the communication from the health service to frontline staff about changes to protocols and procedures, on a scale of 1 to 10, with 1 indicating they were not at all confident and 10 extremely confident, 427 staff responded with a mean of 7 (SD 2.35). Staff were also asked to rate the overall organisational response to the COVID-19 pandemic, 419 staff responses, with a mean of 6.99 (SD 2.38). Indicating that the workforce was reasonably confident in the health services response to the pandemic, with some room for improvement.
Theme 3 Clinicians fear ‘my job is going to kill me’
The third major theme identified was around the fear of the unknown, and the subsequent challenges the leadership group experienced in implementing the pandemic response across a large workforce. Sub themes identified within this major theme were (3.1) fear of the unknown, (3.2) getting staff into the mindset of a pandemic, (3.3) infection prevention confusion, (3.4) developing novel PPE programs, and (3.5) adapting to change; implementing PPE processes within the workforce.
3.1 Fear of the unknown
The subtheme of fear was raised by five (42%) of the interviewed participants. Fear was reported as being multifactorial and included staff being scared to attend work, the impact of fear on human behaviour, and the impact of fear on patient care.
The participants reported that the fear of the unknown experienced by the workforce, included the risk for their own personal safety and of acquiring an infectious disease, as well as the risks associated with taking the disease home to their family (Table 3, Q2 P4, Q4 P2). The consequences of this impacted patient care with staff being afraid to attend work, and afraid to enter dedicated COVID-19 zones (Table 3, Q7 P1).
Fear induced behavioural changes were noted by four (33%) participants, and the subsequent impact this had on the workforce, including increased levels of paranoia, panic, and unprofessional workplace behaviours (Table 3, Q5 P1, Q8 P11). The increased levels of fear were described as having an impact on the decision-making capability of staff, from ensuring the workforce was comfortable with the protective controls implemented by the health service to be able to attend work and provide care, and understanding the risks associated with their actions and seeking out expertise to assist in the decision-making processes (Table 3, Q6 P1, Q3 P3).
3.2 Getting staff into the mindset of a pandemic
Developing a mindset to be able to respond to the pandemic was identified as a sub-theme stemming from fear within the workforce. Five (42%) of the participant responses acknowledged the need to increase the workforce’s level of knowledge and understanding of the elements of the pandemic response, including disease transmission, the use of PPE, and maintaining vigilant practices, as essential elements to reducing fear and getting staff in a pandemic mindset to be able to provide care in a safe way that protects themselves and their patients (Table 3, Q11 P4, Q12 P11, Q13 P9).
3.3 Infection prevention confusion
A lack of Infection prevention knowledge and skills within the workforce was identified by four (33%) of participants as a significant subtheme. The lack of knowledge and skill was identified to be associated with the fundamental elements of an infection prevention program and included a lack of understanding of disease processes and transmission, the differences between airborne and droplet transmission, and the appropriate and safe use of personal protective equipment (PPE) (Table 3, Q11 P4, Q12 P11, Q13 P9). A lack of exposure to infectious diseases in the specialist areas of mental health and midwifery was identified by two participants as a rational for the workforce lack of knowledge, both participants acknowledged a lack of familiarity and experience working with infectious diseases including the use of PPE (Table 3, Q 13 P9, Q16 P5). The transmission route of COVID-19 and the debate between aerosol and droplet transmission of COVID-19 was another barrier identified by several participants resulting in confusion and anxiety within the workforce (Table 3, Q20 P3, Q21 P2).
3.4 Developing novel PPE programs
In response to the knowledge deficits within the workforce and the identified gaps in the education program eight (66%) of the participants acknowledged that the leadership group developed novel programs to facilitate the pandemic response and address the gaps. This included establishing a PPE sub-committee, a respiratory fit-testing program and re-developing the education programs to enable remote learning and introducing an online training component (Table 3, Q24 P11, Q27 P1, Q31 P5). Barriers to implementing this response were identified by two participants and included the rapid roll out of a P2 fit-testing program with limited access to resources (Table 1, Q30 P4), and the original PPE program was found to be lacking, and slow to address the concerns identified within the organisation and contributed to the confusion felt by the workforce (Table 3, Q25-26 P2).
3.5 Adapting to change; implementing PPE processes within the workforce
The barriers associated with implementing programs to provide a safe work environment for the workforce and to facilitate changes was identified by six (50%) participants and included keeping up with rapid changes to PPE guidelines, implementing standardised practice across multiple facilities and embedding the changes within the workforce. PPE guidelines and recommendations changed frequently, resulting in confusion in the workforce, including the different terminology used of levels of PPE, and COVID levels of risk, and the requirements of the health service (Table 3, Q32 P11).
The participants identified that while the workforce were eventually able to adapt to the changing guidelines, it was not without its challenges. The workforce response to PPE use early in the pandemic was dramatic and a clear challenge for staff to when they were used to long lead times for change implementation, but over time they were able to demonstrate their ability to adapt to fast paced change (Table 3, Q33 P11, Q34 P5).
One participant identified the use of clear and reproducible guidelines as a key strategy to establish PPE compliance within the clinical environment, as it facilitated repetition and embedded practices within departments (Table 3, Q35 P3). The uncomfortable nature of wearing PPE for extended periods was identified as a barrier to PPE compliance by three participants, who noted that unless the workforce was used to wearing PPE before the pandemic, for example operating theatre staff, the workforce struggled to adopt the extended use of PPE (Table 3, Q38 P6, Q39 P11, Q40 P4).
Cross-sectional survey response
Despite the lack of infection prevention knowledge and skill being identified as a significant subtheme, when surveyed the front-line healthcare workers responded positively and indicated that they felt there were enough resources available, there were tools available to guide them when needed, and they felt confident in the use of the resources (Table 4). Staff indicated that on average they were confident in the fit of their N95 mask, 7.38 (SD 2.53), the PPE they were provided with would adequately protect them against COVID-19, 7.03 (SD 2.29) and that they understood the importance of the sequence of donning PPE, 8.75 (SD 1.79), and doffing PPE, 9.34 (SD 1.46). One possible explanation for this response lies in the implementation of the novel programs, education packages and frequent updates to guidelines, by the organisation leaders to address the identified deficits.
Theme 4 PPE supply and demand
The fourth major theme identified was personal protective equipment (PPE) supply and demand. Subthemes within this major theme included (4.1) the crisis stage, (4.2) logistic challenges, and (4.3) centralised supply.
T4.1 The crisis stage
The majority of participants (8, 67%) reported that in the initial phase of the pandemic PPE supply and demand created a heightened level of anxiety and fear within the leadership group about ensuring there were adequate supplies of PPE to the workforce. However, three (25%) participants noted that while there was increased levels of anxiety at no point were they ever in a position to not be able to supply PPE to the workforce (Table 5, Q1 P4, Q3 P5, Q6 P6).
Two (12%) participants noted that the Organisation was behind in the preparation phase and forecasting potential PPE shortfalls compared to other health services and struggled to predict the PPE supply needed (Table 5, Q4 P3, Q7 P7). Two (12%) participants also noted the impact PPE supply and demand had on the workforce and the additional challenges that created with department managers attempting to access their own supply channels and communicating the PPE decisions based on supply and demand to the workforce (Table 5, Q11 P2, Q12 P3).
4.2 Logistic challenges
The logistic challenges associated with monitoring stock levels and controls for PPE, along with recognising the sheer volume of PPE required were identified by three (25%) participants during the different phases of the pandemic. During the pandemic planning and preparation phase two (12%) participants noted that there was a lack of preparedness in identifying controls for PPE management as an issue, including storage of substantial volumes of PPE and forecasting reserve supplies (Table 5, Q15 p3, Q16 P7).
4.3 Centralised supply
Two (17%) participants identified that the Victorian Department of Health centralisation of a state supply chain provided the health service with confidence that PPE supply would be maintained and would be equitable to all health services (Table 5, Q19 P7). One (8%) participant acknowledged that the transition to the centralised supply model was not without its challenges initially, largely relating to supply of specific products (Table 5, Q20 P7). While this issue created anxiety and fear within the leaders, at the time of survey the responses indicated that frontline staff did not feel this impact, and that the recommended PPE was readily available to them (strongly agree 37.02%, agree 38.23%) and that there was enough PPE available for all staff within their department (strongly agree 31.48%, agree 43.47%). The survey participants also indicated that they were confident with the use of PPE including donning and doffing and they felt protected by the PPE they were supplied with.
Theme 5 Maintaining a workforce
The fifth major theme identified was around maintaining a workforce and continuing to provide care as an operational health service during a pandemic. Subthemes within this major theme were (5.1) the movement of people, and (5.2) the burden of contact tracing and staff furlough.
5.1 The movement of people
The movement of people within a health service was identified by five (42%) participants as a significant challenge during all phases of the pandemic. In the planning and preparation phase identifying how to restrict the movement of people was a particular challenge, particularly in a tertiary hospital that required meetings, education sessions and staff groups that were required to move throughout the hospital (Table 6, Q1-2 P2, Q3 P10).
Two (17%) participants identified the existing practices of medical and nursing workforce groups was a risk in terms of large numbers of staff congregating together, moving throughout the hospital and also taking breaks together, was increasing the risk of furlough should transmission of COVID-19 occur (Table 6, Q3 P10, Q5 P1). One (8%) participant identified the implementation of changes to models of care as an attempt to restrict this behaviour, however this was not without its challenges, and had some implications for patient care including longer length of stays and additional handovers (Table 6, Q3 P10). With the implementation of work from home models for non-clinical staff, one (8%) leader identified the need for the leadership group to be present on-site and to provide the workforce with reassurance that they were supported (Table 6, Q7 P11).
5.2 The burden of contact tracing and staff furlough
Five (42%) participants recognised the need for the organisation to have efficient systems in place and trained staff to support large scale contact tracing activities that lasted for an extended period (Table 6, Q12 P11, Q13 P1). Developing the resilience to deal with a reduced workforce due to furloughed staff was identified by one participant as having a burden on the health service (Table 6, Q10-11 P6). Maintaining a workforce due to furlough was identified by two (17%) participants as a challenge, partly due to the low base of medical workforce to begin with, and partly due to staff fatigue and increased awareness of COVID leave providing an excuse to have time off (Table 6, Q14-15 P5, Q16 P10).
The COVID-19 pandemic created unique situations that many healthcare leaders had not previously encountered. The broad nature of the pandemic response not only required leadership of an operational health service, but it also required leadership during a crisis with no clear end, and in roles that were newly defined to many. Leadership roles during a prolonged crisis are expected to be the commander and decision makers at the same time as being participative leaders that listen and build relationships between different groups to work collaboratively to solve the crisis .
Overall, the responses from the participants identified both strengths and barriers in the organisation’s response to the pandemic. Strong communication was identified as key, with a clear structure and the ability to get the leaders in the room together. The use of virtual tools and electronic meeting platforms, to facilitate this was an advantage. A study looking at the Victorian COVID-19 pandemic response across four health settings also identified clear and consistent communication as a key strategy that was vital to pandemic management . Similarly, a study looking at healthcare workers well-being identified initiatives that provided open and inclusive communication from the leadership to the workforce would minimise fear and stressors that impact the workforces wellbeing  Between December 2021 and July 2022, 78 pandemic orders were made by the Victorian Minister for Health . The frequent and fast changing guidelines provided additional challenges in communicating and implementing changes to the workforce. A lack of preparedness in pandemic planning was evident with the existing pandemic plan relating to influenza not fit for purpose for a novel respiratory virus. Previous pandemic events, like SARS and H1N1 influenza, have emphasised the importance of comprehensive pandemic management planning that is flexible, however hospitals often rely on generic, localised plans that are not designed for operationalising successful responses during protracted pandemics . When a crisis strikes, single level organisations experience challenges and often find themselves ill prepared to meet the challenges of the uncertain and volatile environment . During the pandemic the need for the command-and-control response was identified by the leaders, to make quick decisions bypassing the more traditional extended consultation process people were familiar with. However, the implementation of the incident command structure and the crisis management response at a scale not experienced by many of the key leaders had an impact on the outcome of the response. A similar study found that some healthcare workers and key personnel seized the opportunity created by the pandemic to promote and expand upon digital technologies, and were able to implement rapid infrastructure changes without the usual government and budgetary constraints .
Infection prevention and control practice standards for the management of COVID-19 were developed by federal and state governments and evolved rapidly as updated international experiences and advice were released. In the early stages of the COVID-19 pandemic, the availability of multiple guidelines had the potential to create confusion as to which guidelines should be followed at a local level. The communication systems within the various health agencies and government were viewed as fragmented, and at times it was unclear who was making decisions, which in turn enhanced the challenges in providing the workforce with the most relevant and recent information while avoiding oversaturation and overwhelming staff . Due to the novel nature of the COVID-19 virus, information on transmission and recommendations for prevention evolved rapidly throughout the pandemic [19, 20]. The speed and frequency at which guidelines changed was also problematic and a considerable challenge that healthcare workers, organisational leaders, and infection prevention and control practitioners faced, particularly in the dissemination and implementation of the most up-to-date recommendations . However, while the challenges in disseminating evolving information was experienced by the leaders, the survey participant responses indicated that frontline staff had confidence in the way the organisation communicated these changes During the crisis stage of the pandemic response, a lack of consistent PPE supplies was identified as one of the most significant issues impacting the leadership group, however the leaders interviews stated that they were able to maintain the supply of stock to their workforce.
There is a potential for bias in the responses from the front-line healthcare workers in the surveys, that cannot be validated through observation within the workplace, however the use of the survey was the most appropriate way to obtain the opinion of a large cohort of the workforce across the organisation. The large survey sample size does however provide confidence that the survey responses were representative of the views of clinicians working at the health service. This study was also only conducted at one organisation during the pandemic, therefore only obtaining the perspective of one group of leaders based on their experiences which could be influenced by existing practices and processes within the organisation. As participants were drawn from across different sites within the health service, this overcame potential bias associated with the differing impact of the COVID-19 pandemic at different study sites.
The wide variety of challenges faced by the leaders during the pandemic identified several gaps within the organisations preparedness that were critical to the response. Health service organisations were required to respond rapidly and with some agility to meet the service needs of the organisation, requiring the implementation of a clear pandemic plan, with provisions for implementing a command structure, and embedded strategies to deliver clear communications, and to address workforce needs. The effectiveness of this hinges on preparedness and familiarity of these structures by key stakeholders, with the intention to provide the workforce with a controlled and coordinated response to alleviate anxieties and fear within the workforce, and to the community members it serves.
Future research looking at comparisons in the response between similar health care organisations could provide valuable insights into aspects of planning and preparedness to inform future responses.
Availability of data and materials
The datasets generated and analysed during the current study are not publicly available due to confidential nature of the participant data but are available from the corresponding author on reasonable request.
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Ethics approval and consent to participate
Ethics approvals for this protocol were obtained from the Mercy Health Human Research Ethics Committee (HREC) and Deakin University Ethics Committee. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants in this research.
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McKenna, K., Bouchoucha, S., Redley, B. et al. “Building the plane while flying it” Reflections on pandemic preparedness and response; an organisational case study. BMC Health Serv Res 23, 940 (2023). https://doi.org/10.1186/s12913-023-09874-x