Table 3 Theme 3 Clinicians fear ‘my job is going to kill me’

3. Clinicians fear ‘my job is going to kill me’

Fear of the unknown

Q1 “There was a lot of political challenges, news, fear from some of the staff around could you come to work, should you not come to work” [….]“So let's also remember the team of people with the supply want to stock the shelves and then our cleaning and housekeeping staff getting rid of this stuff, and going well hang on a minute am I going to get infected with me handling all of these infectious waste bags, so we just had it from end to end, so yeah the donning the doffing, but the getting rid of the stuff at the end of the day” (P4)

Q2 “Staff were just nervous and scared, and really early on you couldn't keep a bottle of hand sanitizer on a table because people would steal it. I want to take you back to that time where gloves and gowns and masks were walking out the door in insane quantities, as well as toilet paper as we all know” (P4)

Q3 “We had situations where a certain craft group was manufacturing their own PPE and we had to try and deal with that concept of you can't do that, this is not safe” (P3)

Q4 “Front line staff were initially very scared, they were afraid of the unknown, their own personal safety, personal safety for their colleagues and their family members as well as the unfamiliarity of things happening quickly around them” (P2)

Q5 “The Doctors fear and the disinformation was shared and spread through the nursing staff, because it was coming from that source it was quite interesting, almost like the Doctors lost the ability to think” [….] “It’s like a Bambi in the spotlight, so frightened about what might happen that they couldn't seem to work through it” (P1)

Q6 “the issue for me was the level of fear in the medical staff, and again people deciding things based on that fear, rather than going to people with more expertise” [….] “so there's certain groups that were more panicked than others, the anaesthetists at Heidelberg certainly” (P1)

Q7 “It also raised a whole heap of things such as the residents in the hot zones weren’t getting basic care, people were too frightened to go in there. People that were furloughed were too frightened to come back to work, so all those things started to come up” (P1)

Q8 “Some people were very paranoid, and there was some not nice behaviours around dealing with people that didn't have the right PPE on” (P11)

Q9 “If there's a lot of anxiety everywhere, your job is to recognize if you have any for yourself and find ways of managing it, then you're more able to assist others to recognize that, so I supported my leaders to try and manage their own anxieties about the world, the life, the uncertainty of things, so that they could assist people reporting to them, and then so on and so forth. They then managers had to do it with team leaders, and team leaders with clinicians and clinicians with clients” (P9)

Q10 “Trying to get people in a place where they felt like they were going to be okay, and to be at work and to still provide care was a big challenge” (P5)

Getting staff into the mindset of the pandemic

Q11 “You need to get everyone to watch the movies like Outbreak and Contagion and get your mindset happening when people are thinking about the donning and doffing processes (P4)

Q12 “We were telling staff to do this but they didn't always understand why, they knew it was to protect them, but they didn't understand sometimes what the PPE was actually doing, that it was protecting both parties, the patients and the staff” [….] “Getting staff to understand the why, like you can tell them to go and have a cup of tea, but understanding that you do it to stay hydrated is a whole different kettle of fish” (P11)

Q13 “So massively steep learning curve to get people familiar with it, comfortable with it, then using it appropriately, using the language appropriately, setting up the donning and doffing stations, so that was a big challenge for mental health that we didn't have to deal with before, whereas in the physical health space I think there was a greater level of comfort and familiarity with that” [….] “It was a steep learning curve for mental health, if you think about what happens in a that environment, unless you're caring for somebody with TB or similar, people were not really familiar with using PPE” (P9)

Q14 “Human behaviour was the problem again, people have forgotten about wearing masks and making sure that they didn't take them off, forgotten about social distancing and all the key elements” (P1)

Infection prevention confusion

Q15 “It was a challenge to actually be able to explain to people what the difference of PPE was, like the different levels of masks” [….] “After a little while we actually realized there were little cohorts in areas that needed some focus on, so they created the PPE oversight group” [….] “Here’s some people who were very qualified and experienced staff, and we have to try and explain to them what proper eyewear means and why you are wearing it, and not to pull your mask off every five minutes, and getting people to be fit tested, nobody's heard the term fit tested before, and didn’t know why” (P11)

Q16 “The midwifery group haven't had a lot of experience working in a general hospital before so the thought of actually looking after people that were highly infectious was very foreign and very scary to that group” [….] “Things that you would normally think people would know and take for granted, people didn't know. Fancy that, doctors didn't know how to get a gown on and off safely” (P5)

Q17 “Once we had actually figured out what are the differences between a surgical mask and a N95 mask, because nobody really heard the terms much before, depending on which area you worked at a lot of the ward staff had no clue what a N95 was” [….] “The ability to don and doff, some people hadn’t even heard the term donning and doffing before, so getting all of that embedded into staff was a real challenge” (P11)

Q18 “You're trying to reassure people that you have their best interests at heart, that you're doing everything you can within guidelines, there's not a lot of high quality evidence for PPE usage so it was very difficult to go to the literature and say here's the literature that shows X, Y, Z, percentages reduction in transmission, based on using this PPE verses that PPE, so it was very challenging” (P3)

Q19 “To mask or not to mask, so very early on in the pandemic there was a lot of debate, I wanted to wear a mask and the organisations position at the time was that a healthy person does not need to wear a mask” (P4)

Q20 “Aerosol generating procedures specifically generated huge fear and anxiety from the very beginning of the pandemic. And then there was this whole creep from aerosol generating procedures that are to broadening that definition to all sorts of other things, I remember back then oh we're drilling into people's bones and the drill is going to be creating aerosols, or we're doing this and this is going to be.. it just got out of hand. I think there's an arbitrariness to some of this, like someone has to draw a line somewhere and say this is what droplet spread is, this is what airborne spread is, when obviously we know that all these things come on a continuum in terms of how infectious something is by start a whole range of factors” [….] “I think people were getting very hung up on a fixed definition, which is important but at the same time we knew that some of the paradigm about droplet spread was probably not true, and that this pathogen was probably more infectious than a traditional droplet pathogen, but also not as infectious as a true airborne pathogen” [….] “You're trying to have these discussions with people and quite often it would just boil down to droplet or airborne, and well it's a bit more complicated than that, like there's an arbitrariness to those definitions. Because you know you have to eventually draw lines and say this is this, and that's this, but the real world is obviously so much more difficult than that” (P3)

Q21 “Even some definitions from anaesthetists around what is an aerosol generating procedure, the epidemiology of this and is it droplet or airborne, I mean there was some confusion around the actual disease itself. There was some confusion around the actual disease itself, and some of the precautions or flow on effects of how we managed the worksite not only in PPE but things like how we disposed of people within the workplace” [….] “It is probably more like the nursing staff in recovery taking a LMA out that is actually potentially at more risk than an anaesthetist under most sort of circumstances in reality. And then the whole conversation about whether someone huffing and panting in labour in the birth suite is an aerosol generating behaviour as opposed to procedure, all sort of had to be worked through” (P2)

Q22 “There was news that staff had heard locally or internationally by colleges about decisions about how much PPE had to be worn, whether you need to wear PAPR suits because your exposed to aerosols, so there was a heightened anxiety and angst really” (P10)

Developing novel PPE programs (education, fit testing)

Q23 “Our PPE education program got much, much bigger, so from an upskilling of staff, wearing gowns, gloves and masks, was traditionally seen as infection control only, it's only there to prevent you from contaminating the patient, now it includes staff safety too” [….] “There was a shift in that focus to say PPE stops infections and it protects you, this is why we need you to wear it, lots more education, people now need to refresh their PPE knowledge every six months” (P4)

Q24 “After a little while we actually realized there were little cohorts that needed some focus, so they created the PPE oversight group” (P11)

Q25 “I think we got videos from Tasmania, not that I have any problems with Tasmania, but why can’t we do that, and then someone said I work at Monash here’s their version” (P2)

Q26 “The SA department of health just churns out this is what you’re going to do, doesn’t matter which department you’re in, and they just do it. They had all of their staff donning and doffing with the Doh SA guideline, with the right PPE in about march of 2020” (P2)

Q27 “All the systems were put in place, we did donning and doffing practice sessions, the online component of that was developed, and it wasn't there instantly, there was something, but not currently what we've got” (P1)

Q28 “we are operationalizing that [education] and moving that into the role of the learning business team, who are all clinical and they will become the experts at assisting with the infection prevention leads within each home” (P1)

Q29 “we have our own learning and development unit within the mental health program and we basically deployed them to that task really quickly so that they would become experts. And they could become spotters and they could use the train the trainer model so they learnt all that they needed to off the experts, then they come and translated that into our environment” (P9)

Q30 “let's bring in a program where we need to fit test 3000 healthcare workers, let's do that, that sounds great, I don't have the equipment, the trained staff, clear processes, clear guidelines. I've got this great document from the Department of Health which tells me this is what you should do, but we're also operating in the healthcare industry that's probably never even seen a P2 mask before. And record it, and make the data available, make sure people know which mask they need to wear, I could go on” (P4)

Q31 “Werribee had been very exposed to COVID, especially in their high-risk areas so they were all on to it (fit testing), they wanted to be safe, they didn't want to take it home to their family, they were much more into let's go and get fit tested. The managers of those COVID areas were like you go and get it organized and get fit tested” (P5)

Adapting to change; implementing PPE processes within the workforce

Q32 “So trying to keep up with what was required from PPE and trying to get everybody to understand it was a challenge” [….] “There was a lot of confusion and too many changes, so you had all our different levels of PPE for COVID peak, green and orange, and then suddenly you're in black, and that's when the Department had put out a message saying this is the level of PPE but you need to have a look at that as an individual health service as well” [….] “And what level of PPE we were having for what scenario, what circumstance and what ward. And sometimes we would have three or four different PPE levels within the one site, depending on what that level of risk that was associated was” [….] “it was like well we've got two very different hospitals, two different cohorts of patients, so one hospital was at a lower level of PPE, one was at the other, and then you had staff going between sites, so then they got confused with what level they were wearing in what area” (P11)

Q33 “Can I just say people lose their minds pretty much every time there's a small change” (P11)

Q34 “We've come so far, I remember back when we first had to wear masks, like we had to put a mask on you, the sky was falling in, this is just a normal mask and everyone whinged about wearing masks” [….] “And the transition to ear loop masks, and there was a thing and all of this hoo haa that went on every day about masks. Were they worn right and wet and how long did you wear them for, and this that and the other, and now everyone's wearing N95s all day and you’re not hearing a peep. And we're not hearing anything about you know my ears hurt and this that and the other, and it’s just like the transformation has been phenomenal, so I think we've come a long way in the PPE world” [….] “Once upon a time that would have been a six week lead up. You know you wear a mask and this is how you do it, this is how you put it on, this is how you take it off, and this is what you do or what you don't do, whereas it was rapid change and frequent change of PPE or all sorts of things” (P5)

Implementing processes with PPE

Q35 “It was just repetition and support about that repetition, so we were very mindful from the beginning to try and bring in processes that were very kind of clear and reproducible. A lot of it centred around we used a lot of visual cues, so it was quite easy, staff didn’t have a lot to remember it was the visual cues were there, and then staff would just follow the process. And then obviously they got to do that over and over again during wave two, and then when wave three came along they were really ready and felt supported in that, and we could just re-action everything. As opposed to one site where we did a lot of that stuff leading into the second wave, and didn't end up using a lot of it because we really didn't have that many patients, and then when it came time to do it again for the third wave it was a lot more challenging because a lot of the staff hadn't had that opportunity to practice, to get over that mental hurdle of okay I'm dealing with COVID patients if I follow the rules and the processes I'm going to be okay so that was probably the main difference” (P3)

Q36 “It was hard work for a lot of the clinical staff, and from the management perspective, it was really hard and you had to try to lead by example and have all the right PPE on yourself. To be able to try and encourage everybody else and show them how to do it, so there's a lot of training and education required on the use of PPE, once we actually had the stocks of it” (P11)

Q37 “Yeah it was frankly an issue around human behaviour, and it's still a challenge for us” (P1)

Q38 “In the early days staff couldn't wait to get into the N95’s and the gowns, like everyone was really relieved because they kept thinking oh why aren’t you putting us in PPE why aren’t you protecting us. And then really that first wave when we did put them in N95s and then they realized how unpleasant it actually was working in those conditions, that this time around they have been more reluctant” (P6)

Q39 “And then the other side of it was actually getting people to wear it. It (PPE) was uncomfortable, like a lot of the reasons people didn't like it was it was uncomfortable, unless you worked in theatres, some areas people weren't used to wearing masks all day” (P11)

Q40 “I know that you put a P2 mask on and someone says you're going to wear that for your 8, 10 or 12 h shift, exhausting” [….] “Wearing a face shield is exhausting, it's uncomfortable, it's hot, it's sweaty. I need a break to go and have some water, I can't do that on the ward, I've actually got to step off the ward and do it, so the staff are tired, overworked, dehydrated, wearing a lot of hot PPE, we still have to keep the hospital a nice cozy temperature for our patients and its our staff who are worn out and done the hard yards” (P4)