The results are divided into three major themes: adaptations to retain human resources, addressing workers' mental and physical health, and actions to maintain a trained workforce. The relationship between the major themes and the data relating to each theme, including minor or subthemes, is presented in Table 2.
Table 2. Interventions, adaptations, practices and actions to support health care workers
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Theme category
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Interventions, adaptations, actions and improvements
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Type
|
Organizational level
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Inter-organizational level
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1. Organizational adaptations to retain human resources.
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A. Implement joint efforts (employer-employees) to maintain jobs as: take holidays and negotiated temporary reducing the staff salary.
|
X
|
|
B. Relocate health workers from out-patient, programmed surgery and other ambulatory services.
|
X
|
|
C. Open and enhance homecare services and telemedicine.
|
X
|
|
D. Allow work from home.
|
X
|
|
E. Contract additional staff to respond to the high volume of patients.
|
X
|
|
2. Actions to improve workers’ physical and mental health, foster motivation, and wellbeing
|
A. Implement on-site drills and biosafety protocols on the proper use of personal protection elements to mitigate the contagion.
B. Provide PPE according to their risk exposure.
|
X
X
|
X
|
C. Implement in-house psychiatrists to accompany their emergency team as a response to mitigate fear.
|
X
|
|
D. Implement regular refreshment breaks and having collective prayers in COVID-19 areas to support teamwork between the frontline workforce.
|
X
|
|
E. Implement personalized transportation, develop technological tools and advocate to reduce violence and stigma against health workers.
|
X
|
X
|
3. Actions, and adaptations to enhance workforce knowledge, training, and availability
|
A. Develop partnerships and agreements to expand the availability of general practitioners and specialists in the country.
|
|
X
|
B. Enhance Adaptations and actions to enhance knowledge, skills and competencies related to the management of complex patients in ICU.
|
|
X
|
C. Allow open access to already existing online training libraries.
|
|
X
|
D. Adapt traditional health training.
|
|
X
|
E. Give the students the option of postponing their practices or allow them to continue voluntarily in the hospitals.
|
|
X
|
F. Provide the personal protection element for students.
|
|
X
|
G. Remove to students from all high-risk areas of contagion.
|
X
|
X
|
3.1 Retaining human resources
Managers stressed the organisational adaptations that hospitals had to implement in order to retain their human resources. These actions changed over the six months that we explored in our study. In general, during the early stage of the emergency (March to approximately May 2020), some hospitals closed their outpatient services in preparation to receive a high volume of COVID-19 patients. Opposed to what was expected, some hospitals reported having their facilities relatively empty during the first months after the emergency was declared in the country. Due to that, some of the regular hospital services as programmed such surgery, outpatient clinics, radiology among others were closed temporarily, having a negative financial impact in the hospitals.
Within a context of significant financial uncertainty, managers had to implement several strategies to maintain the hospital’s human resources while balancing this with the organisation's sustainability. Managers highlighted the importance of protecting as many jobs as possible not only as a way of caring for their workforce but also because they foresaw all their trained and experienced personnel were going to be needed at some point during the emergency. Administrative personnel within closed services were asked to take holidays, and in one case, the hospital negotiated reduced staff salaries temporarily to maintain their contracts:
“The clinic’s billing fell to 50 percent in April. That is a terrible drama. In other words, imagine yourself with expenses of more than 150 percent, and billing half (...) One of the first things we did was to send people on vacations. With some administrative staff and professionals in outpatient services, we agreed to reduce a percentage of their salary” (SH-B-015, hospital manager).
Once hospitals began to experience a higher volume of COVID-19 patients (approximately June 2020 onwards), managers reported new challenges associated with human resource availability. During this second stage of the pandemic, the hospitals relied on all available personnel and in some cases, they had to contract new staff. Managers highlighted how workforce roles were made flexible, so they were available to attend to the emerging needs of the hospital. In some cases, managers asked some staff to be reallocated to homecare services and telemedicine, while in other cases, doctors and nurses working from home were asked to attend the hospital to care for non-COVID patients:
We had to transfer human resources from the emergency centres that were underutilised, and strengthen and grow in services that were being demanded massively by the pandemic, such as home care services, telephone counselling services, teleconsultation services, which is what we call “extramural services” (SH-A-005, hospital manager)
In summary, hospitals faced different challenges throughout the first six months of the pandemic. During the early stage of the emergency, hospitals faced a reduction in activity as fewer patients attended hospital services. This organisational context represented a barrier to keep the workforce of hospitals hired and potentially available in case they were needed. After the first two months, and when most of the hospital services were open, managers' decisions were oriented to reallocating their personnel and adjust their roles according to the emerging needs of each hospital.
3.2 Addressing workers’ physical and mental health
The interviews highlighted health care managers’ concerns about the impacts of COVID-19 on healthcare workers’ physical and mental health. A recurrent theme was the barrier faced by managers about the lack of PPE for staff during the preparation and early phase of the pandemic, and uncertainty over those responsible for its acquisition. Managers had to invest in high volumes of PPE as never before. In the words of a manager, the organisation had:
“the need for use and protection, with personal protection elements, defined by the Ministry, aligned by the Ministry, also led us to invest in human resources, personal protection elements that were not used before the pandemic were consumed [such] volumes, because they are specific personal protection elements for a type of virus, which this was not seen before” (SH-B-005, hospital manager).
Within hospitals, on-site drills and biosafety protocols were implemented on the proper use of PPE to mitigate the contagion that existed among health workers, which worsened the lack of available health personnel and make them more familiar with the routines for treating patients safely:
“We started to do drills, patient drills, and that made us a little less afraid of people. Drills of taking off and putting on personal protection equipment, drills of intubation with the equipment, taking the equipment to that stressful part of the drills, I think that was very useful for us.” (SH-B-017, Service coordinator)
In response to concerns about healthcare workers’ mental health (e.g. associated with fear and uncertainty), a representative of a hospital described the use of in-house psychiatrists to accompany their emergency team. Managers faced the barrier of health professionals afraid of being rejected and stigmatised by society. Having professionals working under these conditions was also presented as a challenge for managers as it made it difficult to motivate people to continue working. A hospital director declared that:
It has been difficult to motivate the staff that feels this way, so they continue working, they stay. This is one of the key elements we have to prioritise in case there is another pandemic, that there is always emotional support and ways to support human resources’ wellbeing.” (SH-A-006, service coordinator).
An emergency care manager stated that the wellbeing and mental health of healthcare workers in intensive care units and emergency care was supported by in-house psychiatry and psychology services such as Balint groups (regular meetings with a trained facilitator for debriefing).
Other measures to foster and enable staff motivation and wellbeing included establishing regular refreshment breaks or ‘hydration situations’ and having daily prayers which led to more emphasis on teamwork. A service coordinator stated that wrap-up meetings among the healthcare staff allowed the introduction of a new motto:
“We started to do each other’s watch, the vigilance of the other and with the motto of ‘if you protect yourself, you protect me’” (SH-B-017, service coordinator).
Interviewees expressed concerns about fear of contagion and death, confinement measures, economic difficulties and social factors that affected some members of the general population’s attitudes toward healthcare workers, generating stigma and violence towards health personnel as potential sources of contagion. In the words of an interviewee:
“the reality overwhelmed the surveys because the reality, for example, in the attacks on doctors and health personnel went from being a survey to threats with flower crowns, with obituaries sent in a threatening way to workplaces, with threatening calls,” (SH-A-003, president).
Thus, a manager of a hospital implemented personalised transportation within the city for healthcare staff to guarantee their safety:
“we had to have buses as school routes because they began to attack our people, we only had physical aggression in one, but there began to be all those difficulties, so we set up transport routes, shared transport” (SH-B-011, hospital manager).
Technological tools were developed to follow up and monitor working conditions and attacks on medical doctors. Professional associations had a crucial role in this task for the surveillance of COVID-19 cases in the healthcare workforce and their working conditions. At the system-wide level, scientific associations advocated provision of legal support for the healthcare staff, to incorporate details for monitoring infected healthcare workers into the official records and launched an app for the surveillance of attacks on medical personnel. In summary, the physical and mental health of healthcare workers were pivotal topics that emerged in the interviews with managers and scientific associations that faced COVID-19.
3.3 Workforce knowledge, training, and availability
Participants stressed that the Colombian health system had a shortage of specialists, general practitioners, and nurses, among other healthcare workers. In addition to this shortage of professionals, the COVID-19 pandemic caused a high inflow of patients due to the fact that the COVID-19 virus has a rapid speed of contagion, generating a new challenge, the need to have more human health resources available to care for these patients.
In response to this need, hospitals, governmental agencies, and universities collaborated and developed agreements to expand the availability of general practitioners and specialists in the country graduating both general practitioners and residents early, increasing workforce capacity:
“Last week in my program six but the country graduated about 25 in total, even so, there are very few intensivists, each intensive care unit should have an intensivist, that is, there are not 7,000 intensivists in Colombia. The Availability increased to around 1,500 residents” (SH B 013, president)
Scientific associations, hospitals and academic entities came together with the aim of improving knowledge and skills for the management of patients in Intensive Care Units (ICU). System-wide collaboration produced online training, continuing education programs (e.g. managing complex patients in ICU, mechanical ventilation, respiratory therapy) to systematise clinical knowledge on managing COVID-19 patients:
“We would not have been able to do all this without the participation and commitment of scientific associations, universities and providers, who joined an initiative of continuous training […]. We, therefore, have some virtual courses that have a level of accompaniment and tutoring when technology and the time of the health team allow it.” (SH-A-023, Manager)
Other academic institutions allowed open access to online training libraries through a national repository (500 to 600 free teaching activities from 55 medical schools in the country), facilitating access to training resources:
“from the point of view of human resource training in health, so one of the first decisions we took was to ask all the medical faculties in the country to collect their virtual courses for us to make a national repository.” (SH-B-013, President)
In summary, inter-organisational cooperation across the health system underpinned human resource planning, with the aim of enhancing existing health care workers' knowledge and skills and increasing the availability of human resources to respond to the pandemic.