A list of the policy options for adapting health care providers to new situations in the workplace during the covid-19 pandemic in Iran, advantages, disadvantages, and implementation considerations of each option is provided in Table 1.
- Creating an activation system of flexible and efficient employees with adjustment of personnel roles
Managing individuals and their roles is critical to adapting to respond to a pandemic due to the rapid pace of changes and requires rapid role adjustment and strengthening of health care personnel to deal with and treat Covid-19 patients in critical situations. One of the options suggested by experts was to carefully survey the duties of health care providers and quickly adjustment of their role, including adding reserve personnel and forming new teams to meet demand. For example, Expert No. 3 said, "During corona peak periods, health care providers are not prepared enough to handle the large number of clients with covid-19 disease, it is suggested to use volunteer staff from other centers to provide treatment". For this purpose, support roles must be defined during the pandemic. These roles include assisting front-line personnel, providing information to families through the patient portal program, providing Covid-19 PCR test results to attending physician or nursing supervisor to manage hospital beds, identifying team members to follow patients at home, coordinating care actions with primary care providers and nursing homes, and identifying occupational health personnel to monitor infected staff (22, 23). Health care managers, according to the workload and specialized fields of individuals should ensure effective work, adjust the work schedule of personnel by considering mid-level and inexperienced personnel along with some experienced or specialized personnel in the health care units (24, 25). To increase communication between various levels of clinical and non-clinical staff to provide the best care, multidisciplinary crisis management team including health care center managers, nursing manager, preventive medicine, microbiology, and medical, ICU, and other acute and intensive care units chiefs would be formed to come together on existing problems and relevant solutions for staff (22). In order to increase the capacity of the workforce, in case of increase of Covid-19 cases, usual works of clinical services and all unnecessary activities of personnel such as unnecessary compulsory training, evaluations and job programs should be eliminated (26, 27). Depending on the different levels of staff, these resources should be transferred quickly from areas with additional personnel to required areas (26). Clinical staff in administrative positions should return to clinical care as much as possible (28). Potential extra staff who can work in high-volume work units related to Covid-19 acceptance, should be identified and from them those who have work experience in emergency situations, cardiorespiratory, and intensive cares should be given priority for transfer (29).
- Adequate training of health care personnel about working conditions with Covid-19 patients
Training should be provided to solve challenges and respond to emergency crises in an appropriate and effective manner (24). According to some experts, training and empowering staff is an important option to increase the tolerance threshold or better adapting to new conditions. Expert No. 7 stated that, "Physicians, nurses and other health care providers have been stressed about working in new situations because of their illness or transmitting it to family members, so training self-care skills for them can be effective". A half-day centralized training in person or online in the field of knowledge and skills of self-protection, professional knowledge and skills, and preventive psychological counseling, based on policies and national guidelines in the form of videos, slides, manuals and illustrations should be provided to all health care personnel before starting work in units related to Covid-19 (29-31). Educational content includes; how to use personal protective equipment, hand hygiene, ward disinfection, medical waste management, sterilization of patient care devices, and occupational exposure management (32). In order to successfully providing of safe and effective clinical services, it is important that unit personnel be trained on the characteristics of Covid-19 disease, treatment methods, and way of care to report any abnormal cases. For example, radiology technologists should be familiarized with the radiographic features of Covid-19, and examine all chest x-rays for any evidence of pneumonic changes, and if abnormal, contact radiologists for immediate reporting (26). To prepare health care personnel, especially physicians and nurses, quick learning of the skills of working in the ICU, with new ventilators to care for critically ill Covid-19 patients, should be provided step by step in the first stage (23).
- Creating a supportive and motivational work environment
A supportive environment means the support received from officials, senior managers, colleagues and the organization's operational plans for personnel (33). In order to personnel adapting with work in a new environment in which they are exposed to physical and mental health threats (15), a 24-hour psychological support system is required for personnel during the Covid-19 outbreak period through an independent permanent telephone line with the ability to transfer to psychiatrists' mobile phones, so that personnel with psychotic symptoms can receive required counseling and psychiatric interventions by phone or support text message (23, 32). A clinical psychologist should visit the units regularly to counsel and review the mental condition of patients and staff, and hold weekly meetings with the voluntary presence of staff to share their experiences (15). Allocation of personnel and the adjustment of their work shifts should be flexible and scientifically appropriate to the pandemic and patients' conditions in the clinical wards of Covid-19, to reduce workload, improve the quality of care and promote physical and mental health during the Covid-19 pandemic (24). Holding managers feedback sessions with staff provides an opportunity for health care workers to participate in workplace decision making (9). Additionally, in these meetings, leaders must articulate expectations of staff in a transparent and compassionate manner in order to promote resilience, self-care, and reduce staff stress. They inform personnel from adequate supply of protective materials and equipment, proper allocation of human resources, work schedules, and attention to their sleep and rest at work (28, 34). To increase staff motivation to work in a new and stressful environment, encouraging and supporting employees by considering physical rewards such as reducing overtime, reducing working hours, flexible planning and psychological rewards such as financial support, recompensation to the family in case of staff illness or death due to work are recommended (35). Study experts recommended that in order to better management of working environment during the COVID-19 pandemic and to provide a suitable work environment, accountable management with good relationships with employees should be strengthened, tasks and resources should be distributed fairly, and payments should be adequate, timely and depending on the specific mental and physical conditions of each employee. Expert No. 6 said "Managers should not use aggressive and assertive behavior, instead they have a cordial relationship with front-line personnel and value their opinions". Expert No 2 stated, "Managers should reassure staff that they will have adequate standard personal protective equipment".
Table 1 Policy options, advantages, disadvantages and implementation considerations for adapting health care providers to new situations in the workplace during the covid-19 pandemic in Iran
Policy option
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Creating an activation system of flexible and efficient employees with adjustment of personnel roles
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Adequate training of health care personnel about working conditions with Covid-19 patients
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Creating a supportive and motivational work environment
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Advantages
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- Improving the efficiency of personnel and increasing their performance
- Provide better and qualified care
- Prevent medical errors and patient adverse outcomes
- Access to accurate data to guide decision making
- Mutual support of personnel to each other in new critical situation
- Reducing staff workload
- Increasing the capacity of employees as increasing Covid-19 cases and being responsive to demand in critical situations
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- Increasing infection control measures and reducing the risk of infection of personnel in the workplace
- Successful provision of safe and effective clinical services
- Ensuring the competence of personnel to work with new conditions and prepare the medical team to care for critically ill Covid-19 patients
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-Reducing patients' stress and improving the mental health of staff working in the new work environment and overcoming fear
- Promoting the physical and mental health of personnel and improving the quality of care during the Covid-19 pandemic
- Creating a positive feeling in employees about work and the ability to cope with stress in a new work environment
- Prevent fatigue and burnout during weeks or months of the epidemic
- Increasing the motivation of staff to work in a new and stressful environment
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Disadvantages
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- Limited time to decide how to prepare health care centers to deal with the Covid-19 crisis
- Need to increase financial resources
- Resistance of personnel to transfer to work in an unfamiliar and stressful environment
- No licensing for selected clinical services
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- Lack of access to equipment, training materials, and the Internet
- The need for human resources for principled training of personnel
- The need for interdisciplinary coordination and cooperation
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- The need for cooperation of psychiatrists and clinical psychologists with the organization
- The need for competent employees to work in critical situations
- Need for financial resources
- Impossibility to hold in person meetings with staff due to the special features of Covid-19
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Implementation considerations
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- Forming a support team by changing the role of personnel along with defining duties (20)
- Setting the work schedule of personnel as presence of young and inexperienced personnel along with specialized and experienced personnel (22, 23)
- Establishing effective communication at different levels of clinical and non-clinical staff by creating one team and teamwork (5, 20, 27)
- Reducing the volume of routine works and eliminating all unnecessary activities of employees (24, 25)
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- Providing a half-day centralized training by the training unit of centers in cooperation with the relevant faculties in person or online for all novice front line personnel before starting work in the corona section on potentially harmful situations and working environment conditions (27-29)
- Providing training to the personnel of the units based on the specialized field and place of activity in relation to the characteristics of Covid-19 disease, treatment methods, and way of care (24)
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- Making an independent permanent telephone line with the ability to transfer to psychiatrists' mobile phones for 24-hour access for staff to receive psychiatric interventions in case of psychotic symptoms (21, 30)
- Clinical psychologists daily visits of units to consult and review the mental health status of staff and patients and to hold weekly meetings with the voluntary presence of staff to share experiences (5, 15)
- Setting a flexible shift schedule for clinical units personnel (22)
- Direct support of organization's managers to the staff by holding weekly meetings with the staff in person or online (26, 34)
- Encouraging staff by considering physical and psychological rewards (33, 35)
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Note: None of the policy options are considered alone, but using options together will be effective.