All healthcare workers have had to adapt during the Covid-19 pandemic. Some areas of the world have had to do so more rapidly than others. The participants in this study had to adapt their day-to-day work processes during the first and second wave, but unlike New York or Italy, did not have an onslaught of patients during the first or second wave. However, as they entered the third wave, “there has been a tectonic shift” (p20). For most, adaptation came with a sense of urgency and “we adapted, but it was an implosion, it was not a successful adaptation” (p14).
As we attempted to tease out this process of implosive adaptation – i.e., having to adapt amidst “walls coming down” (p19) – we identified 3 overlapping stages that healthcare providers worked through with their teams to navigate Covid-19. First, rapid changes in the usual way of doing work sparked a reality check for team members. They described the triggering moments that made them realize that things could deteriorate rapidly. Once the situation became critical, team members faced multiple challenges that forced them to scramble. Most challenges involved working at odds with traditional values. Team members wrestled with the reality that preserving autonomy and hierarchy clashed with efficiency and productivity. As they began to realize what did and did not work early in the pandemic, team members recognized the need to shift their mindset to be able to pivot and move forward. For most participants, these three stages “resonated with the cycle of change [they] went through over the last few months” (p19).
The rest of this section will provide a narrative illustration of the key dimensions of each stage. These narratives have been composed from participants’ quotes(14) in order to preserve the accuracy while offering diversity of participants’ experiences.
The Reality Check
A “reality check” occurred for participants when it became apparent that Covid-19 was a global pandemic that was likely going to walk through the doors of their hospitals and work environments. This shift in their reality created moments of disruption that were – and continued to be – a catalyst for adaptation. Participants described it in several ways.
For many it felt like “every single piece of the puzzle was shifting from masking to where you could travel in the hospital to how people needed to be isolated to who is taking care of patients” (p2). They lost the sense of certainty about what to do on a day-to-day basis. Coupled with shortages of personal protective equipment and conflicting understandings of what PPE was necessary for which procedures, the clinical work environment completely shifted. This was in part because of the acuity of the crisis, but mostly “because of the sort of changing processes and changing rules. So, you’re never quite sure whether you’re doing the right thing” (p5).
While Covid did not overwhelm the local system during the first wave, team members did not escape the anxiety of remaining alert. Many of them talked about the calm before the storm and described it as the idea that “being backstage is more anxiety provoking than being on stage. Because you can't enter your flow when you're preparing for something.” And missing the sense of certainty added to the anxiety because “none of us were naturally trained to think about how to prepare for a pandemic.” (p9)
Those feelings brought the realization that expertise became a commodity in high demand. Some described it as “you know, it's just so pathetic because we really have no expertise but we're the experts. And so, it was just this terrifying reality” (p9). After the acuity of the first wave receded, participants understood that being experts without expertise not only applied to treating Covid patients. For patients with chronic conditions, they began asking “what happens if this person is exposed to COVID? And how is this treatment pathway going to influence that? COVID itself added that layer of complexity that made you second guess” (p17)
In addition to the rapid changes in the usual way of doing work, the reality check brought out the fears that healthcare providers have experienced and how those fears have evolved through time, as this participant described it.
“Talking to colleagues in New York, they told us, you’re going to know somebody, whether it’s a colleague or a family member or yourself who is going to die from this. So, there was actual fear about safety for yourself, bringing the virus home and giving it to loved ones. And there was real concern from the provision of care about what’s going to happen if, say, doctors and nurses get sick, and we don’t have the staffing because of that? Now with vaccines out and this wave, it’s a different fear, we’re not worried about running out of equipment, we’re not worried about personal safety, it’s the numbers of beds and access to ICU and the effect on non-COVID patients and their access to care.” (p20)
In dealing with these reality checks, team members faced multiple challenges that forced them to scramble as they tried to care for others and themselves.
The Scramble
Early in the pandemic, participants agreed with the strategies of switching people around or re-deploying them to different roles or tasks. The way units were staffed changed, as this participant described, “we took the three or four younger, healthier nephrologists, and say, you’re now our ICU nephrologist… and that was a big win” (p11).
While redeployment was viewed as an effective strategy by most, it was difficult for many who found themselves working outside their usual scope of practice with little time to mentally adapt to this change. Particularly for “these nurses in operating room [who] now all of a sudden a few of them are in Emerg, some are in ICU, some are in the COVID assessment unit. So, there was a lot of tears” (p3). As time passed and people realized that it was reasonable to work outside their scope, they became grateful, because that helped alleviate the work. They realized that “the rules have been blended, and we’re very thankful for those that are willing to bend their scope.” (p13).
Working outside the scope brought benefits but also challenges. For instance, a major scramble for participants in our study related to mitigation strategies that had unintended consequences within resuscitation teams. Anesthetists, who were not typically part of resuscitation teams, were recruited to form a special COVID airway team. This airway team was intended to be called for all resuscitations, despite that airway management was within the resuscitation team’s scope. This strategy proved challenging because it created significant tension particularly around: who is deemed the expert? whose expertise applies for what task? and in what context?
For some, the scientific rationale was justified based on previous experience “handling airways in the SARS-1 emergency in the ‘90s [which] found that you want the most skilled people because you want it to go smoothly, minimize exposures, and minimize aerosol-generated procedures” (p18). Based on this rationale the assumption was made that anesthesiologists would be the ideal specialists to compose these teams. However, for other specialists who were previously routinely responsible for airway management in emergencies, it felt like “the things that we have within our scope being done by other” (p14), but also being done with a different sense of what’s important in the moment. It was described as “this clash of cultures, like Emergency, like ICU, where moving fast, adapting quickly is just part of the culture. But then there were these solutions or the strategies of bringing in people from other specialities that had a different mindset and that created a whole sort of issues.” (p19). The perception that new, unfamiliar team members brought a different mindset was particularly frustrating and unwelcomed. This led teams to implement informal work around strategies during the first wave. One of them was to reinforce role separation by saying “you do your job, stay in your lane as an intubation team person [so] that the trauma team still functions autonomously and independently, and treats the intubation team, for better or for worse, as technicians, not as a consultative service.” (p11). Rather than confronting and constraining the airway teams in this way, other groups opted to stop calling them altogether.
The airway team strategy looked good on paper, but its potential was not fully realized. For some the problem was “people kind of being dropped in”, rather than “somebody who was going to be a part of our team”. If the latter had been a possibility, “I think we could meet in the middle”, as some participants indicated. Specially during the first wave, it felt like “many of these processes [were] just dumped in”. (p15)
The scramble of having to incorporate new, unfamiliar team members created strong dissonance that prompted an explicit reflection after the first wave. This reflection revolved around ideas on “how to work with our new intubation teams, … they’re a great resource, but the pros and cons or bumps in the road, how to integrate one more group into our team, and that was an important learning objective for us” (pXX). As the situation improved in relation to healthcare providers becoming more used to Covid patients and getting vaccinated, the reflection resulted in changes to these teams. As one intensivist described it, “it kind of went from being very awkward and almost shunned and pushed away initially to us getting more comfortable, the team changing. By any means it’s not perfect but it fits in a lot better with trauma care and ICU care than it did six months ago.” (p19)
For other healthcare teams, the scramble involved adapting to the loss of team members and the loss of wider support from other specialties. Participants working directly with potential Covid patients outside of the ICU described being viewed as “lepers” (P6) by colleagues in other specialties resulting in “a huge dichotomy between those who are actually doing COVID and those who aren’t” (p13). This dichotomy left healthcare providers having to either appeal to their colleagues to “please, just do this… please, do my test” (p2) or expand their usual scope of practice when specific specialties would no longer come to complete a procedure. They either had to “put that thing in yourself or do that procedure yourself” (p6). Additionally, several participants in the ER realized that redeployment to their department was not being considered. They felt the loss of support when they “looked at that [redeployment] survey” and realized that “they’re clearly not interested in sending anyone to emerge. This was an ICU questionnaire” (p6). The scramble for these teams was not only to adapt “their roles to work for the greater good” (p13) but to maintain their cohesiveness as “people have [had to] pulled together to support each other” (p4). This involved covering each others shifts, offering to be the “Covid nurse” (p7) when your fellow colleagues were concerned, and working to improve team morale.
Overall, we found that teams scrambled the most when incorporating unfamiliar team members or losing the support of specialities that forced them to work outside their scope. For the former, teams had to adapt to mitigation strategies that took experts out of one context (airway management in the operating room) and put them in a different context (airway management in the emergency room) while expecting them to immediately adapt to, and be welcomed into, that context. For the latter, teams had to adapt to the loss of support from other specialties which threatened the way they carried out work and the team’s cohesiveness. In both cases, team members wrestled with how to preserve their autonomy without compromising efficiency and patient care. As they began to realize what worked and what didn’t work early, team members also realized the need for a pivot in mindset to find their way out of the scramble.
The Pivot
As the pivot entails a shift in mindset, it also requires the longest reflection. Health care providers in our study reflected on the many ways in which their perspectives have shifted as they approach the peak of the third wave.
We found that one of the major pivots in mindset occurred in relation to the idea that “there is no emergency in a pandemic” (pXX). Most participants reflected that the biggest change for people was realizing that even though “it’s really hard to have to stop [you must] accept the greater good of the rest of the team by putting your PPE on because you cannot be lost.” (pXX). According to another participant,
“what that means is if the patient arrests, you leave the room, and you leave them arrested. Nobody touches them until everybody has their full PPE on, is in the room, the negative pressure is turned on, and the door is shut. We will lose some patients because of that, but you have to protect the staff in this case. Losing a patient from a cardiac arrest during COVID-19 is terrible. Losing two nurses because they got exposed is a disaster. So, that was a weird thing for everybody to get their head around.” (pXX)
Also, as redeployment became more normalized, we found that team members started to accept it and even offered it, as this participant described it:
“Truthfully, I was likely to be redeployed anywhere. I haven’t worked in Emerg for a while but, should they have needed me there I would have been able to go there. I could be deployed to the ICU to medicine if needed and surgical services, anesthesia or assist. So, I simply said plug me in where you need me.” (pXX)
As others reflected, the learning that came from embracing the idea that making people interchangeable was reasonable, gave team members a boost of optimism despite the challenges, as this participant illustrated it: “we have rheumatologist running the ventilators. But you know, it was very normalizing, I guess. OK, no matter what happens, like we're going to be okay to figure this out.” (pXX)
In the face of the third wave, and likely the worst one for the participants in our study, some began to reflect on how the pivot in mindset “has felt like a whole exercise in dissonance” (p18). Dissonance revealed in various forms: “I have a professional duty but when I look at the behaviour of some in the general public; that creates dissonance. I know I am an independent professional but there are all these rules being imposed on me; that creates dissonance. I have gathered scientific knowledge to support why we should be doing something, but other experts disagree with me; that creates dissonance” (p18). According to participants, the pivot in mindset that allowed them to manage this dissonance, has hinged in whether “the different specialties have had an opportunity to develop a culture of responding to challenges” (p14).
The reality check, the scramble, and the pivot comprised the process of implosive adaptation that we found most of our participants engaging with. While the reality check described the triggers, the scramble detailed the challenges they went through, and finally the pivot prescribed the shifting of mindset that has resulted thus far as they responded to challenges.