FormalPara Clinician’s capsule

What is known about the topic?

Emergency department (ED) workers are on the front lines during pandemics, facing important stressors and changes to their work.

What did this study ask?

What were ED workers’ perspectives during the first wave of the COVID-19 pandemic in Canada?

What did this study find?

ED workers believe they have a responsibility to care for patients through a pandemic, in solidarity with their ED colleagues.

Why does this study matter to clinicians?

Leadership should encourage ED workers’ commitments by involving the ED team in decision-making and protecting them from burnout.

Introduction

Coronavirus disease 2019 (COVID-19) has affected millions in Canada [1], leading to transformative changes in emergency departments (EDs). ED workers have had to minimize physical contacts with potentially contagious patients [2,3,4]. They have faced complex issues conceptualized in three interrelated categories: (1) the balance between the duty to care and personal safety; (2) modified interactions with patients and families; (3) relationships with their colleagues, work environment and leadership [5, 6]. COVID-19-related research has focused on ED physicians’ and nurses’ mental health or burnout [7,8,9,10,11,12]. ED physicians report a strong moral obligation to care for patients, while dealing with their own fears of contracting COVID-19 [13]. Understanding ED workers’ concerns and perspectives is fundamental to design supportive, responsive emergency preparedness policies during this ongoing pandemic. The objective of this study was to prospectively examine Canadian ED workers’ perspectives during the first wave of COVID-19.

Methods

Setting

This was a qualitative study of ED workers in 9 urban Canadian EDs between April 9th and July 29th, 2020. This study was designed before it was known how patient populations or regions would be affected. A convenience sample of EDs sought to include even numbers of pediatric and general EDs from the Pediatric Emergency Research Canada network and from a group of EDs in Quebec (N = 4 general; 5 pediatric), with Eastern and Western Canada sites (N = 6 Québec; 2 Alberta; 1 British Columbia) [14].

Participants

Diversity in workers’ roles was sought through purposeful sampling to obtain a rich representation of ED work and team dynamics [14]. Direct contact and open invitations to all ED workers identified interested participants. Participants were chosen based on interest and availability until 5–8 ED workers were enrolled. We sought to recruit 2–4 of each physicians, nurses, other workers (respiratory therapists, social workers, administrative support, cleaning staff, patient attendants, child life specialists) [15]. Research assistants at each site explained the study and provided written consent forms. Verbal consent was recorded. Participants were asked to keep discussions confidential. Ethics approval was obtained at all participating sites.

Study design and data collection

Focus groups were preferred over individual interviews based on the importance of ED teamwork [16]. Each participant was invited to 3 monthly 60-min (English/French) focus groups, using a secured videoconference application. Sites that began data collection after May 15th, 2020 conducted two focus groups. Individual interviews were offered to participants preferring this method or unable to join focus groups.

Our approach was based on the tradition of qualitative inquiry in natural contexts [17, 18]. Our purpose was to report descriptions and interpretations of information shared by participants, and then to move the analytical focus from particular comments towards a conceptual perspective [19, 20]. Framework analysis guided the study design; data collection and analysis followed the process of familiarization, identification of a thematic framework, indexing, charting, mapping and interpretation [21].

Study investigators designed the semi-structured interview guide to investigate the study’s 3 main themes: (1) personal and professional experiences; (2) patient care and ED work; (3) interactions with peers, institutions, public health authorities, and government (Appendix 1). The guide was reviewed by the research team, available in French and English and piloted without changes.

Focus groups were conducted by researchers with either personal experiences of the study phenomenon or more objective perspectives [22]. Predetermined themes and subthemes were explored during each interview. Weekly team meetings allowed for subthemes to be echoed back and specific items to be added. Novel subthemes were explored at different ED sites, geographical areas, types of EDs, and time points. Consensus was not sought during interviews. To encourage participation and to avoid potential power differentials, physician participants were usually interviewed with physician or nursing peers. The standards for reporting qualitative research guidelines were used [23].

Data analysis

Focus groups were recorded and audio files transcribed verbatim. A thematic framework was developed based on the interview guide themes [21]. Then, a descriptive strategy was used to structure data and emerging subthemes into the coding tree as they were identified by interviewers and coders during team meetings. Data was coded using NVivo v.12 (QSR International Pty Ltd.). Reliability and stability of the coding process was assessed regularly by intercoder testing; corrections to code definition and coding tree structures were made to resolve discrepancies during team meetings. Progressively, a thematic framework of non-mutually exclusive codes was developed. Finally, key themes and subthemes were mapped, triangulated and interpreted to define concepts, generate meaning and provide a final conceptual framework [21]. Quotes were translated from French to English by two bilingual researchers.

Triangulation

To obtain a comprehensive understanding of the research phenomenon and to enhance trustworthiness of findings, data triangulation was sought by including workers with different roles and diverse study sites (geographically distinct, varied expertise) [24, 25]. Data was triangulated and contrasts were examined specifically between general/pediatric sites, Eastern/Western sites, and professional groups.

Results

During the 16-week study period, 53 ED workers participated in 36 focus groups and 15 interviews; 25 participants (47%) worked in an general ED (Table 1). Six workers participated exclusively in individual interviews (Appendix 2). Focus groups included the same participants, except 1 participant who participated in 1 focus group followed by 2 interviews, and 4 additional interviews with participants unavailable for focus groups.

Table 1 Participant demographic characteristics (n = 53)
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Theme 1: Personal responsibility (Table 2)

Table 2 Quotes for theme 1 and subthemes: personal responsibility
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The responsibility to care for patients

Participants felt it was their responsibility as highly trained, specialised, and experienced workers to continue to provide emergency care to patients throughout the pandemic. This was instinctive, building on a previously established professional identity and responsibility as an ED worker. Participants reported they had the requisite knowledge, experience, and attributes to sustain the pressure of working during a pandemic (e.g., efficiency, adaptability, creativity, resilience, ability to manage chaos). Working during the pandemic provided participants with a sense of purpose. Participants never referred to external obligations as incentives to work.

Balancing risks and protection

The ED was considered a high-risk environment to contract COVID-19. Participants reported concerns for their own physical health. Potentially infecting their families and contacts was a new additional worry. Appropriate protection measures were the fundamental prerequisite to being able to work. Participants described uncertainty regarding personal protective equipment (PPE) availability, type of PPE required, and how to ensure safety in the ED. Initially, these were sources of concern and vulnerability, but participants eventually reported feeling safe, following the implementation of adequate measures. Protecting the ED team was paramount as workers believed their expertise was hard to replace.

A responsibility to the ED team

ED teamwork, a core value of ED functioning, was amplified during the pandemic through common goals (protect each other, provide optimal patient care), improved interdisciplinarity (shared tasks to minimize patient contact), and solidarity. Although the pandemic could be an added source of conflicts within the ED, participants found support in their ED team and they trusted them to ensure their safety. ED managers were considered trustworthy members of the team if they were physically present and responsive.

Theme 2: ED team engagement in guideline development (Table 3)

Table 3 Quotes for theme 2 and subthemes: ED team engagement in guideline development
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Engaged ED teams

Participants believed ED teams had the expertise to rapidly design guidelines that could best ensure their safety and the provision of quality patient care, all the while recognizing that they could not operate without the involvement of other clinical teams and management levels, who possessed essential knowledge to inform decisions (PPE availability, infection control and prevention).

The importance of decisions based on the best available scientific knowledge

Although managing uncertainty was considered common in emergency care, participants found dealing with the unknowns of COVID-19 challenging. Participants acknowledged that developing clinical guidelines was fraught with complexity given the uncertainty and urgency. Professionals especially trusted decisions based on science, believing public health should stay impartial.

Management and communication

Frequently changing directives and conflicting guidelines revealed the lack of available knowledge to inform decisions. With this paucity of information, participants wondered how PPE protocols were designed, speculating that choices might be based on availability instead of offering the best possible protection, generating institutional conflicts. Initiatives that streamlined information towards clearly identified sources within EDs allowed for better information management and were appreciated, as was responsive communication and empathetic ED leadership. “Top-down” clinical guidelines—believed necessary for the implementation of prompt institution-wide procedures—had to be adjusted as they were not grounded in the reality of ED work, causing frustration.

Theme 3: Sources of moral distress and fatigue (Table 4)

Table 4 Participants’ quotes for theme 3 and subthemes: Sources of moral distress and fatigue
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New distressing clinical practices

Participants struggled with numerous changes in practices and new barriers. Revised resuscitation guidelines required that ED workers don PPE before providing patient care, encouraging definitive airway management to prevent aerosolization. These changes represented some of the most difficult scenarios for ED workers who felt patient care might be delayed. ED workers struggled with the balance between their responsibility to care for patients, and their need to protect themselves and their colleagues. Quebec adult EDs saw their practice change significantly with regards to end-of-life care as they were confronted by patient deaths, daily, which many felt unprepared for.

Challenging distance with patients and families

During the first weeks of the pandemic, ED workers spent less time in patients’ rooms, minimizing physical contact out of fear and PPE rationing, while feeling that PPE hindered communication and patient care. Family visiting restrictions added to workers’ concerns as patients were often alone, even in their end-of-life. ED workers tried to mitigate this problem by innovating and communicating with families through videoconference applications. Once protection protocols had stabilized, many ED professionals increased their physical presence with patients, seeking to provide the best care possible. Many advocated for more family presence.

Ongoing sources of potential burnout

Working in the ED during the first wave was complicated by many new stressors within and outside the ED. Participants reported receiving a “tsunami” of information, including frequently changing clinical guidelines and media updates. Workers continued to provide care while their ED’s physical layouts were dramatically modified, including construction of new negative pressure rooms or ED annexes. Participants reported concern for the healthcare workforce’s long-term sustainability, given the increased work pace, hours, mental load, new environments and practices. ED workers struggled to find time and space to recuperate, while managing restricted family activities, and potential loss of income. Rigid managerial strategies imposed on the workforce (decrees increasing work hours or forcing vacation cancellations) were experienced as a lack of recognition and breach of trust. Participants reported a disconnect between their own and laypeople’s pandemic experiences, especially as isolation measures lifted.

Evolution over time

Initially, participants reported mixed feelings of fear and willingness to act. Within weeks, they had adapted to numerous changes and a “new normal”. Worker fatigue and potential burnout emerged: “At the beginning of a crisis, you’re full of energy. And now we’ve hit a wall. And I think some people are starting to feel tired. You can’t sustain that level of energy forever (Physician).”

Contrasts

Differences emerged regarding end-of-life care as participants from general EDs in Quebec experienced high numbers of patient deaths. Differences were also identified regarding professional background and decisional authority: physicians possessed more autonomy to act while nurses experienced more rigid managerial decisions (Appendix 3). No other differences were observed in comparing regions, ED types or worker identities.

Interpretation of findings

In this study, ED workers’ dispositions to work during the COVID-19 pandemic were personal, driven by a deep engagement towards patient care and ED colleagues. Professional duty to care was experienced as a personal responsibility for ED workers, independently of external, legal or deontological obligations [26]. Participants reported both moral distress and change fatigue. Ensuring ED workers are consulted and involved in clinical practice changes may improve the adaptation of universal guidelines to specific EDs. Clear communications strategies facilitated the transfer and management of important and often changing information. Given workers’ personal commitments to patient care and their colleagues, procedures casting doubt on the availability of PPE or forcing increased work hours, were experienced as a lack of reciprocity.

Comparison to previous studies

Workers interviewed demonstrated commitment to patient care and solidarity with their colleagues. However, they anticipated that future waves would be harder to withstand, as they experienced ongoing stressors (change fatigue, stress, exhaustion, and burnout due to rapid continuous change in the workplace). Research has demonstrated various effects of this pandemic on ED worker mental health [7,8,9,10,11,12, 27]. ED workers identified ongoing sources of moral distress—when a clinician, aware of the right action to take feels constrained from taking it—including altered patient care, restrictive family visiting policies, and institutional decisions that were not adapted to the ED [28, 29]. Resources exist to assist ED workers in fostering resilience, but these alone are insufficient to sustain them through protracted crises [30]. COVID-19 pandemic policies and education programs have focused on PPE use and patient care guidelines [31,32,33]. Our study suggests that ED workers may also benefit from training on navigating other underrepresented aspects of working during a pandemic, like its moral complexity and emotional load.

There are, however, resources exist to support leadership in being responsive to their workforce’s experiences [34]. Incident command systems can include workforce wellbeing in their institutional pandemic response plans, throughout the response. Clear communication within EDs facilitate the transfer of timely accurate information [32, 35]. Ensuring ED workers are involved in clinical practice changes may improve the adaptation of universal guidelines. Finally, workers expressed that procedures casting doubt on availability of PPE, increased work hours, cancelled vacations or deployments were experienced as profound breaches of trust and lack of recognition.

Strengths and limitations

This study was conducted in large urban Canadian EDs, potentially limiting the results’ applicability to other settings. The study was designed before it was known how patient populations would be affected and included a slight majority of pediatric sites. Subgroup comparisons found major differences regarding end-of-life care in general EDs but mainly similarities across other themes explored in this study. A majority of participants were physicians and nurses, and this study likely does not capture the realities of all ED workers, although participants’ answers were similar in subgroup analyses. Several researchers conducted data collection, which could limit coherence. Close team communication, reflexivity and the repeated availability of participants ensured data reliability [22, 36, 37]. Participation in focus groups was excellent, likely due to pre-existing group cohesiveness [15]. All participants remained in the workforce throughout the study period, likely representing a subgroup of engaged workers. Their perspectives are important to foster worker engagement and long-term commitment but may not represent those who left the workforce early in the pandemic and may have experienced greater fear or distress.

Clinical implications

Reciprocal policies that proactively take care of ED workers’ wellbeing are important. Involving teams in pandemic ED guideline development should help prevent pressures caused by change fatigue and moral distress. Workers should be given time and guided opportunity to reflect on the moral and emotional issues.

Research implications

Ongoing examination of the long-term physical, psychological and moral effects of working through a protracted pandemic are necessary. Leadership initiatives that have contributed to positive work environments and helped retain ED workers should be shared. Future studies should seek to understand the perspectives of those who left the ED workforce.

Conclusion

ED workers believe they have a responsibility to provide care through a pandemic, driven by engagement towards their patients and colleagues. Leadership can be supportive by being present and responsive, transparent in communication, and by involving ED staff in the development of policies adapted to specific EDs. These practices will likely help protect from burnout, ensuring the workforce’s long-term sustainability.