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The COVID-19 pandemic has had an extraordinary effect on hospital staff. From a “standing start”, each hospital has dealt with uncertainty and fear to create new processes to limit the spread of the disease, care for patients, and ensure the wellbeing of staff. Health leaders, managers and frontline staff have developed a wealth of experience from what has been for many the most challenging event in their clinical experience to date.

The patient journey through the operating theatre is complex, involving multiple safety checks, and interactions with staff from many different departments and professional groups. The risk of staff infection in operating theatres is markedly increased due to aerosol generating procedures during airway manoeuvres, moving contaminated bedding or surgical drapes, and any surgery involving the airway. At each point on the journey, a detailed process is required to manage the risk of droplets and aerosols infecting staff.[[1]]

Perioperative services were faced with the urgent task of creating new protocols and processes, sourcing PPE equipment and training staff.  New protocols and training were developed for limiting staff exposure, donning and doffing, patient transfers, aerosol generating procedures, team communication and managing potential in-theatre emergencies. The literature to inform these infection prevention protocols is vast and continues to evolve.[[2–5]] The safety and wellbeing of healthcare workers became a priority, both to protect staff from infection with a potentially fatal disease, and to maintain a functioning healthcare system. International reports speak to high rates of psychological stress and burnout among operating room staff during the pandemic, and concerns about the increased cognitive load on work performance, fewer opportunities for trainees to develop skills, difficult communication associated with PPE, and absenteeism.[[6–12]]

To understand how perioperative services responded to the emergence of COVID-19 and the lessons learnt we explored the experiences and perspectives of perioperative leads from hospitals around the country. The objective of this study is to share these experiences and learn from them.

Method

The Auckland Health Research Ethics Committee approved this study (AH3336). Informed consent was obtained from all participants.

Context

The public health system in Aotearoa is divided into 20 district health boards (DHBs) responsible for the population in their region. The study took place after the first wave of the COVID-19 pandemic, during a period when elimination had been (temporarily) achieved in the community.

Study design

We undertook a qualitative study with thematic analysis of semi-structured interviews.

Sample and sampling

We used a snowballing sampling strategy to identify and recruit perioperative services clinical leaders, managers and key planning personnel, initially contacting anaesthetic and surgical department heads, asked for referrals to relevant nursing, anaesthetic technician, anaesthesia and surgical leaders and advertising the study in a surgical newsletter.

Reflexive statement

JW is a clinical academic and anaesthetist, with expertise in patient safety, teamwork and simulation-based education. VB is an anaesthetist, former perioperative lead and President of the Australian and New Zealand college of Anaesthetists. KJ is an anaesthetist involved in hospital disaster response planning. JL is a research fellow with a psychology background. ML is a public health clinician and clinical academic with expertise in Māori health.

Data collection and management

The semi-structured interview question guide was developed through discussion within the research team and informed by the literature on hospital responses to COVID-19 overseas. The question guide explored participant experiences of, and reflections on, planning for the pandemic (Interview guide Supplement 1).

Interviews were conducted via video conference or telephone or face-to-face by JL, JW, VB and ML. Recruitment continued until a representative sample across hospitals and professional groups was obtained and we reached data sufficiency, in that additional interviews were not adding new information. Interviews were audio-recorded, transcribed by an independent transcriber, de-identified, and entered into NVivo software.

Data analysis

Thematic analysis followed the six-step approach described by Braun and Clarke.[[13]] (View Table 1).

Results

Thirty-three perioperative leaders, managers or core planning personnel from 16 DHBs participated in interviews, which was 72% of those we invited. Interview duration was 20 to 60 minutes. Participants were from small (7), medium (12) and large (14) DHBs, comprising 17 anaesthetists, six surgeons, six nurses and one anaesthetic technician. Of these, 91% held a formal management or educator role and 9% identified as Māori.

We identified three interrelated themes describing the main issues for participants: “no one source of truth”, “resourcing challenges” and “staff stress and anxiety”. A fourth theme, “lessons learnt”, captures participant reflections what worked, and recommendations for the future.

Theme 1: no one source of truth

Participants described prolific, constantly changing information, limited initial support and siloed approaches to planning with tensions between departments and professional groups.

Prolific, constantly changing information

Participants experienced an overload of constantly changing information including scientific advice, international experiences, and recommendations, circulated by colleagues or leaders or accessed via the internet. “Facts” and recommendations often conflicted between sources, and between professional bodies. This in turn hindered development of protocols, staff trust and inter-department consensus on core issues, such as the PPE precautions needed in different circumstances.

There was so much information and every day it was changing—by the time you —disseminated all the information to everyone—the next day, it all […] changed again. (Participant (P) 25, Nurse Educator, medium DHB)
There were hundreds of articles coming out every day from all across the world that people would just send around, you know. It was like complete information overload (P8, Anaesthesia HoD, small DHB)

Limited initial support for department leaders

Participants recounted receiving minimal guidance from senior hospital management and the Ministry of Health (MoH) in the initial stages of the pandemic. In the face of urgent need for action, many found hospital management slow to make decisions, answer queries or approve proposed policies. Similarly, national guidance emerged after many departments or hospitals had done their own initial planning. National and hospital level plans were often described as being focused on “bigger picture” issues as community spread or visitor procedures, leaving perioperative teams to develop their own plans for conducting surgery safely.

A lot of the work here was not sanctioned by the ministry or sanctioned by the DHB. A lot of scared staff members decided to do it on their own and were supported by the managers (P14, Anaesthesia HOD, medium DHB)
It felt like they [MoH] were very much focused on what we’re going to do as a country. Fair enough, because there’s a huge amount of work to be done there. But in terms of what are we going to do as a health service and how are we going to do this in ICU, actually manage people. It felt like that [actual management of ICU patients] was initially very driven at an individual level. (P10, Anaesthesia HOD, large DHB)

Confused messages and distrust about PPE stock and protection

Participants struggled to get an accurate picture about PPE requirements, and many distrusted the information provided by their hospital or the MoH about PPE stock levels and the protective adequacy of the available PPE and protocols.

One of our biggest concerns initially was the very mixed and confused messages around the requirement for N95 masks and low-level PPE. (P30, Surgical HOD, large DHB)
That was a source of constant frustration, you know, seeing pictures from people in other countries with completely different PPE to what we were expected to use… is that because we didn’t have anything better, is that because there was nothing better available, you know, and those are big questions that I couldn't answer at any stage. (P15, Anaesthesia HOD, medium DHB)

Siloed approaches and tensions between departments

Some perioperative services had limited collaborative planning between professional groups and departments, and many had different solutions to issues such as screening and PPE. These differences were often attributed to varying perceptions of risk or conflicting guidance from professional colleges. Within many perioperative services, surgeons were not well integrated into the initial planning and staff training. Some perioperative clinicians took it upon themselves to run joint training, sometimes involving ED or ICU, but without senior management support. In other hospitals, planning was collaborative across departments from the outset.

Everyone was just in such a hurry and so every kind of silo had to sort their own area out. We did drills [with ICU, ED and theatre] but that was the clinicians working together. There wasn't any kind of hospital oversight. (P17, Anaesthesia HOD, large DHB)
There was a lot of conflict between specialities about how they wanted their patients brought into theatre. And in the end, we had to say, no we’re having one journey for the patient. If we have one for obstetrics and then we have one for gen. surg. etc – nobody’s going to get it right, we’re going to forget and get it all wrong. (P2, Nurse Manager, large DHB)

Theme 2: Resourcing challenges

Staff described resourcing challenges to prepare for a potential influx of COVID-19 patients due to limited baseline preparedness, increased workload, access to PPE, deficient physical facilities, and limited ongoing preparedness for a second wave.

Limited baseline preparation

Participants described essentially starting from scratch in their preparations for COVID-19. Disaster response plans provided little relevant guidance, while participants were either unaware of existing pandemic plans or found that substantial work was needed to translate the high-level pandemic plans into department-level plans applicable to COVID-19. IT systems or hardware needed to be upgraded to enable Zoom and remote work. Protocols, plans, training and equipment upgrades needed to be established urgently, and many described being caught out by the speed at which COVID-19 became an imminent threat in New Zealand.

I guess ideally, we would have done that work in January. But I guess, how fast COVID moved and our lack of understanding meant that we didn’t really do that work until quite late in the piece.  (P15, Anaesthesia HOD, medium DHB)

Workload

Participants recounted the huge volume of work involved in planning and preparing to conduct surgery in the context of potential COVID-19 cases, with some working “80 to 100 hours a week”, or “every day during the six-seven-week period”. In addition to the work involved in reviewing literature and developing protocols and education communications with staff, supporting staff wellbeing took up large amounts of time that limited their capacity for other planning and management tasks. Many of those interviewed had responsibilities not only for their own department, but also supporting other departments including ICU, or wider Māori and Pacific networks.

[The] time you spend managing your staff probably tripled overnight because of the stress, anxiety (P12, Nurse Manager, medium DHB)
I’m very strong with [supporting] all my Māori and Pacific nursing groups, PPNA [Pan Pacific Nurses Association], the Pacific Medical Association, Nursing, Māori Nurses, Niuean Nurses. So, we all had things that were asked of us (P26, Nurse Consultant, large DHB)

Participants emphasised the additional time and staffing required for surgery on patients who might, or did, have COVID-19. In some cases this doubled staff numbers, or quadrupled the time needed for the surgery. Additional resources for potential COVID-19 patients limited the resources available to treat other patients.

When you take a patient through [theatre] and you treat them as if they’re COVID [positive]—it’s just enormously time consuming and that has a big impact obviously—the quantity and the work that you can do for all the other patients so there’s lost opportunity cost and it’s exhausting for the staff as well. (P1, Anaesthesia HOD, large DHB)

Real or perceived PPE shortages

Most participants were initially worried that the local or national stock of PPE would run out, and these fears in turn led to rationing of PPE, tensions between individuals and departments, and staff stress. Some DHBs found that their existing pandemic stocks were out of date or perished, and new stocks were sometimes unsuitable.

Early on [DHB name] had very little [PPE]. I mean, it was terrifying and we were very mindful of the fact that we could’’t afford to waste it…. I think also just the reliability of the information, you know, the minster was up there saying there’ll be enough PPE but it didn’t feel like that was based on any great factual information. (P2, Anaesthesia HOD, medium DHB)

Challenges caused by local physical facilities

Local physical facilities generated challenges with isolating and caring for patients, often related to lack of appropriate spaces or negative pressure rooms. Challenges were difficult to address within the constraints of existing, sometimes ageing and outdated, hospital buildings although some hospitals had new walls built or used plastic sheeting to create isolation areas.

Our hospital is so old, and our facilities are so outdated. So a lot of the wards would have struggled. We have maybe two negative pressure rooms in our wards in total and one in ED. (P5, Anaesthetist, large DHB)

Concerns about existing workforce capacity

Many recounted concerns about insufficient staff numbers and inadequate numbers of staffed ICU beds to respond to large numbers of COVID-19 cases. This would be exacerbated by staff exposure to the virus contributing to stand downs and sickness.

We struggle with ICU capacity on a day-to-day basis—we would not have had the staff to care for patients and we would not have had the space to keep patients. That is admittedly our weakness. We have the skills—we just don’t have enough people. (P10, Anaesthetic HOD, Large DHB)
We’re chronically understaffed and that’s not just specialists…. it simply would not be possible to deal with a pandemic with that amount of staff. (P16, Anaesthesia HOD, medium DHB)

Limited ongoing planning and training

Limited planning or training had occurred between the initial lockdown period and the time of their interview. Ongoing planning and training were described as difficult to resource when people already had high workloads trying to catch up on missed surgeries from the initial lockdown.

We‘ve already lost a bit of that institutional knowledge, the match readiness[for COVID-19]. And we’ve been slain by business as usual because everybody’s in catch-up. Every hospital I visited this year has been overwhelmed by acute caseloads… it’s very hard for us to get people out to train. (P6, Anaesthesia HOD, large DHB)
They’ve got so many surgeries to do but I think sometimes they put those as [ahead of] actually getting the staff prepped up to be able to do the mahi effectively and in a positive way. (P26, Nurse Consultant, large DHB)

Theme 3: Staff stress and anxiety

Participants described unprecedented staff stress and anxiety and the impact this had on workforce capacity.

High stress and anxiety

Most participants described high levels of staff stress or anxiety, which extended to large portions of the workforce in some departments. Staff stress was described in all professional groups, but most commonly among nurses. Fear was perceived to be largely driven by concerns about catching COVID-19 or passing it to their families. Fears also related to the ability of services and PPE stocks to cope with an influx of patients, and challenges associated with childcare, lost income or concern for family members overseas.

I’ve never seen fear like it—I’ve been through Swine Flu, I went through bird flu, I went through HIV—I have never seen such a level of fear as I did last year. (P22, Nurse Manager, large DHB)

Staff stress impacted workforce capacity

Participants described instances where stress and anxiety led to absenteeism, unnecessary PPE use for COVID-negative patients, impaired decision-making and unwillingness to be involved in the treatment of COVID-19 patients. A number indicated that there remained a general sense of burnout among staff, following the initial 2020 response and the subsequent attempt to catch up on missed elective surgery procedures. The impact on staff wellbeing and turnover in turn had the potential to impact on the workforce’s capacity to care for patients.

There was a mass exodus of large portions of the staff- there were nursing staff—who point blank refused to nurse patients who were query COVID. (P7, Anaesthesia HOD, small DHB)
And the recovery nurses… about 90 percent have now resigned from the DHB… they were put under quite a lot of pressure to upskill to ICU, which is a completely different specialty for them and they felt very uncomfortable. (P16, Anaesthesia HOD, medium DHB)

Theme 4: Lessons learnt

Participants identified numerous ways they had—or planned to—address the challenges described above. These “lessons learnt” had a strong focus on communication, caring for staff, collaboration, leadership style, downtime to enable preparation, and support for external, or national resources to help with planning.

Communication

Participants described the importance of communicating with staff early and regularly, and structuring information so staff could easily navigate to the latest, most relevant information. They also described the importance of expressing empathy for staff anxiety, ensuring avenues for reciprocal communication, being honest and acknowledging uncertainty. There was no single best option for communication format; face-to-face and Zoom meetings could help with staff buy-in for decisions, while email was not helpful for staff with limited access or time to look at emails at work.

Collaboration

Identifying talented individuals within their departments added huge value to planning, education and preparing for COVID-19. Many noted that establishing interdisciplinary and interdepartmental collaboration at the outset through formal interdepartmental meetings and working groups, and personal relationships or networks improved the quality and consistency of plans.

Invest in staff wellbeing

Participants emphasised the importance of listening to and acknowledging staff concerns and fears and described a range of helpful interventions designed to support staff wellbeing. One Māori participant emphasised the importance of whanaungatanga and manaakitanga in both caring for patients with COVID-19 and looking after Māori staff and the wider workforce, as well as ensuring staff remained engaged and committed to working in perioperative services.

Well-articulated plans and associated training to protect staff from infection could help reduce staff anxiety. Simulation was a useful, though resource intensive training modality.

Leadership style

Participants reflected that to be successful leaders, they needed to be adaptable to changing circumstances and information while acknowledging that their staff needed them to be decisive in their planning to booster confidence. One reflected on the need to acknowledge a range of staff perspectives on tolerance to personal risk which may differ from their own.

Enabling preparation

Stopping services was described as critical to preparation; the Government lockdown freed up resources to enable services to develop plans and train staff. This work was difficult to achieve when services were working at full capacity and difficult to maintain once full operating lists resumed.

External resources

External information sources including recommendations and resources from overseas colleagues, professional organisations other DHBs were instrumental in formulating plans. Many participants also looked for additional national guidance while acknowledging that guidelines may need local adaptations for physical layout and staffing resources.

Participant recommendations are outlined in Text Box 1.

Discussion

Perioperative leaders and managers responding to the first wave of COVID-19 described a sense of urgency and previously unseen levels of staff stress in the face of prolific, and constantly changing information. Like others, participants described COVID-19 as a “disaster of uncertainty”.[[14]] Despite the existence of national pandemic response plans, participants described limited preparedness and increased workload due to the need to rapidly make plans for the response. There were concerns around PPE and the suitability of their facilities. There was an impact on workforce capacity through absenteeism, stand-downs and sickness. Pre-existing perioperative management structures and processes were not always configured to facilitate collaboration between professional groups, between departments and with senior management. All this led to increased tensions and confusion in planning.

Participating perioperative leaders expressed concerned about preparedness for future waves. From their experiences, they recommended investment in staff communication and wellbeing, improved systems and collaboration, and consideration of new facilities (See Text Box 1).

Health leaders had a large role to play in the COVID-19 response. There were calls for leaders to be transparent, agile, responsive and empathetic, all whilst themselves dealing with uncertainty and a large workload. Caring for staff wellbeing is critical, but managers also need to be supported to manage their own stress and exhaustion.[[15]] Many of our leaders in this study described behaviours considered important for fostering work engagement and reducing psychological distress.[[14,16]] This included empathetic listening to staff, communicating information in a transparent, timely, regular and structured manner, and being accessible and open toward their staff.[[13]]

Surge capacity of health services

A feature of this pandemic, taken from the literature on mass casualties, is the need for "surge capacity” or ability to expand a service in response to non-routine demands. Surge capacity has been described in terms of “stuff” (sufficient supplies and equipment), “staff” (adequate and appropriately trained workforce), “structure” (facilities) and “systems” (integrated policies and procedures).[[17]] The experiences our interviewees could usefully be considered within this framework: “stuff” is most obviously PPE, guidelines and policy documents; “staff” includes training and retaining the workforce; “structure” in the context of a pandemic alludes to appropriate spaces for clinical care of infectious patients; and “systems” could be those mechanisms to enable collaboration, planning and communication. These categories could be usefully applied for planning future local responses.

Complex adaptive systems

Our hospitals can each be considered as a complex adaptive system within the larger national healthcare system. Complex adaptive systems have multiple interdependent parts. They interact with the environment and learn and adapt to changes through feedback loops.[[18]] While broad guidelines can be helpful, agents and units within these systems require autonomy to respond as local conditions dictate[[18]]—which suggests that detailed government or even senior hospital management guidelines may both help or hinder planning for our perioperative departments depending on the degree to which they allow for adaptation to local circumstances. Leaders on the ground, and those who emerged as new leaders, required autonomy to adapt plans to local context.

Furthermore, complex adaptive systems depend on multiple internal connections to communicate and share resources, and in some hospitals it seemed these connections needed new work. Guidelines from the United States Institute of Medicine[[19]] emphasise building connections to accelerate the flow of information and share resources in times of surprise. Communication and collaboration featured as lessons learnt by our interviewees. Many connections have now been built—between the different services involved in perioperative care, and between hospitals. Maintaining them when the dust settles will be important.

The shift to a single nationwide health service under Health New Zealand in partnership with the Māori Health Authority will include regional networks of hospital and specialist services,[[20]] with the potential to support improved surge capacity planning. Embedded regional planning was proposed within the Health and Disability System Review to enable population health analysis, guidance and coordination, and shared expertise in planning, guidance, and other operational functions.[[20]]

Looking to the future

In early 2020, there was hope, almost an expectation, that COVID-19 could be eliminated or kept out of New Zealand, as had been the case with SARS-CoV-1 and Ebola. At the time of our interviews there was a feeling that we were done with COVID-19, and were left with large surgical waiting lists, staff losses, and a degree of workforce burnout. Identified challenges in physical facilities were yet to be resolved and future planning had been subsumed into catching up with the backlog of work.

In late 2021, we had a much better understanding of the virus, improved access to PPE, a largely vaccinated population and new technologies for detection and treatment. However, we are now faced with the prospect of endemic COVID-19 and its variants, and many of the challenges for surge capacity in perioperative services remain. We still have workforce vacancies, many ageing and out-dated hospital facilities, and our healthcare systems continue to present barriers to collaboration between departments, professional groups and between hospitals. Our study identified differences in access to resources and/or planning capacity between small and large hospitals, in part due to the size of their workforce and physical infrastructure. Smaller, rural hospitals may struggle more in the event of a surge of COVID-19 patients, and many of these have high Māori populations. Māori, including Māori staff, are more likely to get sick or die from COVID-19 than Non-Māori.[[21,22]] Inequities in our health system require a “whole of nation” systems response.

While each new virus, or other “surprise” event will bring its own unique challenges, lessons learnt can inform the fundamental requirements of our complex hospital systems and their ability to surge in response to the next challenge. Hospital staff move on, and institutional knowledge is lost. Lessons from the current pandemic need to be captured for future generations. We hope the present paper goes some way towards this.

Limitations and future research

This study presents a snapshot in time and the extent to which our pandemic response, including changes in leadership style, has changed following the “practice run” with COVID-19 in early 2020 remains to be tested. Our study included a good spread of DHBs around the country, and professional roles within perioperative services, but our findings may not be generalisable to other hospital services or other countries.

We recruited only three Māori participants. Further research could explore the values and leadership behaviours that enable and empower Māori staff during challenging times. Supporting and retaining this workforce will be critical for Māori health equity, and in response to future pandemic threats.[[23]]

Conclusion

The experiences and reflections of perioperative leaders from hospitals around Aotearoa New Zealand to the COVID-19 pandemic paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress, hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Summary

Abstract

Aim

Once it became apparent that COVID-19 would reach Aotearoa New Zealand, perioperative services responded urgently to contain viral spread, keep staff safe and maintain patient care. We aimed to understand how perioperative leaders around the country responded to the pandemic, their experiences, reflections and the lessons learnt. Our goal is to inform future pandemic responses.

Method

We undertook a qualitative study with thematic analysis of semi-structured interviews. We recruited perioperative leads involved in the COVID-19 response using snowball sampling, following initial contact with anaesthetic and surgical department heads.

Results

We interviewed 33 perioperative leads from 16 of the country’s 20 district health boards, with representation across hospitals of different sizes and the professional groups working in operating theatres. Four main themes were identified from data. These were: “no one source of truth,” with prolific, constantly changing information, limited initial support from hospital senior executives, and siloed approaches and tensions between departments and professional groups; resourcing challenges attributed to limited baseline preparedness and increased workload; deficiencies in PPE and physical facilities; staff stress and anxiety, and the impact this had on workforce capacity; ongoing preparedness for future waves; and reflections on “lessons learnt”. These lessons focused strongly on communication, caring for staff, collaboration, downtime to enable preparation, and a need for external, potentially national co-ordination and resources to facilitate planning.

Conclusion

Perioperative leaders’ experiences and reflections of COVID-19 paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Author Information

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland; Anaesthetist, Auckland City Hospital, Auckland. Dr Vanessa Beavis: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Kim Jamieson: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Mataroria Lyndon: Senior Lecturer, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland. Dr Jennifer Long: Research Fellow, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland.

Acknowledgements

We would like to thank the participants who kindly shared their time, experience and wisdom with the research team.

Correspondence

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland. Anaesthetist, Auckland City Hospital Private Bag 92019, Auckland 1142. +6421588644.

Correspondence Email

j.weller@auckland.ac.nz

Competing Interests

Nil.

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The COVID-19 pandemic has had an extraordinary effect on hospital staff. From a “standing start”, each hospital has dealt with uncertainty and fear to create new processes to limit the spread of the disease, care for patients, and ensure the wellbeing of staff. Health leaders, managers and frontline staff have developed a wealth of experience from what has been for many the most challenging event in their clinical experience to date.

The patient journey through the operating theatre is complex, involving multiple safety checks, and interactions with staff from many different departments and professional groups. The risk of staff infection in operating theatres is markedly increased due to aerosol generating procedures during airway manoeuvres, moving contaminated bedding or surgical drapes, and any surgery involving the airway. At each point on the journey, a detailed process is required to manage the risk of droplets and aerosols infecting staff.[[1]]

Perioperative services were faced with the urgent task of creating new protocols and processes, sourcing PPE equipment and training staff.  New protocols and training were developed for limiting staff exposure, donning and doffing, patient transfers, aerosol generating procedures, team communication and managing potential in-theatre emergencies. The literature to inform these infection prevention protocols is vast and continues to evolve.[[2–5]] The safety and wellbeing of healthcare workers became a priority, both to protect staff from infection with a potentially fatal disease, and to maintain a functioning healthcare system. International reports speak to high rates of psychological stress and burnout among operating room staff during the pandemic, and concerns about the increased cognitive load on work performance, fewer opportunities for trainees to develop skills, difficult communication associated with PPE, and absenteeism.[[6–12]]

To understand how perioperative services responded to the emergence of COVID-19 and the lessons learnt we explored the experiences and perspectives of perioperative leads from hospitals around the country. The objective of this study is to share these experiences and learn from them.

Method

The Auckland Health Research Ethics Committee approved this study (AH3336). Informed consent was obtained from all participants.

Context

The public health system in Aotearoa is divided into 20 district health boards (DHBs) responsible for the population in their region. The study took place after the first wave of the COVID-19 pandemic, during a period when elimination had been (temporarily) achieved in the community.

Study design

We undertook a qualitative study with thematic analysis of semi-structured interviews.

Sample and sampling

We used a snowballing sampling strategy to identify and recruit perioperative services clinical leaders, managers and key planning personnel, initially contacting anaesthetic and surgical department heads, asked for referrals to relevant nursing, anaesthetic technician, anaesthesia and surgical leaders and advertising the study in a surgical newsletter.

Reflexive statement

JW is a clinical academic and anaesthetist, with expertise in patient safety, teamwork and simulation-based education. VB is an anaesthetist, former perioperative lead and President of the Australian and New Zealand college of Anaesthetists. KJ is an anaesthetist involved in hospital disaster response planning. JL is a research fellow with a psychology background. ML is a public health clinician and clinical academic with expertise in Māori health.

Data collection and management

The semi-structured interview question guide was developed through discussion within the research team and informed by the literature on hospital responses to COVID-19 overseas. The question guide explored participant experiences of, and reflections on, planning for the pandemic (Interview guide Supplement 1).

Interviews were conducted via video conference or telephone or face-to-face by JL, JW, VB and ML. Recruitment continued until a representative sample across hospitals and professional groups was obtained and we reached data sufficiency, in that additional interviews were not adding new information. Interviews were audio-recorded, transcribed by an independent transcriber, de-identified, and entered into NVivo software.

Data analysis

Thematic analysis followed the six-step approach described by Braun and Clarke.[[13]] (View Table 1).

Results

Thirty-three perioperative leaders, managers or core planning personnel from 16 DHBs participated in interviews, which was 72% of those we invited. Interview duration was 20 to 60 minutes. Participants were from small (7), medium (12) and large (14) DHBs, comprising 17 anaesthetists, six surgeons, six nurses and one anaesthetic technician. Of these, 91% held a formal management or educator role and 9% identified as Māori.

We identified three interrelated themes describing the main issues for participants: “no one source of truth”, “resourcing challenges” and “staff stress and anxiety”. A fourth theme, “lessons learnt”, captures participant reflections what worked, and recommendations for the future.

Theme 1: no one source of truth

Participants described prolific, constantly changing information, limited initial support and siloed approaches to planning with tensions between departments and professional groups.

Prolific, constantly changing information

Participants experienced an overload of constantly changing information including scientific advice, international experiences, and recommendations, circulated by colleagues or leaders or accessed via the internet. “Facts” and recommendations often conflicted between sources, and between professional bodies. This in turn hindered development of protocols, staff trust and inter-department consensus on core issues, such as the PPE precautions needed in different circumstances.

There was so much information and every day it was changing—by the time you —disseminated all the information to everyone—the next day, it all […] changed again. (Participant (P) 25, Nurse Educator, medium DHB)
There were hundreds of articles coming out every day from all across the world that people would just send around, you know. It was like complete information overload (P8, Anaesthesia HoD, small DHB)

Limited initial support for department leaders

Participants recounted receiving minimal guidance from senior hospital management and the Ministry of Health (MoH) in the initial stages of the pandemic. In the face of urgent need for action, many found hospital management slow to make decisions, answer queries or approve proposed policies. Similarly, national guidance emerged after many departments or hospitals had done their own initial planning. National and hospital level plans were often described as being focused on “bigger picture” issues as community spread or visitor procedures, leaving perioperative teams to develop their own plans for conducting surgery safely.

A lot of the work here was not sanctioned by the ministry or sanctioned by the DHB. A lot of scared staff members decided to do it on their own and were supported by the managers (P14, Anaesthesia HOD, medium DHB)
It felt like they [MoH] were very much focused on what we’re going to do as a country. Fair enough, because there’s a huge amount of work to be done there. But in terms of what are we going to do as a health service and how are we going to do this in ICU, actually manage people. It felt like that [actual management of ICU patients] was initially very driven at an individual level. (P10, Anaesthesia HOD, large DHB)

Confused messages and distrust about PPE stock and protection

Participants struggled to get an accurate picture about PPE requirements, and many distrusted the information provided by their hospital or the MoH about PPE stock levels and the protective adequacy of the available PPE and protocols.

One of our biggest concerns initially was the very mixed and confused messages around the requirement for N95 masks and low-level PPE. (P30, Surgical HOD, large DHB)
That was a source of constant frustration, you know, seeing pictures from people in other countries with completely different PPE to what we were expected to use… is that because we didn’t have anything better, is that because there was nothing better available, you know, and those are big questions that I couldn't answer at any stage. (P15, Anaesthesia HOD, medium DHB)

Siloed approaches and tensions between departments

Some perioperative services had limited collaborative planning between professional groups and departments, and many had different solutions to issues such as screening and PPE. These differences were often attributed to varying perceptions of risk or conflicting guidance from professional colleges. Within many perioperative services, surgeons were not well integrated into the initial planning and staff training. Some perioperative clinicians took it upon themselves to run joint training, sometimes involving ED or ICU, but without senior management support. In other hospitals, planning was collaborative across departments from the outset.

Everyone was just in such a hurry and so every kind of silo had to sort their own area out. We did drills [with ICU, ED and theatre] but that was the clinicians working together. There wasn't any kind of hospital oversight. (P17, Anaesthesia HOD, large DHB)
There was a lot of conflict between specialities about how they wanted their patients brought into theatre. And in the end, we had to say, no we’re having one journey for the patient. If we have one for obstetrics and then we have one for gen. surg. etc – nobody’s going to get it right, we’re going to forget and get it all wrong. (P2, Nurse Manager, large DHB)

Theme 2: Resourcing challenges

Staff described resourcing challenges to prepare for a potential influx of COVID-19 patients due to limited baseline preparedness, increased workload, access to PPE, deficient physical facilities, and limited ongoing preparedness for a second wave.

Limited baseline preparation

Participants described essentially starting from scratch in their preparations for COVID-19. Disaster response plans provided little relevant guidance, while participants were either unaware of existing pandemic plans or found that substantial work was needed to translate the high-level pandemic plans into department-level plans applicable to COVID-19. IT systems or hardware needed to be upgraded to enable Zoom and remote work. Protocols, plans, training and equipment upgrades needed to be established urgently, and many described being caught out by the speed at which COVID-19 became an imminent threat in New Zealand.

I guess ideally, we would have done that work in January. But I guess, how fast COVID moved and our lack of understanding meant that we didn’t really do that work until quite late in the piece.  (P15, Anaesthesia HOD, medium DHB)

Workload

Participants recounted the huge volume of work involved in planning and preparing to conduct surgery in the context of potential COVID-19 cases, with some working “80 to 100 hours a week”, or “every day during the six-seven-week period”. In addition to the work involved in reviewing literature and developing protocols and education communications with staff, supporting staff wellbeing took up large amounts of time that limited their capacity for other planning and management tasks. Many of those interviewed had responsibilities not only for their own department, but also supporting other departments including ICU, or wider Māori and Pacific networks.

[The] time you spend managing your staff probably tripled overnight because of the stress, anxiety (P12, Nurse Manager, medium DHB)
I’m very strong with [supporting] all my Māori and Pacific nursing groups, PPNA [Pan Pacific Nurses Association], the Pacific Medical Association, Nursing, Māori Nurses, Niuean Nurses. So, we all had things that were asked of us (P26, Nurse Consultant, large DHB)

Participants emphasised the additional time and staffing required for surgery on patients who might, or did, have COVID-19. In some cases this doubled staff numbers, or quadrupled the time needed for the surgery. Additional resources for potential COVID-19 patients limited the resources available to treat other patients.

When you take a patient through [theatre] and you treat them as if they’re COVID [positive]—it’s just enormously time consuming and that has a big impact obviously—the quantity and the work that you can do for all the other patients so there’s lost opportunity cost and it’s exhausting for the staff as well. (P1, Anaesthesia HOD, large DHB)

Real or perceived PPE shortages

Most participants were initially worried that the local or national stock of PPE would run out, and these fears in turn led to rationing of PPE, tensions between individuals and departments, and staff stress. Some DHBs found that their existing pandemic stocks were out of date or perished, and new stocks were sometimes unsuitable.

Early on [DHB name] had very little [PPE]. I mean, it was terrifying and we were very mindful of the fact that we could’’t afford to waste it…. I think also just the reliability of the information, you know, the minster was up there saying there’ll be enough PPE but it didn’t feel like that was based on any great factual information. (P2, Anaesthesia HOD, medium DHB)

Challenges caused by local physical facilities

Local physical facilities generated challenges with isolating and caring for patients, often related to lack of appropriate spaces or negative pressure rooms. Challenges were difficult to address within the constraints of existing, sometimes ageing and outdated, hospital buildings although some hospitals had new walls built or used plastic sheeting to create isolation areas.

Our hospital is so old, and our facilities are so outdated. So a lot of the wards would have struggled. We have maybe two negative pressure rooms in our wards in total and one in ED. (P5, Anaesthetist, large DHB)

Concerns about existing workforce capacity

Many recounted concerns about insufficient staff numbers and inadequate numbers of staffed ICU beds to respond to large numbers of COVID-19 cases. This would be exacerbated by staff exposure to the virus contributing to stand downs and sickness.

We struggle with ICU capacity on a day-to-day basis—we would not have had the staff to care for patients and we would not have had the space to keep patients. That is admittedly our weakness. We have the skills—we just don’t have enough people. (P10, Anaesthetic HOD, Large DHB)
We’re chronically understaffed and that’s not just specialists…. it simply would not be possible to deal with a pandemic with that amount of staff. (P16, Anaesthesia HOD, medium DHB)

Limited ongoing planning and training

Limited planning or training had occurred between the initial lockdown period and the time of their interview. Ongoing planning and training were described as difficult to resource when people already had high workloads trying to catch up on missed surgeries from the initial lockdown.

We‘ve already lost a bit of that institutional knowledge, the match readiness[for COVID-19]. And we’ve been slain by business as usual because everybody’s in catch-up. Every hospital I visited this year has been overwhelmed by acute caseloads… it’s very hard for us to get people out to train. (P6, Anaesthesia HOD, large DHB)
They’ve got so many surgeries to do but I think sometimes they put those as [ahead of] actually getting the staff prepped up to be able to do the mahi effectively and in a positive way. (P26, Nurse Consultant, large DHB)

Theme 3: Staff stress and anxiety

Participants described unprecedented staff stress and anxiety and the impact this had on workforce capacity.

High stress and anxiety

Most participants described high levels of staff stress or anxiety, which extended to large portions of the workforce in some departments. Staff stress was described in all professional groups, but most commonly among nurses. Fear was perceived to be largely driven by concerns about catching COVID-19 or passing it to their families. Fears also related to the ability of services and PPE stocks to cope with an influx of patients, and challenges associated with childcare, lost income or concern for family members overseas.

I’ve never seen fear like it—I’ve been through Swine Flu, I went through bird flu, I went through HIV—I have never seen such a level of fear as I did last year. (P22, Nurse Manager, large DHB)

Staff stress impacted workforce capacity

Participants described instances where stress and anxiety led to absenteeism, unnecessary PPE use for COVID-negative patients, impaired decision-making and unwillingness to be involved in the treatment of COVID-19 patients. A number indicated that there remained a general sense of burnout among staff, following the initial 2020 response and the subsequent attempt to catch up on missed elective surgery procedures. The impact on staff wellbeing and turnover in turn had the potential to impact on the workforce’s capacity to care for patients.

There was a mass exodus of large portions of the staff- there were nursing staff—who point blank refused to nurse patients who were query COVID. (P7, Anaesthesia HOD, small DHB)
And the recovery nurses… about 90 percent have now resigned from the DHB… they were put under quite a lot of pressure to upskill to ICU, which is a completely different specialty for them and they felt very uncomfortable. (P16, Anaesthesia HOD, medium DHB)

Theme 4: Lessons learnt

Participants identified numerous ways they had—or planned to—address the challenges described above. These “lessons learnt” had a strong focus on communication, caring for staff, collaboration, leadership style, downtime to enable preparation, and support for external, or national resources to help with planning.

Communication

Participants described the importance of communicating with staff early and regularly, and structuring information so staff could easily navigate to the latest, most relevant information. They also described the importance of expressing empathy for staff anxiety, ensuring avenues for reciprocal communication, being honest and acknowledging uncertainty. There was no single best option for communication format; face-to-face and Zoom meetings could help with staff buy-in for decisions, while email was not helpful for staff with limited access or time to look at emails at work.

Collaboration

Identifying talented individuals within their departments added huge value to planning, education and preparing for COVID-19. Many noted that establishing interdisciplinary and interdepartmental collaboration at the outset through formal interdepartmental meetings and working groups, and personal relationships or networks improved the quality and consistency of plans.

Invest in staff wellbeing

Participants emphasised the importance of listening to and acknowledging staff concerns and fears and described a range of helpful interventions designed to support staff wellbeing. One Māori participant emphasised the importance of whanaungatanga and manaakitanga in both caring for patients with COVID-19 and looking after Māori staff and the wider workforce, as well as ensuring staff remained engaged and committed to working in perioperative services.

Well-articulated plans and associated training to protect staff from infection could help reduce staff anxiety. Simulation was a useful, though resource intensive training modality.

Leadership style

Participants reflected that to be successful leaders, they needed to be adaptable to changing circumstances and information while acknowledging that their staff needed them to be decisive in their planning to booster confidence. One reflected on the need to acknowledge a range of staff perspectives on tolerance to personal risk which may differ from their own.

Enabling preparation

Stopping services was described as critical to preparation; the Government lockdown freed up resources to enable services to develop plans and train staff. This work was difficult to achieve when services were working at full capacity and difficult to maintain once full operating lists resumed.

External resources

External information sources including recommendations and resources from overseas colleagues, professional organisations other DHBs were instrumental in formulating plans. Many participants also looked for additional national guidance while acknowledging that guidelines may need local adaptations for physical layout and staffing resources.

Participant recommendations are outlined in Text Box 1.

Discussion

Perioperative leaders and managers responding to the first wave of COVID-19 described a sense of urgency and previously unseen levels of staff stress in the face of prolific, and constantly changing information. Like others, participants described COVID-19 as a “disaster of uncertainty”.[[14]] Despite the existence of national pandemic response plans, participants described limited preparedness and increased workload due to the need to rapidly make plans for the response. There were concerns around PPE and the suitability of their facilities. There was an impact on workforce capacity through absenteeism, stand-downs and sickness. Pre-existing perioperative management structures and processes were not always configured to facilitate collaboration between professional groups, between departments and with senior management. All this led to increased tensions and confusion in planning.

Participating perioperative leaders expressed concerned about preparedness for future waves. From their experiences, they recommended investment in staff communication and wellbeing, improved systems and collaboration, and consideration of new facilities (See Text Box 1).

Health leaders had a large role to play in the COVID-19 response. There were calls for leaders to be transparent, agile, responsive and empathetic, all whilst themselves dealing with uncertainty and a large workload. Caring for staff wellbeing is critical, but managers also need to be supported to manage their own stress and exhaustion.[[15]] Many of our leaders in this study described behaviours considered important for fostering work engagement and reducing psychological distress.[[14,16]] This included empathetic listening to staff, communicating information in a transparent, timely, regular and structured manner, and being accessible and open toward their staff.[[13]]

Surge capacity of health services

A feature of this pandemic, taken from the literature on mass casualties, is the need for "surge capacity” or ability to expand a service in response to non-routine demands. Surge capacity has been described in terms of “stuff” (sufficient supplies and equipment), “staff” (adequate and appropriately trained workforce), “structure” (facilities) and “systems” (integrated policies and procedures).[[17]] The experiences our interviewees could usefully be considered within this framework: “stuff” is most obviously PPE, guidelines and policy documents; “staff” includes training and retaining the workforce; “structure” in the context of a pandemic alludes to appropriate spaces for clinical care of infectious patients; and “systems” could be those mechanisms to enable collaboration, planning and communication. These categories could be usefully applied for planning future local responses.

Complex adaptive systems

Our hospitals can each be considered as a complex adaptive system within the larger national healthcare system. Complex adaptive systems have multiple interdependent parts. They interact with the environment and learn and adapt to changes through feedback loops.[[18]] While broad guidelines can be helpful, agents and units within these systems require autonomy to respond as local conditions dictate[[18]]—which suggests that detailed government or even senior hospital management guidelines may both help or hinder planning for our perioperative departments depending on the degree to which they allow for adaptation to local circumstances. Leaders on the ground, and those who emerged as new leaders, required autonomy to adapt plans to local context.

Furthermore, complex adaptive systems depend on multiple internal connections to communicate and share resources, and in some hospitals it seemed these connections needed new work. Guidelines from the United States Institute of Medicine[[19]] emphasise building connections to accelerate the flow of information and share resources in times of surprise. Communication and collaboration featured as lessons learnt by our interviewees. Many connections have now been built—between the different services involved in perioperative care, and between hospitals. Maintaining them when the dust settles will be important.

The shift to a single nationwide health service under Health New Zealand in partnership with the Māori Health Authority will include regional networks of hospital and specialist services,[[20]] with the potential to support improved surge capacity planning. Embedded regional planning was proposed within the Health and Disability System Review to enable population health analysis, guidance and coordination, and shared expertise in planning, guidance, and other operational functions.[[20]]

Looking to the future

In early 2020, there was hope, almost an expectation, that COVID-19 could be eliminated or kept out of New Zealand, as had been the case with SARS-CoV-1 and Ebola. At the time of our interviews there was a feeling that we were done with COVID-19, and were left with large surgical waiting lists, staff losses, and a degree of workforce burnout. Identified challenges in physical facilities were yet to be resolved and future planning had been subsumed into catching up with the backlog of work.

In late 2021, we had a much better understanding of the virus, improved access to PPE, a largely vaccinated population and new technologies for detection and treatment. However, we are now faced with the prospect of endemic COVID-19 and its variants, and many of the challenges for surge capacity in perioperative services remain. We still have workforce vacancies, many ageing and out-dated hospital facilities, and our healthcare systems continue to present barriers to collaboration between departments, professional groups and between hospitals. Our study identified differences in access to resources and/or planning capacity between small and large hospitals, in part due to the size of their workforce and physical infrastructure. Smaller, rural hospitals may struggle more in the event of a surge of COVID-19 patients, and many of these have high Māori populations. Māori, including Māori staff, are more likely to get sick or die from COVID-19 than Non-Māori.[[21,22]] Inequities in our health system require a “whole of nation” systems response.

While each new virus, or other “surprise” event will bring its own unique challenges, lessons learnt can inform the fundamental requirements of our complex hospital systems and their ability to surge in response to the next challenge. Hospital staff move on, and institutional knowledge is lost. Lessons from the current pandemic need to be captured for future generations. We hope the present paper goes some way towards this.

Limitations and future research

This study presents a snapshot in time and the extent to which our pandemic response, including changes in leadership style, has changed following the “practice run” with COVID-19 in early 2020 remains to be tested. Our study included a good spread of DHBs around the country, and professional roles within perioperative services, but our findings may not be generalisable to other hospital services or other countries.

We recruited only three Māori participants. Further research could explore the values and leadership behaviours that enable and empower Māori staff during challenging times. Supporting and retaining this workforce will be critical for Māori health equity, and in response to future pandemic threats.[[23]]

Conclusion

The experiences and reflections of perioperative leaders from hospitals around Aotearoa New Zealand to the COVID-19 pandemic paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress, hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Summary

Abstract

Aim

Once it became apparent that COVID-19 would reach Aotearoa New Zealand, perioperative services responded urgently to contain viral spread, keep staff safe and maintain patient care. We aimed to understand how perioperative leaders around the country responded to the pandemic, their experiences, reflections and the lessons learnt. Our goal is to inform future pandemic responses.

Method

We undertook a qualitative study with thematic analysis of semi-structured interviews. We recruited perioperative leads involved in the COVID-19 response using snowball sampling, following initial contact with anaesthetic and surgical department heads.

Results

We interviewed 33 perioperative leads from 16 of the country’s 20 district health boards, with representation across hospitals of different sizes and the professional groups working in operating theatres. Four main themes were identified from data. These were: “no one source of truth,” with prolific, constantly changing information, limited initial support from hospital senior executives, and siloed approaches and tensions between departments and professional groups; resourcing challenges attributed to limited baseline preparedness and increased workload; deficiencies in PPE and physical facilities; staff stress and anxiety, and the impact this had on workforce capacity; ongoing preparedness for future waves; and reflections on “lessons learnt”. These lessons focused strongly on communication, caring for staff, collaboration, downtime to enable preparation, and a need for external, potentially national co-ordination and resources to facilitate planning.

Conclusion

Perioperative leaders’ experiences and reflections of COVID-19 paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Author Information

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland; Anaesthetist, Auckland City Hospital, Auckland. Dr Vanessa Beavis: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Kim Jamieson: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Mataroria Lyndon: Senior Lecturer, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland. Dr Jennifer Long: Research Fellow, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland.

Acknowledgements

We would like to thank the participants who kindly shared their time, experience and wisdom with the research team.

Correspondence

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland. Anaesthetist, Auckland City Hospital Private Bag 92019, Auckland 1142. +6421588644.

Correspondence Email

j.weller@auckland.ac.nz

Competing Interests

Nil.

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2) Schutzer-Weissmann J, Magee DJ, Farquhar-Smith P. Severe acute respiratory syndrome coronavirus 2 infection risk during elective peri-operative care: A narrative review. Anaesthesia. 2020; 75(12):1648-1658.

3) Stewart CL, Thornblade LW, Diamond DJ, Fong Y, Melstrom LG. Personal protective equipment and Covid-19: A review for surgeons. Ann Surg. 2020; 272(2):e132-e138.

4) Chadi SA, Guidolin K, Caycedo-Marulanda A, Sharkawy A, Spinelli A, Quereshy FA, et al. Current evidence for minimally invasive surgery during the Covid-19 pandemic and risk mitigation strategies: A narrative review. Ann Surg. 2020; 272(2):e118-e24.

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7) Lee MCC, Thampi S, Chan HP, Khoo D, Chin BZB, Foo DPX, et al. Psychological distress during the Covid-19 pandemic amongst anaesthesiologists and nurses. Br J Anaesth. 2020; 125(4):e384-e386.

8) Low TY, So JBY, Madhavan KK, Hartman M. Wellbeing of surgical staff since the Covid-19 pandemic. Br J Surg. 2020; 107(11): e478.

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The COVID-19 pandemic has had an extraordinary effect on hospital staff. From a “standing start”, each hospital has dealt with uncertainty and fear to create new processes to limit the spread of the disease, care for patients, and ensure the wellbeing of staff. Health leaders, managers and frontline staff have developed a wealth of experience from what has been for many the most challenging event in their clinical experience to date.

The patient journey through the operating theatre is complex, involving multiple safety checks, and interactions with staff from many different departments and professional groups. The risk of staff infection in operating theatres is markedly increased due to aerosol generating procedures during airway manoeuvres, moving contaminated bedding or surgical drapes, and any surgery involving the airway. At each point on the journey, a detailed process is required to manage the risk of droplets and aerosols infecting staff.[[1]]

Perioperative services were faced with the urgent task of creating new protocols and processes, sourcing PPE equipment and training staff.  New protocols and training were developed for limiting staff exposure, donning and doffing, patient transfers, aerosol generating procedures, team communication and managing potential in-theatre emergencies. The literature to inform these infection prevention protocols is vast and continues to evolve.[[2–5]] The safety and wellbeing of healthcare workers became a priority, both to protect staff from infection with a potentially fatal disease, and to maintain a functioning healthcare system. International reports speak to high rates of psychological stress and burnout among operating room staff during the pandemic, and concerns about the increased cognitive load on work performance, fewer opportunities for trainees to develop skills, difficult communication associated with PPE, and absenteeism.[[6–12]]

To understand how perioperative services responded to the emergence of COVID-19 and the lessons learnt we explored the experiences and perspectives of perioperative leads from hospitals around the country. The objective of this study is to share these experiences and learn from them.

Method

The Auckland Health Research Ethics Committee approved this study (AH3336). Informed consent was obtained from all participants.

Context

The public health system in Aotearoa is divided into 20 district health boards (DHBs) responsible for the population in their region. The study took place after the first wave of the COVID-19 pandemic, during a period when elimination had been (temporarily) achieved in the community.

Study design

We undertook a qualitative study with thematic analysis of semi-structured interviews.

Sample and sampling

We used a snowballing sampling strategy to identify and recruit perioperative services clinical leaders, managers and key planning personnel, initially contacting anaesthetic and surgical department heads, asked for referrals to relevant nursing, anaesthetic technician, anaesthesia and surgical leaders and advertising the study in a surgical newsletter.

Reflexive statement

JW is a clinical academic and anaesthetist, with expertise in patient safety, teamwork and simulation-based education. VB is an anaesthetist, former perioperative lead and President of the Australian and New Zealand college of Anaesthetists. KJ is an anaesthetist involved in hospital disaster response planning. JL is a research fellow with a psychology background. ML is a public health clinician and clinical academic with expertise in Māori health.

Data collection and management

The semi-structured interview question guide was developed through discussion within the research team and informed by the literature on hospital responses to COVID-19 overseas. The question guide explored participant experiences of, and reflections on, planning for the pandemic (Interview guide Supplement 1).

Interviews were conducted via video conference or telephone or face-to-face by JL, JW, VB and ML. Recruitment continued until a representative sample across hospitals and professional groups was obtained and we reached data sufficiency, in that additional interviews were not adding new information. Interviews were audio-recorded, transcribed by an independent transcriber, de-identified, and entered into NVivo software.

Data analysis

Thematic analysis followed the six-step approach described by Braun and Clarke.[[13]] (View Table 1).

Results

Thirty-three perioperative leaders, managers or core planning personnel from 16 DHBs participated in interviews, which was 72% of those we invited. Interview duration was 20 to 60 minutes. Participants were from small (7), medium (12) and large (14) DHBs, comprising 17 anaesthetists, six surgeons, six nurses and one anaesthetic technician. Of these, 91% held a formal management or educator role and 9% identified as Māori.

We identified three interrelated themes describing the main issues for participants: “no one source of truth”, “resourcing challenges” and “staff stress and anxiety”. A fourth theme, “lessons learnt”, captures participant reflections what worked, and recommendations for the future.

Theme 1: no one source of truth

Participants described prolific, constantly changing information, limited initial support and siloed approaches to planning with tensions between departments and professional groups.

Prolific, constantly changing information

Participants experienced an overload of constantly changing information including scientific advice, international experiences, and recommendations, circulated by colleagues or leaders or accessed via the internet. “Facts” and recommendations often conflicted between sources, and between professional bodies. This in turn hindered development of protocols, staff trust and inter-department consensus on core issues, such as the PPE precautions needed in different circumstances.

There was so much information and every day it was changing—by the time you —disseminated all the information to everyone—the next day, it all […] changed again. (Participant (P) 25, Nurse Educator, medium DHB)
There were hundreds of articles coming out every day from all across the world that people would just send around, you know. It was like complete information overload (P8, Anaesthesia HoD, small DHB)

Limited initial support for department leaders

Participants recounted receiving minimal guidance from senior hospital management and the Ministry of Health (MoH) in the initial stages of the pandemic. In the face of urgent need for action, many found hospital management slow to make decisions, answer queries or approve proposed policies. Similarly, national guidance emerged after many departments or hospitals had done their own initial planning. National and hospital level plans were often described as being focused on “bigger picture” issues as community spread or visitor procedures, leaving perioperative teams to develop their own plans for conducting surgery safely.

A lot of the work here was not sanctioned by the ministry or sanctioned by the DHB. A lot of scared staff members decided to do it on their own and were supported by the managers (P14, Anaesthesia HOD, medium DHB)
It felt like they [MoH] were very much focused on what we’re going to do as a country. Fair enough, because there’s a huge amount of work to be done there. But in terms of what are we going to do as a health service and how are we going to do this in ICU, actually manage people. It felt like that [actual management of ICU patients] was initially very driven at an individual level. (P10, Anaesthesia HOD, large DHB)

Confused messages and distrust about PPE stock and protection

Participants struggled to get an accurate picture about PPE requirements, and many distrusted the information provided by their hospital or the MoH about PPE stock levels and the protective adequacy of the available PPE and protocols.

One of our biggest concerns initially was the very mixed and confused messages around the requirement for N95 masks and low-level PPE. (P30, Surgical HOD, large DHB)
That was a source of constant frustration, you know, seeing pictures from people in other countries with completely different PPE to what we were expected to use… is that because we didn’t have anything better, is that because there was nothing better available, you know, and those are big questions that I couldn't answer at any stage. (P15, Anaesthesia HOD, medium DHB)

Siloed approaches and tensions between departments

Some perioperative services had limited collaborative planning between professional groups and departments, and many had different solutions to issues such as screening and PPE. These differences were often attributed to varying perceptions of risk or conflicting guidance from professional colleges. Within many perioperative services, surgeons were not well integrated into the initial planning and staff training. Some perioperative clinicians took it upon themselves to run joint training, sometimes involving ED or ICU, but without senior management support. In other hospitals, planning was collaborative across departments from the outset.

Everyone was just in such a hurry and so every kind of silo had to sort their own area out. We did drills [with ICU, ED and theatre] but that was the clinicians working together. There wasn't any kind of hospital oversight. (P17, Anaesthesia HOD, large DHB)
There was a lot of conflict between specialities about how they wanted their patients brought into theatre. And in the end, we had to say, no we’re having one journey for the patient. If we have one for obstetrics and then we have one for gen. surg. etc – nobody’s going to get it right, we’re going to forget and get it all wrong. (P2, Nurse Manager, large DHB)

Theme 2: Resourcing challenges

Staff described resourcing challenges to prepare for a potential influx of COVID-19 patients due to limited baseline preparedness, increased workload, access to PPE, deficient physical facilities, and limited ongoing preparedness for a second wave.

Limited baseline preparation

Participants described essentially starting from scratch in their preparations for COVID-19. Disaster response plans provided little relevant guidance, while participants were either unaware of existing pandemic plans or found that substantial work was needed to translate the high-level pandemic plans into department-level plans applicable to COVID-19. IT systems or hardware needed to be upgraded to enable Zoom and remote work. Protocols, plans, training and equipment upgrades needed to be established urgently, and many described being caught out by the speed at which COVID-19 became an imminent threat in New Zealand.

I guess ideally, we would have done that work in January. But I guess, how fast COVID moved and our lack of understanding meant that we didn’t really do that work until quite late in the piece.  (P15, Anaesthesia HOD, medium DHB)

Workload

Participants recounted the huge volume of work involved in planning and preparing to conduct surgery in the context of potential COVID-19 cases, with some working “80 to 100 hours a week”, or “every day during the six-seven-week period”. In addition to the work involved in reviewing literature and developing protocols and education communications with staff, supporting staff wellbeing took up large amounts of time that limited their capacity for other planning and management tasks. Many of those interviewed had responsibilities not only for their own department, but also supporting other departments including ICU, or wider Māori and Pacific networks.

[The] time you spend managing your staff probably tripled overnight because of the stress, anxiety (P12, Nurse Manager, medium DHB)
I’m very strong with [supporting] all my Māori and Pacific nursing groups, PPNA [Pan Pacific Nurses Association], the Pacific Medical Association, Nursing, Māori Nurses, Niuean Nurses. So, we all had things that were asked of us (P26, Nurse Consultant, large DHB)

Participants emphasised the additional time and staffing required for surgery on patients who might, or did, have COVID-19. In some cases this doubled staff numbers, or quadrupled the time needed for the surgery. Additional resources for potential COVID-19 patients limited the resources available to treat other patients.

When you take a patient through [theatre] and you treat them as if they’re COVID [positive]—it’s just enormously time consuming and that has a big impact obviously—the quantity and the work that you can do for all the other patients so there’s lost opportunity cost and it’s exhausting for the staff as well. (P1, Anaesthesia HOD, large DHB)

Real or perceived PPE shortages

Most participants were initially worried that the local or national stock of PPE would run out, and these fears in turn led to rationing of PPE, tensions between individuals and departments, and staff stress. Some DHBs found that their existing pandemic stocks were out of date or perished, and new stocks were sometimes unsuitable.

Early on [DHB name] had very little [PPE]. I mean, it was terrifying and we were very mindful of the fact that we could’’t afford to waste it…. I think also just the reliability of the information, you know, the minster was up there saying there’ll be enough PPE but it didn’t feel like that was based on any great factual information. (P2, Anaesthesia HOD, medium DHB)

Challenges caused by local physical facilities

Local physical facilities generated challenges with isolating and caring for patients, often related to lack of appropriate spaces or negative pressure rooms. Challenges were difficult to address within the constraints of existing, sometimes ageing and outdated, hospital buildings although some hospitals had new walls built or used plastic sheeting to create isolation areas.

Our hospital is so old, and our facilities are so outdated. So a lot of the wards would have struggled. We have maybe two negative pressure rooms in our wards in total and one in ED. (P5, Anaesthetist, large DHB)

Concerns about existing workforce capacity

Many recounted concerns about insufficient staff numbers and inadequate numbers of staffed ICU beds to respond to large numbers of COVID-19 cases. This would be exacerbated by staff exposure to the virus contributing to stand downs and sickness.

We struggle with ICU capacity on a day-to-day basis—we would not have had the staff to care for patients and we would not have had the space to keep patients. That is admittedly our weakness. We have the skills—we just don’t have enough people. (P10, Anaesthetic HOD, Large DHB)
We’re chronically understaffed and that’s not just specialists…. it simply would not be possible to deal with a pandemic with that amount of staff. (P16, Anaesthesia HOD, medium DHB)

Limited ongoing planning and training

Limited planning or training had occurred between the initial lockdown period and the time of their interview. Ongoing planning and training were described as difficult to resource when people already had high workloads trying to catch up on missed surgeries from the initial lockdown.

We‘ve already lost a bit of that institutional knowledge, the match readiness[for COVID-19]. And we’ve been slain by business as usual because everybody’s in catch-up. Every hospital I visited this year has been overwhelmed by acute caseloads… it’s very hard for us to get people out to train. (P6, Anaesthesia HOD, large DHB)
They’ve got so many surgeries to do but I think sometimes they put those as [ahead of] actually getting the staff prepped up to be able to do the mahi effectively and in a positive way. (P26, Nurse Consultant, large DHB)

Theme 3: Staff stress and anxiety

Participants described unprecedented staff stress and anxiety and the impact this had on workforce capacity.

High stress and anxiety

Most participants described high levels of staff stress or anxiety, which extended to large portions of the workforce in some departments. Staff stress was described in all professional groups, but most commonly among nurses. Fear was perceived to be largely driven by concerns about catching COVID-19 or passing it to their families. Fears also related to the ability of services and PPE stocks to cope with an influx of patients, and challenges associated with childcare, lost income or concern for family members overseas.

I’ve never seen fear like it—I’ve been through Swine Flu, I went through bird flu, I went through HIV—I have never seen such a level of fear as I did last year. (P22, Nurse Manager, large DHB)

Staff stress impacted workforce capacity

Participants described instances where stress and anxiety led to absenteeism, unnecessary PPE use for COVID-negative patients, impaired decision-making and unwillingness to be involved in the treatment of COVID-19 patients. A number indicated that there remained a general sense of burnout among staff, following the initial 2020 response and the subsequent attempt to catch up on missed elective surgery procedures. The impact on staff wellbeing and turnover in turn had the potential to impact on the workforce’s capacity to care for patients.

There was a mass exodus of large portions of the staff- there were nursing staff—who point blank refused to nurse patients who were query COVID. (P7, Anaesthesia HOD, small DHB)
And the recovery nurses… about 90 percent have now resigned from the DHB… they were put under quite a lot of pressure to upskill to ICU, which is a completely different specialty for them and they felt very uncomfortable. (P16, Anaesthesia HOD, medium DHB)

Theme 4: Lessons learnt

Participants identified numerous ways they had—or planned to—address the challenges described above. These “lessons learnt” had a strong focus on communication, caring for staff, collaboration, leadership style, downtime to enable preparation, and support for external, or national resources to help with planning.

Communication

Participants described the importance of communicating with staff early and regularly, and structuring information so staff could easily navigate to the latest, most relevant information. They also described the importance of expressing empathy for staff anxiety, ensuring avenues for reciprocal communication, being honest and acknowledging uncertainty. There was no single best option for communication format; face-to-face and Zoom meetings could help with staff buy-in for decisions, while email was not helpful for staff with limited access or time to look at emails at work.

Collaboration

Identifying talented individuals within their departments added huge value to planning, education and preparing for COVID-19. Many noted that establishing interdisciplinary and interdepartmental collaboration at the outset through formal interdepartmental meetings and working groups, and personal relationships or networks improved the quality and consistency of plans.

Invest in staff wellbeing

Participants emphasised the importance of listening to and acknowledging staff concerns and fears and described a range of helpful interventions designed to support staff wellbeing. One Māori participant emphasised the importance of whanaungatanga and manaakitanga in both caring for patients with COVID-19 and looking after Māori staff and the wider workforce, as well as ensuring staff remained engaged and committed to working in perioperative services.

Well-articulated plans and associated training to protect staff from infection could help reduce staff anxiety. Simulation was a useful, though resource intensive training modality.

Leadership style

Participants reflected that to be successful leaders, they needed to be adaptable to changing circumstances and information while acknowledging that their staff needed them to be decisive in their planning to booster confidence. One reflected on the need to acknowledge a range of staff perspectives on tolerance to personal risk which may differ from their own.

Enabling preparation

Stopping services was described as critical to preparation; the Government lockdown freed up resources to enable services to develop plans and train staff. This work was difficult to achieve when services were working at full capacity and difficult to maintain once full operating lists resumed.

External resources

External information sources including recommendations and resources from overseas colleagues, professional organisations other DHBs were instrumental in formulating plans. Many participants also looked for additional national guidance while acknowledging that guidelines may need local adaptations for physical layout and staffing resources.

Participant recommendations are outlined in Text Box 1.

Discussion

Perioperative leaders and managers responding to the first wave of COVID-19 described a sense of urgency and previously unseen levels of staff stress in the face of prolific, and constantly changing information. Like others, participants described COVID-19 as a “disaster of uncertainty”.[[14]] Despite the existence of national pandemic response plans, participants described limited preparedness and increased workload due to the need to rapidly make plans for the response. There were concerns around PPE and the suitability of their facilities. There was an impact on workforce capacity through absenteeism, stand-downs and sickness. Pre-existing perioperative management structures and processes were not always configured to facilitate collaboration between professional groups, between departments and with senior management. All this led to increased tensions and confusion in planning.

Participating perioperative leaders expressed concerned about preparedness for future waves. From their experiences, they recommended investment in staff communication and wellbeing, improved systems and collaboration, and consideration of new facilities (See Text Box 1).

Health leaders had a large role to play in the COVID-19 response. There were calls for leaders to be transparent, agile, responsive and empathetic, all whilst themselves dealing with uncertainty and a large workload. Caring for staff wellbeing is critical, but managers also need to be supported to manage their own stress and exhaustion.[[15]] Many of our leaders in this study described behaviours considered important for fostering work engagement and reducing psychological distress.[[14,16]] This included empathetic listening to staff, communicating information in a transparent, timely, regular and structured manner, and being accessible and open toward their staff.[[13]]

Surge capacity of health services

A feature of this pandemic, taken from the literature on mass casualties, is the need for "surge capacity” or ability to expand a service in response to non-routine demands. Surge capacity has been described in terms of “stuff” (sufficient supplies and equipment), “staff” (adequate and appropriately trained workforce), “structure” (facilities) and “systems” (integrated policies and procedures).[[17]] The experiences our interviewees could usefully be considered within this framework: “stuff” is most obviously PPE, guidelines and policy documents; “staff” includes training and retaining the workforce; “structure” in the context of a pandemic alludes to appropriate spaces for clinical care of infectious patients; and “systems” could be those mechanisms to enable collaboration, planning and communication. These categories could be usefully applied for planning future local responses.

Complex adaptive systems

Our hospitals can each be considered as a complex adaptive system within the larger national healthcare system. Complex adaptive systems have multiple interdependent parts. They interact with the environment and learn and adapt to changes through feedback loops.[[18]] While broad guidelines can be helpful, agents and units within these systems require autonomy to respond as local conditions dictate[[18]]—which suggests that detailed government or even senior hospital management guidelines may both help or hinder planning for our perioperative departments depending on the degree to which they allow for adaptation to local circumstances. Leaders on the ground, and those who emerged as new leaders, required autonomy to adapt plans to local context.

Furthermore, complex adaptive systems depend on multiple internal connections to communicate and share resources, and in some hospitals it seemed these connections needed new work. Guidelines from the United States Institute of Medicine[[19]] emphasise building connections to accelerate the flow of information and share resources in times of surprise. Communication and collaboration featured as lessons learnt by our interviewees. Many connections have now been built—between the different services involved in perioperative care, and between hospitals. Maintaining them when the dust settles will be important.

The shift to a single nationwide health service under Health New Zealand in partnership with the Māori Health Authority will include regional networks of hospital and specialist services,[[20]] with the potential to support improved surge capacity planning. Embedded regional planning was proposed within the Health and Disability System Review to enable population health analysis, guidance and coordination, and shared expertise in planning, guidance, and other operational functions.[[20]]

Looking to the future

In early 2020, there was hope, almost an expectation, that COVID-19 could be eliminated or kept out of New Zealand, as had been the case with SARS-CoV-1 and Ebola. At the time of our interviews there was a feeling that we were done with COVID-19, and were left with large surgical waiting lists, staff losses, and a degree of workforce burnout. Identified challenges in physical facilities were yet to be resolved and future planning had been subsumed into catching up with the backlog of work.

In late 2021, we had a much better understanding of the virus, improved access to PPE, a largely vaccinated population and new technologies for detection and treatment. However, we are now faced with the prospect of endemic COVID-19 and its variants, and many of the challenges for surge capacity in perioperative services remain. We still have workforce vacancies, many ageing and out-dated hospital facilities, and our healthcare systems continue to present barriers to collaboration between departments, professional groups and between hospitals. Our study identified differences in access to resources and/or planning capacity between small and large hospitals, in part due to the size of their workforce and physical infrastructure. Smaller, rural hospitals may struggle more in the event of a surge of COVID-19 patients, and many of these have high Māori populations. Māori, including Māori staff, are more likely to get sick or die from COVID-19 than Non-Māori.[[21,22]] Inequities in our health system require a “whole of nation” systems response.

While each new virus, or other “surprise” event will bring its own unique challenges, lessons learnt can inform the fundamental requirements of our complex hospital systems and their ability to surge in response to the next challenge. Hospital staff move on, and institutional knowledge is lost. Lessons from the current pandemic need to be captured for future generations. We hope the present paper goes some way towards this.

Limitations and future research

This study presents a snapshot in time and the extent to which our pandemic response, including changes in leadership style, has changed following the “practice run” with COVID-19 in early 2020 remains to be tested. Our study included a good spread of DHBs around the country, and professional roles within perioperative services, but our findings may not be generalisable to other hospital services or other countries.

We recruited only three Māori participants. Further research could explore the values and leadership behaviours that enable and empower Māori staff during challenging times. Supporting and retaining this workforce will be critical for Māori health equity, and in response to future pandemic threats.[[23]]

Conclusion

The experiences and reflections of perioperative leaders from hospitals around Aotearoa New Zealand to the COVID-19 pandemic paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress, hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Summary

Abstract

Aim

Once it became apparent that COVID-19 would reach Aotearoa New Zealand, perioperative services responded urgently to contain viral spread, keep staff safe and maintain patient care. We aimed to understand how perioperative leaders around the country responded to the pandemic, their experiences, reflections and the lessons learnt. Our goal is to inform future pandemic responses.

Method

We undertook a qualitative study with thematic analysis of semi-structured interviews. We recruited perioperative leads involved in the COVID-19 response using snowball sampling, following initial contact with anaesthetic and surgical department heads.

Results

We interviewed 33 perioperative leads from 16 of the country’s 20 district health boards, with representation across hospitals of different sizes and the professional groups working in operating theatres. Four main themes were identified from data. These were: “no one source of truth,” with prolific, constantly changing information, limited initial support from hospital senior executives, and siloed approaches and tensions between departments and professional groups; resourcing challenges attributed to limited baseline preparedness and increased workload; deficiencies in PPE and physical facilities; staff stress and anxiety, and the impact this had on workforce capacity; ongoing preparedness for future waves; and reflections on “lessons learnt”. These lessons focused strongly on communication, caring for staff, collaboration, downtime to enable preparation, and a need for external, potentially national co-ordination and resources to facilitate planning.

Conclusion

Perioperative leaders’ experiences and reflections of COVID-19 paint a picture of limited prior preparation or planning for a pandemic, requiring an immediate pivot from routine care to emergency response. In an environment of uncertainty, information overload and staff stress hospital leaders worked to obtain resources, maintain staff safety and engagement, develop new systems and in some cases, create new facilities. Sharing the experiences and lessons learned about communication and collaboration, policy development and staff training may go some way to facilitate a smoother implementation of a pandemic response the next time around.

Author Information

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland; Anaesthetist, Auckland City Hospital, Auckland. Dr Vanessa Beavis: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Kim Jamieson: Anaesthetist, Auckland City Hospital, Level 8 Department of Anaesthesia, Auckland. Dr Mataroria Lyndon: Senior Lecturer, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland. Dr Jennifer Long: Research Fellow, Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland.

Acknowledgements

We would like to thank the participants who kindly shared their time, experience and wisdom with the research team.

Correspondence

Professor Jennifer Weller: Head of Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland. Anaesthetist, Auckland City Hospital Private Bag 92019, Auckland 1142. +6421588644.

Correspondence Email

j.weller@auckland.ac.nz

Competing Interests

Nil.

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