Health system resilience and health workforce capacities: Comparing health system responses during the COVID-19 pandemic in six European countries

Strengthening health system leadership in practice

The field of health leadership is shifting rapidly, and there is an opportunity to learn with health leaders about what is needed to support health leadership education, research, and practice. In 2022, to augment student feedback and faculty praxis, Royal Roads University conducted 12 virtual interviews with senior health system leaders across various settings to learn how health leaders can better respond to emerging and future leadership needs and priorities facing health systems. Findings from this study informed the development of a health-specific elective for the Master of Arts in Leadership, Health Specialization program entitled Considerations for Health Systems Renewal. This elective explores the following topics that emerged from this research study: (1) an orientation to possibility; (2) emerging strategic human resource concerns; (3) healthcare innovation; (4) relational and social systems leadership; (5) polarity thinking; (6) trauma-informed leadership; and (7) Canadian healthcare networks. In this article, we share our research process and findings to arrive at these recommendations.

The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries

BACKGROUND

The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing.

AIMS

We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support.

MATERIAL AND METHODS

A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts.

RESULTS AND DISCUSSION

Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses.

CONCLUSION

Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

Healthcare workforce equity for health equity: An overview of its importance for the level of primary health care

BACKGROUND

Healthcare workforce crises often stem from healthcare workers' inequities. This study provides an overview of the main PHC workforce policy questions related to health equity, offering examples of evidence necessary to support the implementation of policies and strategies that increase equity in the health workforce and access to the PHC workforce and services.

METHODS

The equity-related policies in PHC and workforce were linked with the indicators listed in the Global Health Workforce Network Data and Evidence Hub and guidelines for health workforce management.

RESULTS

The policy-relevant questions in PHC cover many workforce issues such as the optimal size, equitable distribution, relevant competencies to ensure equitable healthcare access, and equitable approaches for retention, training, recruitment, benefits and incentive schemes and governance. This will require intersectionality evidence of the optimised staffing to PHC workload, that PHC practitioners' training demonstrates evidence-based knowledge aligned with locally relevant expertise.

CONCLUSION

Critical for equitable PHC access and health equity is the establishment of efficient measurement of PHC workforce equity and its implications for population health. Using indicators that measure health and workforce equity in research, policy, and practices may improve recruitment and retention, and respond more effectively to the PHC workforce crises.

Community health workers for health systems resilience during COVID-19: protocol for qualitative evidence synthesis

INTRODUCTION

COVID-19 exposed the fragility of health systems, where even the most basic health services in high-income and low-income and middle-income nations could not withstand the health systems shock due to the pandemic. Community health workers (CHWs) can contribute to improving the resilience of health systems, specifically to withstand shocks and emergencies and to avoid disruptions of routine service delivery. We aim to explore and understand the 'individual' and 'systems-level' resilience factors that shaped the involvement of CHWs in the COVID-19 response.

METHODS AND ANALYSIS

We will search five electronic databases (PubMed, Cochrane Library, EMBASE, CINAHL and SciELO (Spanish)) and conduct citation screening to identify studies on CHWs' response during the COVID-19 pandemic. Two review authors will independently screen the studies for inclusion and to extract data. The software Rayyan will be used to assist in screening the relevant literature. A thematic analysis approach will be followed to analyse and synthesise the qualitative evidence. The quality of the included studies will be critically assessed using the Critical Skills Appraisal Programme Tool. We will use the GRADE CERQual(Grading of Recommendations, Assessment, Development, and Evaluations - Confidence in the Evidence from Reviews of Qualitative Research) approach to assess certainty in the synthesised findings of the qualitative evidence.

ETHICS AND DISSEMINATION

This study will be conducted on published evidence, with no living participants; thus, no ethical approval is required. The final review will be submitted and published in a peer-reviewed journal. We will also develop a policy brief to communicate the review findings to the stakeholders.

Comparing the cross-national impact of the COVID-19 pandemic on care received by community-dwelling older adults in 2020 and 2021: restoring formal home care versus polarizing informal care?

The COVID-19 pandemic has changed the supply of formal and informal home care to older adults in many countries across the world. This study aims to compare the initial picture of how the supply of formal and informal home care to older adults in European countries and Israel changed during the first pandemic year (from mid-2020 to mid-2021) and to examine the changes that these countries made in the provision of adequate care to older adults. Using data from the two COVID-19 waves of SHARE, we show that the provision of formal home care services improved in the investigated period, as in 2021 the share of those who reported difficulties in receiving formal home care dropped significantly compared to the previous year. By contrast, informal care provision patterns experienced a growing polarization, with some countries continuing in reporting a strong support from this source, and others moving towards a remarkable reduction in the help coming from informal networks. These findings can serve as a basis for the development of evidence-based recommendations that can inform future care policies at the national level and to implement more sustainable models for older adults living in the community.

The impact of COVID-19 pandemic on healthcare workers under the "Ten New Guidelines" in Taizhou, China

Purpose

We explored the influence of the "Ten new guidelines" on healthcare workers' preparedness, work impact, personal life impact, concerns, and support in Taizhou, China.

Methods

A hospital-based self-administered online survey was conducted to investigate the levels of COVID-19 related experience among healthcare workers in December 2022. In total, 472 out of 2080 healthcare workers (22.7 % response rate) completed the questionnaires with valid responses. Stepwise linear regression was used to investigate the independence of factors associated with preparedness, work impact, personal life impact, concerns, and support.

Results

The results revealed that working position (p < 0.001), pressure (p = 0.005), and negative affect (p < 0.001) were significantly associated with preparedness. Working position (p = 0.015), number of children (p = 0.040), working years (p = 0.019), COVID-19 risk perception (p < 0.001), work overload (p < 0.001), and negative affect (p < 0.001) were significantly associated with work impact. In addition, COVID-19 risk perception (p < 0.001), work overload (p < 0.001), pressure (p = 0.002), history of COVID-19 infection (p = 0.008), and awareness of possible infectious time (p = 0.031) were significantly associated with personal life impact. COVID-19 risk perception (p < 0.001), negative affect (p < 0.001), and work overload (p = 0.020) were significantly associated with concerns. Sex (p = 0.020) and negative affect (p = 0.016) were significantly associated with support.

Conclusion

Negative affect was the most significant factor associated with COVID-19 related questions among healthcare workers under "Ten new guidelines" during COVID-19 pandemic.

Post-COVID health policy responses to healthcare workforce capacities: A comparative analysis of health system resilience in six European countries

A cross countries in Europe, health policy is seeking to adapt to the post-pandemic 'permacrisis', where high demands on the healthcare workforce and shortages continue and combine with climate change, and war. The success of these efforts depends on the capacities of the healthcare workforce. This study aims to compare health policy responses to strengthen the capacities of the healthcare workforce and to explore the underpinning dynamics between health systems, policy actors and health policies. The study draws on a qualitative, comparative analysis of Austria, the Czech Republic, Denmark, Germany, Italy and the Netherlands. The findings suggest that policy responses at the national level focused on hospitals and absorptive capacities, while policy responses at local/regional levels also included general practice and adaptive capacities. There were only few examples of policies directed at transformative capacities. The underling dynamics were shaped by health systems, where individual parts are closely connected, by embeddedness in specific service delivery and areas, and by power dynamics. In conclusion, sub-national health policy responses emerge as key to effective responses to the post-pandemic permacrisis, where health professions are central policy actors. Sub-national health policy responses build on existing power relations, but also have the potential to transcend these power relations.

Hospital-Level COVID-19 Preparedness and Crisis Management in Czechia

Objectives: The COVID-19 pandemic exposed the inadequacy of pandemic preparedness mechanisms worldwide. This study gathered comprehensive data from Czech hospitals, identified possible weaknesses in important areas of crisis preparedness, and quantified changes performed to enhance crisis resilience of healthcare facilities. Methods: Drawing on literature review on pandemic preparedness and hospital crisis management and detailed interviews with hospital representatives, a questionnaire was designed and distributed by email among quality managers of all Czech hospitals. Statistical analysis of their responses was conducted using EZR software. Fisher's exact test and Kruskal-Wallis test, with post hoc testing, were used to assess statistical significance. Results: Achieving response rate of 31.9%, responses from 65 hospitals were analysed. New crisis management policies were necessary in 72.3% of responding hospitals. Furthermore, a majority of the respondents changes indicated the need for changes in policies on general pandemic, human resources and infrastructure and material preparedness. Conclusion: The COVID-19 crisis required significant alterations to previously established hospital crisis management protocols and establishment of new ones. The absence of a unified system for crisis preparedness was noted at hospital and national levels.

The patient representation struggle during the COVID-19 pandemic: Missed opportunities for resilient healthcare systems

BACKGROUND

The role of patient participation and representation during crises, such as the COVID-19 pandemic, has been under-researched. Existing studies paint a pessimistic picture of patient representation during the pandemic. However, there are indications that patient representatives have adapted to the new situation and can contribute to the resilience of healthcare systems. This paper aims to further explore the potential contribution of patient representatives for healthcare system resilience during the COVID-19 pandemic.

METHODS

The study used a qualitative approach. We conducted a thematic analysis on the following data: interviews with client council members (n = 32) and representatives from patient organizations (n = 6) and focus groups (n = 2) to investigate patient representation on both the national policy level and organizational level in the Netherlands.

RESULTS

We identified the crisis discourse, the dependent position, the diversity of patient perspectives and the layered decision-making structure as themes that help to understand what made patient representation in pandemic times a struggle for national and local patient representatives. The analysis of the subjects these representatives put forward during decision-making shows that their input can play an important role in broadening discussions, challenging decisions, and suggesting alternatives during a crisis. We identified several strategies (e.g., collaborating with other actors, proactively putting subjects on the policy agenda, finding new ways of contacting their 'constituency') used by the patient representatives studied to exert influence despite the difficulties encountered.

CONCLUSIONS

The struggle for patient representation during pandemic decision-making is a missed opportunity for resilient healthcare systems as these representatives can play a role in opening up discussions and putting different perspectives to the fore. Moreover, the adaptive strategies used by representatives to influence decision-making offer lessons for future representation activities. However, adaptations to the crisis decision-making structure are also needed to enable patient representatives to play their role.

PATIENT CONTRIBUTION

We conducted interviews with patient representatives and discussed our preliminary findings with patient representatives during the focus groups. Zorgbelang, a patient organization supporting client councils and enabling and organizing patient participation for organizations and municipalities, was partner in this research and contributed to the interview guide, conducting interviews and focus groups. Additionally, the analysis made by the first author was discussed and refined multiple times with the partners of Zorgbelang and one of them co-authored this paper.

COVID-19 healthcare and social-related needs from the perspective of Spanish patients and healthcare providers: a qualitative analysis of responses to open-ended questions

Introduction

Identifying stakeholders' needs is crucial to informing decisions and policy development. This study aims to identify healthcare and social-related needs and effective strategies associated with COVID-19 from the first-person perspectives of patients and healthcare providers.

Methods

Cross-sectional online survey design including qualitative open-ended questions, conducted in primary care and hospital settings across Spain, with 12 out of 19 regions represented. Adults aged 18 years and older, who (a) resided in Spain and had a history of COVID-19 or (b) worked as healthcare providers delivering direct or indirect care for people with COVID-19 in Spanish primary care or hospitals during 2020 were eligible to participate. Recruitment was conducted via social-media networks (Twitter, LinkedIn, and WhatsApp) and communication channels of key organizations including patient and professional associations and groups. A total of 182 people were invited to complete the surveys and 76 people completed the surveys (71% women), of which 33 were home-isolated patients, 14 were hospitalized patients, 16 were primary care professionals, and 13 were hospital care professionals.

Results

A total of 327 needs and 86 effective strategies and positive aspects were identified across surveys and classified into the following overarching themes: (i) Accessibility, (ii) Basic needs, (iii) Clinical care, (iv) Person-and-family centered care, (v) Caring for the healthcare professional, (vi) Protocolization, information, health campaigns, and education, (vii) Resource availability, (viii) and Organizational needs/strategies.

Discussion

Findings indicate the Spanish health and social care systems were generally unprepared to combat COVID-19. Implications for research, practice, and policy focus on integrating first-person perspectives as best practice to identify, prioritize and address needs to increase health and social care systems capacity and preparedness, as well as providing well-co-coordinated responses across government, healthcare, and non-government sectors to promote and protect the physical and mental health of all.

Comparative health policy goes qualitative: Broadening the focus of research after COVID-19

The COVID-19 pandemic has pushed health policy frontstage and exposed the stark differences in government capacities to respond to the crisis. This has created new demands for comparative heath policy to support knowledge creation on a large scale. However, comparative health policy has not necessarily been well prepared; studies have focused on health systems and used typologies together with descriptive, quantitative methods. This makes it difficult to capture the multi-level nature of health policy, the diverse actors involved and the many societal facets of governance performance. We argue for broadening the perspective to include health policy as a bottom-up process with diverse interests. This calls for expanding the methodology of comparative health policy by also using approaches that make greater use of explorative, qualitative research. We introduce possible developmental pathways to illustrate what this may look like. The Pan-European Commission shows how to broaden the definition of comparative health policy, notably as transnational and planetary. The gender analysis matrix illustrates how comparative health policy can strengthen its assessment of performance by focussing on gender equity. The street-level bureaucrat framework highlights how analysing frontline work can help conduct small-scale bottom-up comparisons of health policy. Together, these developmental pathways demonstrate the potential to broaden comparative health policy towards greater responsiveness to the societal performance of governments, such as social inequalities created by the COVID-19 pandemic. This also opens opportunities for strengthening the global outlook of comparative health policy.

A management perspective on resilience in healthcare: a framework and avenues for future research

Recent major health shocks, such as the 2014-16 Ebola, the Zika outbreak, and, last but not least, the COVID-19 pandemic, have strongly contributed to drawing attention to the issue of resilience in the healthcare domain. Nevertheless, the scientific literature appears fragmented, creating difficulties in developing incremental research in this relevant managerial field.To fill this gap, this systematic literature review aims to provide a clear state of the art of the literature dealing with resilience in healthcare. Specifically, from the analysis of the theoretical articles and reviews, the key dimensions of resilience are identified, and a novel classification framework is proposed. The classification framework is then used to systematize extant empirical contributions. Two main dimensions of resilience are identified: the approach to resilience (reactive vs. proactive) and the type of crisis to deal with (acute shocks vs. chronic stressors). Four main streams of research are thus identified: (i) proactive approaches to acute shocks; (ii) proactive approaches to chronic stressors; (iii) reactive approaches to acute shocks; and (iv) reactive approaches to chronic stressors. These are scrutinised considering three additional dimensions: the level of analysis, the resources to nurture resilience, and the country context. The classification framework and the associated mapping contribute to systematising the fragmented literature on resilience in healthcare, providing a clear picture of the state of the art in this field and drawing a research agenda that opens interesting paths for future research.

Migrant healthcare workers during COVID-19: bringing an intersectional health system-related approach into pandemic protection. A German case study

Introduction

Migrant healthcare workers played an important role during the COVID-19 pandemic, but data are lacking especially for high-resourced European healthcare systems. This study aims to research migrant healthcare workers through an intersectional health system-related approach, using Germany as a case study.

Methods

An intersectional research framework was created and a rapid scoping study performed. Secondary analysis of selected items taken from two COVID-19 surveys was undertaken to compare perceptions of national and foreign-born healthcare workers, using descriptive statistics.

Results

Available research is focused on worst-case pandemic scenarios of Brazil and the United Kingdom, highlighting racialised discrimination and higher risks of migrant healthcare workers. The German data did not reveal significant differences between national-born and foreign-born healthcare workers for items related to health status including SARS-CoV-2 infection and vaccination, and perception of infection risk, protective workplace measures, and government measures, but items related to social participation and work conditions with higher infection risk indicate a higher burden of migrant healthcare workers.

Conclusions

COVID-19 pandemic policy must include migrant healthcare workers, but simply adding the migration status is not enough. We introduce an intersectional health systems-related approach to understand how pandemic policies create social inequalities and how the protection of migrant healthcare workers may be improved.

COVID-19 and healthcare worker mental well-being: Comparative case studies on interventions in six countries

Healthcare worker (HCW) mental well-being has become a global public health priority as health systems seek to strengthen their resilience in the face of the COVID-19 pandemic. Analysing data from the Health System Response Monitor, we present six case studies (Denmark, Italy, Kyrgyzstan, Lithuania, Romania, and the United Kingdom) as a comparative review of policy interventions supporting HCW mental health during the pandemic. The results illustrate a wide range of interventions. While Denmark and the United Kingdom built on pre-existing structures to support HCW mental wellbeing during the pandemic, the other countries required new interventions. Across all cases, there was a reliance on self-care resources, online training tools, and remote professional support. Based on our analysis, we develop four policy recommendations for the future of HCW mental health supports. First, HCW mental health should be seen as a core facet of health workforce capacity. Second, effective mental health supports requires an integrated psychosocial approach that acknowledges the importance of harm prevention strategies and organisational resources (psychological first aid) alongside targeted professional interventions. Third, personal, professional and practical obstacles to take-up of mental health supports should be addressed. Fourth, any specific support or intervention targeting HCW's mental health is connected to, and dependent on, wider structural and employment factors (e.g. system resourcing and organisation) that determine the working conditions of HCWs.

A synthesis of concepts of resilience to inform operationalization of health systems resilience in recovery from disruptive public health events including COVID-19

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict' Health systems resilience has become a ubiquitous concept as countries respond to and recover from crises such as the COVID-19 pandemic, war and conflict, natural disasters, and economic stressors inter alia. However, the operational scope and definition of health systems resilience to inform health systems recovery and the building back better agenda have not been elaborated in the literature and discourse to date. When widely used terms and their operational definitions appear nebulous or are not consistently used, it can perpetuate misalignment between stakeholders and investments. This can hinder progress in integrated approaches such as strengthening primary health care (PHC) and the essential public health functions (EPHFs) in health and allied sectors as well as hinder progress toward key global objectives such as recovering and sustaining progress toward universal health coverage (UHC), health security, healthier populations, and the Sustainable Development Goals (SDGs). This paper represents a conceptual synthesis based on 45 documents drawn from peer-reviewed papers and gray literature sources and supplemented by unpublished data drawn from the extensive operational experience of the co-authors in the application of health systems resilience at country level. The results present a synthesis of global understanding of the concept of resilience in the context of health systems. We report on different aspects of health systems resilience and conclude by proposing a clear operational definition of health systems resilience that can be readily applied by different stakeholders to inform current global recovery and beyond.

"We are the ones who will have to make the change": Cuban health cooperation and the integration of Cuban medical graduates into practice in the Pacific

BACKGROUND

This paper responds to Asante et al. (in Hum Resour Health, 2014), providing an updated picture of the impacts of Cuban medical training in the Pacific region based on research carried out in 2019-2021, which focused on the experiences of Pacific Island doctors trained in Cuba and their integration into practice in their home countries.

METHODS

The research focussed on two case studies-Solomon Islands and Kiribati. Study methods for this research included multi-sited ethnographic methods and semi-structured interviews as well as qualitative analysis of policy documents, reports, and media sources.

RESULTS

The Cuban health assistance programme has had a significant impact on the medical workforce in the Pacific region increasing the number of doctors employed by Pacific Ministries of Health between 2012 and 2019. Qualitatively, there have been some notable improvements in the medical workforce and health delivery over this period. However, the integration of the Cuban-trained doctors into practise has been challenging, with criticisms of their clinical, procedural and communication skills, and the need for the rapid development of bridging and internship training programmes (ITPs) which were inadequately planned for at the outset of the programme.

CONCLUSIONS

The Cuban programme in the Pacific is an important model of development assistance for health in the region. While Cuba's offer of scholarships was the trigger for a range of positive outcomes, the success of the programme has relied on input from a range of actors including support from other governments and institutions, and much hard work by the graduates themselves, often in the face of considerable criticism. Key impacts of the programme to date include the raw increase in the number of doctors and the development of the ITPs and career pathways for the graduates, although this has also led to the reorientation of Cuban graduates from preventative to curative health. There is considerable potential for these graduates to contribute to improved health outcomes across the region, particularly if their primary and preventative health care skills are utilised.

Comparing Health Workforce Policy during a Major Global Health Crisis: A Critical Conceptual Debate and International Empirical Investigation

BACKGROUND

The health workforce is central to healthcare systems and population health, but marginal in comparative health policy. This study aims to highlight the crucial relevance of the health workforce and contribute comparative evidence to help improve the protection of healthcare workers and prevention of inequalities during a major public health crisis.

METHODS

Our integrated governance framework considers system, sector, organizational and socio-cultural dimensions of health workforce policy. The COVID-19 pandemic serves as the policy field and Brazil, Canada, Italy, and Germany as illustrative cases. We draw on secondary sources (literature, document analysis, public statistics, reports) and country expert information with a focus on the first COVID-19 waves until the summer of 2021.

RESULTS

Our comparative investigation illustrates the benefits of a multi-level governance approach beyond health system typologies. In the selected countries, we found similar problems and governance gaps concerning increased workplace stress, lack of mental health support, and gender and racial inequalities. Health policy across countries failed to adequately respond to the needs of HCWs, thus exacerbating inequalities during a major global health crisis.

CONCLUSIONS

Comparative health workforce policy research may contribute new knowledge to improve health system resilience and population health during a crisis.

Health systems resilience: is it time to revisit resilience after COVID-19?

The concept of health system resilience has been challenged by the COVID-19 pandemic. Even well-established health systems, considered resilient, collapsed during the pandemic. To revisit the concept of resilience two years and a half after the initial impact of COVID-19, we conducted a qualitative study with 26 international experts in health systems to explore their views on concepts, stages, analytical frameworks, and implementation from a comparative perspective of high- and low-and-middle-income countries (HICs and LMICs). The interview guide was informed by a comprehensive literature review, and all interviewees had practice and academic expertise in some of the largest health systems in the world. Results show that the pandemic did modify experts' views on various aspects of health system resilience, which we summarize and propose as refinements to the current understanding of health systems resilience.

Health System Resilience as the Basis for Explanation Versus Evaluation Comment on "The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic"

The onset and impacts of COVID-19 have prompted attention to national health system preparedness for, and capacity to adapt in response to, public health emergencies and other shocks. This preparedness and adaptive capacity are often framed as 'health system resilience' a concept previously associated more with assessments of health systems in conflict-affected and fragile states. Yet health system resilience remains a slippery concept, defined and applied in multiple ways. Reflecting on the Hodgins and colleagues' study "the COVID-19 system shock framework: capturing health system innovation during the COVID-19 pandemic," this article restates the limitations of health systems resilience as a concept capable of anchoring evaluative assessments of health system performance but stresses its value in the context of explanatory research investigating how and why health systems adapt, with due attention to the power of actors' whose choices inform the nature and direction of change.

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria, Australia

BACKGROUND

The COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs.

OBJECTIVE

Our aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia.

METHODS

This is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria's pandemic response guidelines, were analysed. The primary outcome was 'insufficient ICU skill mix'-whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff.

RESULTS

Overall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the 'business-as-usual' number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs.

CONCLUSION

The redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

Hospital Staffing during the COVID-19 Pandemic in Sweden

Staff management challenges in the healthcare system are inherently different during pandemic conditions than under normal circumstances. Surge capacity must be rapidly increased, particularly in the intensive care units (ICU), to handle the increased pressure, without depleting the rest of the system. In addition, sickness or fatigue among the staff can become a critical issue. This study explores the lessons learned by first- and second-line managers in Sweden with regard to staff management during the COVID-19 pandemic. A mixed-methods approach was used, with preliminary qualitative interview (n = 38) and principal quantitative questionnaire (n = 272) studies, based on principal component and multiple regression analyses. The results revealed that the pandemic created four types of challenges relating to staff management: staff movement within hospitals; addition of external staff; addition of hours for existing staff through overtime and new shift schedules; and avoidance of lost hours due to sickness or fatigue. Furthermore, the effects of these managerial challenges were different in the first wave than in later waves, and they significantly differed between the ICU and other units. Therefore, a greater proactive focus on staff management would be beneficial in future pandemic situations.

The resilient potential behaviours in an Internal Medicine Department: Application of resilience assessment grid

Background

The healthcare system is frequently subject to unpredictable conditions such as organisational changes and pandemics. In order to perform as required under these conditions (i.e. exhibiting resilient behaviour), it is necessary to know the current position of the organisation with respect to the four resilient potentials i.e. respond, monitor, learn and anticipate. The study aimed to understand and assess resilient performance of an Internal Medicine Department in a public hospital in Denmark using the resilience assessment grid (RAG).

Methods

A modified Delphi method was used to develop the context specific RAG, using interviews to generate items, two rounds of expert panel reviews and pilot testing the developed RAG questionnaire. The four sets of structured RAG questions were tested and revised until satisfactory face and content validity for application was achieved. The final version of the RAG (28-item Likert scale) questionnaire was sent electronically to 87 healthcare professionals (clinicians and managers) in January 2021 and 2022. The data was statistically analysed and illustrated in radar charts to assist in interpreting the resilience profiles.

Results

While the resilience profiles in 2021 and 2022 were similar, the scores in 2022 were slightly lower for some of the sub-indicators. The results indicate areas for improvement, especially related to the Internal Medicine Department’s potential to respond and learn. The results from the RAG were presented to the chief clinical consultants and managers to identify initiatives for quality improvement and for planning a new workflow at the Internal Medicine Department.

Conclusion

The RAG is a managerial tool to assess the potential resilient performance of the organisation in respect to the four resilience potentials, i.e., responding, monitoring, learning, and anticipating. It can be used to construct the resilience profile of the system over time to manage organisational changes.

Healthcare Workers' Perceptions and Medically Approved COVID-19 Infection Risk: Understanding the Mental Health Dimension of the Pandemic. A German Hospital Case Study

Introduction

This study analyses how healthcare workers (HCWs) perceived risks, protection and preventive measures during the COVID-19 pandemic in relation to medically approved risks and organizational measures. The aim is to explore “blind spots” of pandemic protection and make mental health needs of HCWs visible.

Methods

We have chosen an “optimal-case” scenario of a high-income country with a well-resourced hospital sector and low HCW infection rate at the organizational level to explore governance gaps in HCW protection. A German multi-method hospital study at Hannover Medical School served as empirical case; document analysis, expert information and survey data (n = 1,163) were collected as part of a clinical study into SARS-CoV-2 serology testing during the second wave of the pandemic (November 2020-February 2021). Selected survey items included perceptions of risks, protection and preventive measures. Descriptive statistical analysis and regression were undertaken for gender, profession and COVID-19 patient care.

Results

The results reveal a low risk of 1% medically approved infections among participants, but a much higher mean personal risk estimate of 15%. The majority (68.4%) expressed “some” to “very strong” fear of acquiring infection at the workplace. Individual protective behavior and compliance with protective workplace measures were estimated as very high. Yet only about half of the respondents felt strongly protected by the employer; 12% even perceived “no” or “little” protection. Gender and contact with COVID-19 patients had no significant effect on the estimations of infection risks and protective workplace behavior, but nursing was correlated with higher levels of personal risk estimations and fear of infection.

Conclusions

A strong mismatch between low medically approved risk and personal risk perceptions of HCWs brings stressors and threats into view, that may be preventable through better information, training/education and risk communication and through investment in mental health and inclusion in pandemic preparedness plans.

Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health

BACKGROUND

A cohesive and strategic governance approach is needed to improve the health workforce (HW). To achieve this, the WHO Global Strategy on Human Resources for Health (HRH) promotes mechanisms to coordinate HRH stakeholders, HRH structures and capacity within the health sector to support the development and implementation of a comprehensive HW agenda and regular reporting through WHO's National Health Workforce Accounts (NHWA).

METHODS

Using an adapted HRH governance framework for guidance and analysis, we explored the existence and operation of HRH coordination mechanisms and HRH structures in Malawi, Nepal, Sudan and additionally from a global perspective through 28 key informant interviews and a review of 165 documents.

RESULTS

A unified approach is needed for the coordination of stakeholders who support the timely development and oversight of an appropriate costed HRH strategy subsequently implemented and monitored by an HRH unit. Multiple HRH stakeholder coordination mechanisms co-exist, but the broader, embedded mechanisms seemed more likely to support and sustain a comprehensive intersectoral HW agenda. Including all stakeholders is challenging and the private sector and civil society were noted for their absence. The credibility of coordination mechanisms increases participation. Factors contributing to credibility included: high-level leadership, organisational support and the generation and availability of timely HRH data and clear ownership by the ministry of health. HRH units were identified in two study countries and were reported to exist in many countries, but were not necessarily functional. There is a lack of specialist knowledge needed for the planning and management of the HW amongst staff in HRH units or equivalent structures, coupled with high turnover in many countries. Donor support has helped with provision of technical expertise and HRH data systems, though the benefits may not be sustained.

CONCLUSION

While is it important to monitor the existence of HRH coordination mechanisms and HRH structure through the NHWA, improved 'health workforce literacy' for both stakeholders and operational HRH staff and a deeper understanding of the operation of these functions is needed to strengthen their contribution to HW governance and ultimately, wider health goals.

Healthcare Workers From Diverse Ethnicities and Their Perceptions of Risk and Experiences of Risk Management During the COVID-19 Pandemic: Qualitative Insights From the United Kingdom-REACH Study

Introduction

Healthcare workers (HCWs) are at higher risk of being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Previous studies have examined factors relating to infection amongst HCWs, including those from ethnic minority groups, but there is limited data regarding the lived experiences of HCWs in relation to self-protection and how they deal with SARS-CoV-2 infection prevention. In this study, we presented data from an ethnically diverse sample of HCWs in the United Kingdom (UK) to understand their perceptions of risks and experiences with risk management whilst working throughout the COVID-19 pandemic.

Methods

We undertook a qualitative study as part of the United Kingdom Research study into Ethnicity and COVID-19 outcomes among Healthcare workers (United Kingdom-REACH) conducting semi-structured interviews and focus groups which were recorded with participants' permission. Recordings were transcribed and thematically analyzed.

Findings

A total of 84 participants were included in the analysis. Five broad themes emerged. First, ethnic minority HCWs spoke about specific risks and vulnerabilities they faced in relation to their ethnicity. Second, participants' experience of risk assessments at work varied; some expressed satisfaction while many critiqued it as a "tick-box" exercise. Third, most participants shared about risks related to shortages, ambiguity in guidance, and inequitable distribution of Personal Protective Equipment (PPE), particularly during the start of the pandemic. Fourth, participants reported risks resulting from understaffing and inappropriate redeployment. Finally, HCWs shared the risk mitigation strategies which they had personally employed to protect themselves, their families, and the public.

Conclusion

Healthcare workers identified several areas where they felt at risk and/or had negative experiences of risk management during the pandemic. Our findings indicate that organizational shortcomings may have exposed some HCWs to greater risks of infection compared with others, thereby increasing their emotional and mental burden. Ethnic minority HCWs in particular experienced risks stemming from what they perceived to be institutional and structural racism, thus leading to a loss of trust in employers. These findings have significance in understanding staff safety, wellbeing, and workforce retention in multiethnic staff groups and also highlight the need for more robust, inclusive, and equitable approaches to protect HCWs going forward.