key: cord-0899875-tzpjj5rr
authors: Alanezi, Fahad; Aljahdali, Anan; Alyousef, Seham; Alshaikh, Wyam; Mushcab, Hayat; AlThani, Bashair; Alghamedy, Fatemah; Alotaibi, Hussah; Alrajhi, Sharifah; Alabbadi, Dhabia
title: Investigating healthcare practitioners’ attitudes towards the COVID-19 outbreak in Saudi Arabia: a general qualitative framework for managing the pandemic
date: 2020-12-08
journal: Inform Med Unlocked
DOI: 10.1016/j.imu.2020.100491
sha: efa7e300d2dbfcf13ccad5e5494b4abbdc649999
doc_id: 899875
cord_uid: tzpjj5rr

BACKGROUND: Some previous studies have investigated the attitudes of healthcare professionals towards certain aspects of the COVID-19 outbreak. In addition, some general frameworks have been proposed to manage the pandemic. OBJECTIVE: The purpose of this article was to analyze the attitudes of healthcare practitioners in Saudi Arabia towards the treatment of patients with COVID-19, work planning of practitioners, leadership approaches to manage the pandemic, sharing information strategies, medical errors, compliance with procedures, and challenges faced by the practitioners. Furthermore, another objective was to propose a general framework for managing the COVID-19 outbreak in Saudi Arabia. METHODS: To achieve these purposes, a survey was designed based on an online questionnaire that was initially sent via WhatsApp, Twitter, Facebook, and email to 336 healthcare practitioners working in 7 hospitals in Saudi Arabia. The response rate was 30.4%. RESULTS: The outcomes indicated that healthcare practitioners in Saudi Arabia had positive attitudes towards effective communication and interaction between health professionals and patients, leadership and maintenance of team coordination, work planning, communication and cooperation between team members, training and skills development of healthcare professionals, implementing strict procedures to avoid errors and control the spread of the COVID-19 pandemic, maintaining an adequate supply of medicines and medical equipment, and obtaining the support of the government, the community, and the people. CONCLUSION: Based on the findings, it was possible to suggest that the management of health care operations related to the COVID-19 outbreak in Saudi Arabia requires effective collaboration and information sharing among various stakeholders. In this sense, communication, effective leadership, coordination and work planning, adequate treatment for patients, strict compliance with hospital rules and procedures, preventive and regulatory measures, and training and support for health professionals, were parameters considered in the general qualitative framework suggested in this study for managing the COVID-19 pandemic in Saudi Arabia. The propositions presented in this study can help the Saudi Arabian government implement an effective plan to control the spread of the COVID-19 pandemic in this country.

noted the importance of equipping health workers with personal protective equipment [10] .

In South Africa, the lack of leadership has created limitations in the provision of services to combat COVID-19 [11] . As for China, healthcare providers were concerned about the risks and the need to use personal protective equipment [12] . Other general aspects about the attitudes of health professionals towards patients have been pointed out in several previous studies [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] .

It is important to mention that during pandemics, the attitudes of health professionals can be influenced by the risk of exposure to infection or by increased stress and workload [25] .

In this regard, some studies have investigated the impact of pandemics on the attitudes of healthcare professionals and the challenges they face [26] [27] [28] . Overall, positive attitudes of healthcare professionals towards patient safety [29] , privacy [30] , and technology-enabled approaches such as remote monitoring of patients [31] have been observed. In relation to the COVID-19 outbreak, the work environment has varied greatly from a normal healthcare setting to a situation that involves rapid changes in service delivery, procedures and compliance, ethical issues, and treatment preferences related to the support and acceptance of patients, among other factors. In these circumstances, leadership is very important to maintain a positive attitude in the midst of the COVID-19 pandemic [25] .

Furthermore, some general frameworks have been proposed to handle the crisis generated by the COVID-19 outbreak [32] [33] [34] [35] [36] [37] [38] [39] . However, these frameworks are very broad and do not specify the procedures that must be carried out to manage the COVID-19 pandemic in each country. In general, these frameworks are directed to the institutions, Related to this research, it is convenient to point out that the human resources departments of hospitals have considered that the attitudes of health personnel are an important area to consider in the process of developing strategies to improve the efficiency of these institutions [17] . Regarding this topic, several studies have investigated, from various perspectives, how the attitudes of health workers towards medicine, work culture and professionalism, robots in service, patients, and other aspects can help to improve the overall quality of health care [15, [16] [17] [18] [19] [20] [21] .

Based on the aforementioned aspects and considering that in Saudi Arabia only a limited study [6] was found on the attitudes of health professionals towards the COVID-19 outbreak, and no study was observed on the proposal of a framework to face the crisis generated by the pandemic, the objective of this article was to analyze the attitudes of healthcare practitioners in Saudi Arabia towards the treatment of COVID-19 patients, work planning of healthcare providers, leadership approaches for handling the COVID-19 pandemic, information sharing methodologies, medical errors and procedural compliance, J o u r n a l P r e -p r o o f and challenges faced by the healthcare practitioners in dealing with the COVID-19 outbreak. Also, taking into account the attitudes of healthcare practitioners, a general framework for managing the COVID-19 pandemic in Saudi Arabia was suggested.

It is pertinent to mention that this study is significant because it analyzes the attitudes of healthcare practitioners towards areas not considered in similar studies, and proposes a practical framework to manage the COVID-19 pandemic in Saudi Arabia where there are no published studies on this subject [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [32] [33] [34] [35] [36] [37] [38] [39] . The importance of this study lies in the fact that it is the first investigation carried out in Saudi Arabia in order to propose a qualitative general framework to manage the COVID-19 pandemic based on the opinions of healthcare practitioners' in this country. Taking into account the proposals presented in this study, the Saudi Arabian government can implement an effective plan in hospitals to control the spread of the COVID-19 pandemic in the Kingdom of Saudi Arabia.

To achieve the objective of this study, an online questionnaire-based survey was designed to collect data on the attitudes of Saudi Arabian healthcare practitioners towards the treatment of COVID-19 patients, work planning of practitioners, leadership strategies for handling the COVID-19 pandemic, information sharing methodologies, medical errors and procedural compliance, and challenges faced by the practitioners in dealing with the COVID-19 outbreak.

J o u r n a l P r e -p r o o f 

The questionnaire consisted of 7 sections that included closed and multiple choice questions or items. Each item was rated using the 5-point Likert scale: 1.Strongly disagree; 2.Disagree; 3. Neutral; 4.Agree; 5.Strongly agree [40] . The questionnaire is shown in Appendix A.

The first section of the questionnaire consisted of 6 items aimed at obtaining the demographic information of the participants (age, gender, education level, profession, work experience).

The second section had 12 questions focusing on the attitudes of the healthcare practitioners towards the treatment of patients and work activities (Please rate the following items using the Lickert scale: prescribing should take into account patients' expectations of treatment; physicians and patients should agree on a treatment plan that takes into account tell me what to do; I sometimes feel uncomfortable telling team members from other disciplines that they need to take some action).

The fourth section consisted of 7 items related to information sharing (Please rate the following statements using the Lickert scale: a regular debriefing of procedures and decisions after a session or shift is an important part of developing and maintaining effective team coordination; team members in charge should verbalize plans for procedures or actions and should be sure that the information is understood and acknowledged by others ; I am encouraged by my leaders and co-workers to report any incidents I may observe; it is better to agree with other medical team members than to voice a different opinion; the physician's responsibilities include coordination between his or her work team J o u r n a l P r e -p r o o f and other support teams; medical team members share responsibilities for prioritizing activities in high workload situations ; all members of the medical team are qualified to give me feedback).

The fifth section consisted of 6 items related to error/procedural compliance (Please rate the following statements using the Lickert scale: errors are a sign of incompetence;

procedures and policies are strictly followed in our department; human error is inevitable; team members frequently disregard rules or guidelines developed for our department such as hand washing, treatment protocols/clinical pathways, and sterile field; I rarely witness an error where one or more team members lack the knowledge to perform the needed action; medical errors are discussed to prevent recurrence).

The sixth section included 12 questions about the existence of several challenges (Please rate the following statements using the Lickert scale: work overload; poor salary; fewer staff; poor organizational culture; poor leadership; limited or no access to technology; lack of training; lack of healthcare resources such as ventilators/ accessories, gloves, masks etc.; lack of sufficient financial resources; lack of support from government; lack of support from community/people; poor operational framework for managing pandemic).

Finally, the seventh section comprised 5 statements related to the importance of developing a healthcare framework for the management of the COVID-19 pandemic (Please rate the following statements using the Lickert scale: highly important; important; neutral; not important; not necessary)

Considering the objective and characteristics of this study, a purposive sampling method was adopted to collect the data [41] . The survey link was initially sent to 336 healthcare practitioners working in the 7 selected hospitals mentioned above using WhatsApp, Twitter, Facebook, and emails. Only 102 practitioners completed the survey. 80 of them did not start the survey and 154 sent incomplete responses. The response rate was 30.4%.

The low response rate may be due to the fact that healthcare practitioners were very busy J o u r n a l P r e -p r o o f dealing with the COVID-19 outbreak. The survey was conducted for a period of four weeks, between March 23 and April 12, 2020.

The questionnaire was validated through a pilot study conducted with nine healthcare practitioners (six nurses, 2 managers and 1 physician). Based on feedback from participants, some changes were made to the questions' formulations, and the grammatical errors in Arabic were addressed. In addition, the Cronbach's alpha for all items of the questionnaire were estimated to evaluate its reliability; the Cronbach's alpha of all items were greater than 0.83 (>0.70); this revealed good consistency [42] .

The relative frequencies and the Cronbach's alpha for each item of the questionnaire was estimated using basic descriptive statistics. Tables and Figures were used to represent the data.

The demographic information of the participants is shown in Fig.1 . This table indicates that 62.8% of the participants were female and 37.2% were male. Considering the age groups, most of the participants (95.0%) were between 25 and 54 years old, and the rest of the participants were between 18 and 24 years old, or were older than 54 years. Focusing on the educational level, 41.2% of the participants had a master's degree, 27.5% of them were Ph.D., 21.6% were Bachelor's degree holders, 5.9% were Diploma holders, and 3.9% had other educational qualifications. The professions of the participants were diverse. Of these, 28 .4% were nurses, 23.5% senior physicians, 12.7% assistant physicians, 10.8% consultants or chief physicians or medical students, 8.8% pharmacists or administrators, J o u r n a l P r e -p r o o f and the rest of the participants had other medical professions. Regarding the experience of the participants, most of them (56.9%) had a work experience of more than ten years, followed by 30.4% who had six to ten years of work experience, and other participants had less than 5 years of experience. agreed) that senior staff should encourage questions from junior staff, as the COVID-19 is a new infection, and the details of symptoms and treatment procedures are different from other viral diseases. Also, the majority of them stated that they relied on their superiors' advice in critical situations. In relation to juniors assuming control of treatment and care, more than half of the respondents (22.55% strongly agreed and 32.35% agreed) opposed the idea of juniors taking control, while a considerable number of participants (18.63% disagreed and 6.86% strongly disagreed) considered that juniors may assume control. In addition, the majority of the participants preferred that leadership be in medical staff members. However, 66, 67% of the participants (agreed and strongly agreed) stated that they feel uncomfortable in telling team members from other disciplines to take some action. Table 2 displays the results of the participants' opinions regarding information sharing approaches. Most participants suggested that methodologies such as regular debriefing, verbalizing plans and actions related to treatment and procedures, regular reporting of incidents, and team member coordination were important information approaches.

However, the majority of participants pointed out that it is better to agree with other team members than to express a different opinion. Moreover, the respondents observed that the need for support and collaboration among team members were important approaches for prioritizing activities in high workload situations.

The perceptions of participants regarding errors and procedural compliance are presented in Fig.3 . The results indicated that most of participants pointed out that errors were a sign of incompetence, and that human errors were inevitable. However, these risks can be J o u r n a l P r e -p r o o f effectively addressed by adopting strict policies and regulations in the workplace. In this context, more than 70% of the respondents (20.59% strongly agreed and 55.88% agreed) denoted that they strictly followed all procedures and policies in their respective departments. It was interesting to note that more than 60% (13.73% strongly agreed and 54.90% agreed) perceived that the team members did not lack the knowledge to carry out the necessary actions. However, more than 60% (21.57% strongly agreed and 40.20% agreed) observed that team members frequently disregarded rules or guidelines (hand washing, treatment protocols/clinical pathways, sterile field, etc.), which can be one of the most serious concerns when dealing with COVID-19. Also, most of the participants stated that they discuss medical errors to prevent the recurrence of COVID-19. Table 3 outlines the major challenges that healthcare practitioners faced during the COVID-19 pandemic. Some of the key challenges included work overload, lack of training, insufficient staff, poor operational framework for managing the pandemic, poor leadership, poor organizational culture, lack of healthcare resources, and lack of support from government, community, and people.

On the other hand, Fig. 4 shows the opinion of the participants on the importance of a healthcare operational framework for managing the COVID-19 outbreak in Saudi Arabia.

The findings revealed that 92.15 % of the respondents believed that the development of an integrated framework was important (80.39% highly important and 11.76% important).

Similarly, Fig. 5 illustrates the characteristics of a general qualitative framework for managing the COVID-19 outbreak in Saudi Arabia. The findings indicated that physicians should consider the expectations and views of patients regarding the treatment offered for the COVID-19 pandemic. As COVID-19 is caused by a novel coronavirus, and a vaccine has not yet been discovered [43] , it may not be possible to consider patients' opinions and expectations about their treatment. However, patients must be fully informed about the benefits and risks of the available treatment and off-label medications, which are prescribed by the World Health Organization (WHO) [43] .

In this context, the majority of participants have stated that it is sometimes appropriate to make treatment decisions without patients' opinions, considering the safety of patients and others, and the fact that patients may transmit the disease to others without knowing that they are infected [44] . The large number of elderly patients who were affected with COVID-19 may be a cause for concern, as few healthcare participants reflected negative attitudes towards them [45] . However, most of the participants had no objection to working in the ICUs, where seriously ill COVID-19 patients are treated. In any case, communication J o u r n a l P r e -p r o o f and interaction between healthcare professionals and patients must be effective and sincere and must be considered as a central aspect in the elaboration of any general framework for the management of the COVID-19 outbreak in Saudi Arabia. For this reason, this aspect was included in the characteristics of the general framework proposed in this study.

Concerning work planning, the majority of the participants preferred reduced working hours and fewer night shifts; this might not be possible considering the current situation with limited healthcare resources and a rapidly increasing number of patients [46] . In addition, the respondents thought that work overload was a major challenge faced by healthcare practitioners in Saudi Arabia. These findings indicated that workforce and healthcare organization planning is an important factor in providing treatment and care, and must be included in any framework for managing the COVID-19 outbreak.

Also, the respondents suggested that effective leadership, support from senior staff, and collaboration between all teams from different disciplines were crucial factors for handling the COVID-19 crisis [25] . Therefore, this aspect was also incorporated in the framework for managing the COVID-19 outbreak in Saudi Arabia.

On the other hand, the participants thought that lack of training was a challenge faced by healthcare practitioners. About this topic, one important observation detected in the survey was related to the possibility that junior team members could take control of treatment, prevention, and care during the crisis. In this regard, due to the rapid increase in COVID-19 cases, a shortage of healthcare practitioners may occur and a situation may arise in which members of the junior team have to make some decisions related to treatment and care. Therefore, it is essential that they are adequately trained and have enough skills to handle the COVID-19 crisis. In these circumstances, the support from all stakeholders including physicians, patients, and members of other disciplines in hospitals is necessary. Regarding J o u r n a l P r e -p r o o f this issue, some studies have identified that stakeholders participation and skills training are important approaches to ensuring the preparedness of hospitals in pandemic management [47] [48] [49] [50] [51] . In this sense, the training and skills development of healthcare practitioners is a crucial aspect required in any general framework for managing the COVID-19 outbreak in Saudi Arabia.

The outcomes regarding errors and compliance with procedures reflected that human errors are inevitable, but can be addressed by adopting strict policies, measures, and methods in hospitals. One of the main causes of concerns was that more than 60% of the participants have stated that their team members frequently disregard rules and guidelines (hand washing, treatment protocols/clinical pathways, sterile field, etc.), which may result in serious damages and can become a source of spreading the infection. Consequently, it was assessed that operational and human errors can result in serious damages if not properly addressed [52, 53] , and there is a need for strict guidelines such as isolation, quarantine, border control, social-distancing, sanitation, etc., for controlling the spread of the COVID-19 [54] . This can be achieved by improving stakeholder participation, effective leadership, frequent training, and skills enhancement [48] [49] [50] . It is also important to protect healthcare practitioners working in hospitals, and steps must be taken to enforce an effective and supportive organizational culture with strict procedures and compliances, which makes effective and efficient use of resources, and develops operative strategies to improve the efficiency and effectiveness of healthcare operations [55, 56] . Therefore, the implementation of strict procedures to control the spread of the COVID-19 infection is an issue that must be taken into account in the operation of a framework for managing the COVID-19 pandemic. Participants also expressed that they faced several challenges due to the lack of medical equipment and resources, and a lack of support from the government and communities.

Hence, another aspect included in the framework was maintaining an adequate supply of medicines and medical equipment, and obtaining the support of the government, communities and people.

Based on the previous analysis, it is possible to suggest the implementation of a general qualitative framework for managing the COVID-19 crisis in Saudi Arabian hospitals. As shown in Fig.5 , the framework consists of 5 interrelated operations. 

The main limitations of this study were the small sample size of participants and the fact that an intentional sampling method was used in 7 hospitals in Saudi Arabia. Therefore, the results of this research cannot be generalized to all hospitals in Saudi Arabia. Future studies should be aimed at including most of the Saudi Arabian hospitals.

The healthcare practitioners' attitudes towards the COVID-19 outbreak in Saudi Arabia J o u r n a l P r e -p r o o f Analysis of current issues about the COVID-19 pandemic, prevention methods, development of key indicators, analysis of experiences related to pandemics or novel infectious diseases, analysis of statistical data, challenges, and development of approaches for the management of healthcare operations.

Management and communication between stakeholders, such as doctors, patients, international organizations, communities, and local government, help to organize the containment and treatment procedures to be adopted to control the spread of the COVID-19 pandemic. These actions also help the search for financial resources and medical supplies.

Organizational and workforce planning requires the implementation of an organizational culture that uses and manages human and material resources efficiently and effectively, and minimizes work overload. Effective leadership and collaboration between all teams are crucial factors for handling the COVID-19 crisis.

It is necessary to develop an organizational structure that allows the training and acquisition of knowledge and skills of healthcare professionals. It is very important to train health personnel, especially doctors and nurses who are directly involved with patients affected by COVID-19.

Evaluation of the effectiveness of the strategies implemented to control the pandemic. In this sense, through indicators, it is observed if the applied strategies adequately controlled the pandemic. If a positive result (Yes) is observed, the strategies are maintained, but if the results are negative (No), the strategies are changed or modified by other alternatives. 

WHO Coronavirus Disease (COVID-19). Dashboard. Available

COVID-19: The first documented coronavirus pandemic in history

The socio-economic implications of the coronavirus pandemic (COVID-19): A review

Coronavirus Disease 2019 (COVID-19).Symptoms of Coronavirus. Available

Coronavirus disease (COVID-19): How is it transmitted? Available

Perception and attitude of healthcare workers in Saudi Arabia with regard to Covid-19 pandemic and potential associated predictors

Knowledge and attitude towards COVID-19 and associated factors among health care providers in Northwest Ethiopia

Knowledge, attitude, and practices toward COVID-19 in primary healthcare providers: a cross-sectional study from three tertiary are hospitals of Peshawar

Knowledge, attitudes and fears of healthCare workers towards the corona virus disease (COVID-19) pandemic in South-South, Nigeria

Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt

How leadership matters in healthcareespecially in a crisis

Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan

Behaviours and attitudes in response to the COVID-19 pandemic: Insights from a cross-national Facebook survey

Singapore COVID-19 pandemic response as a successful model framework for low-resource health care settings in Africa?

A cross sectional survey to assess healthcare professionals' attitudes to and understanding of probiotics

Patients' satisfaction with HIV care providers in public health facilities in Lusaka: a study of patients who were Lost-tofollow-up from HIV care and treatment

Attitude for healthcare professionals | hospital and patient relationship. frontenders

Professionalism In Healthcare Professionals. Health & Care Professions Council

Finnish healthcare professionals' attitudes towards robots: Reflections on a population sample

Audit of healthcare professionals' attitudes towards patients who self-harm and adherence to national guidance in a UK burns and plastic surgery department

Knowledge, attitudes and practices regarding rabies risk in community members and healthcare professionals

Healthcare professionals' attitudes, knowledge and self-efficacy levels regarding the use of self-hypnosis in childbirth: a prospective questionnaire survey

Health care professionals -attitudes towards their own health

A literature review of healthcare professionals' attitudes towards patients with mental illness

What healthcare workers need from leaders in COVID-19 crisis

Healthcare workers' attitudes to working during pandemic influenza: a qualitative study

Health workers' experiences of coping with the Ebola epidemic in Sierra Leone's health system: a qualitative study

The COVID-19 pandemic and mental health impacts

Health care professionals' attitudes regarding patient safety: cross-sectional survey

Healthcare professionals' attitudes towards privacy in healthcare information systems

Healthcare professionals' attitudes towards remote patient monitoring through sensor networks

A systemic resilience approach to dealing with Covid-19 and future shocks

Pandemic management framework for governments in fighting the novel coronavirus (Covid-19)

Framework for implementation of COVID-19 community mitigation measures for lower-resource countries

A policy framework for tackling the economic and social impact of the COVID-19 crisis

Framework for the Response of Integrated Health Service Delivery Networks to COVID-19

COVID-19 contain framework: a guide for local decision-makers

A Framework for E-Health Strategy for managing pandemics in Saudi Arabia: in the context of COVID-19

A technique for the measurement of attitudes

Comparison of convenience sampling and purposive sampling

The use of Cronbach's alpha when developing and reporting research instruments in science education

World Health Organization. Off-label use of medicines for COVID-19

Can people spread the coronavirus if they don't have symptoms? 5 questions answered about asymptomatic COVID-19

Abuse and Ageism During COVID-19

Accessed

Saudi Arabia expects 200,000 cases if measures not followed

Protecting home health care workers: a challenge to pandemic influenza preparedness planning

Did pandemic preparedness aid the response to pandemic (H1N1) 2009? A qualitative analysis in seven countries within the WHO European Region

Simulation-based training of extracorporeal membrane oxygenation during H1N1 influenza pandemic

Just-in-time training of dental responders in a simulated pandemic immunization response exercise

Reporting errors in infectious disease outbreaks, with an application to Pandemic Influenza A/H1N1

Unused and expired medicines: a national pandemic. The journal of Ecologically Sustainable Medicine

Addressing ethical issues in pandemic influenza planning discussion papers

Mental health care for medical staff in China during the COVID-19 outbreak

Supporting the health care workforce during the COVID-19 global epidemic

Effective health risk communication about pandemic influenza for vulnerable populations

Effective communication during an influenza pandemic: the value of using a crisis and emergency risk communication framework

Communication and information sharing at VA facilities during the 2009 novel H1N1 influenza pandemic

Implications of public understanding of avian influenza for fostering effective risk communication

AGE: <15 years; 15-24 years; 25-34 years

Work Experience: <2 years; 2-5 years; 5-10 years

Prescribing should take into account patients' expectations of treatment • Physicians and patients should agree a treatment plan that takes into account their views • Physicians should try to help patients to make as informed as possible the benefits and risks of alternative treatments

• It is not always necessary for physicians to take into account of patients' priorities

Please rate the following statements related to Leadership Management on a scale of

• Senior staff should encourage questions from junior medical and nursing staff if

Please rate the following statements related to Information Sharing on a scale of

• A regular debriefing of procedures and decisions after a session or shift is an important part of developing and maintaining effective team coordination

• The physician's responsibilities include coordination between his or her work team and other support teams

Strongly Disagree; 2: Disagree; 3: Neutral; 4: Agree; 5: Strongly Agree) • Errors are a sign of incompetence • Procedures and policies are strictly followed in our department • Human error is inevitable • Team members frequently disregard rules or guidelines

Please rate the existence of the following challenges on a scale of

• Lack of healthcare resources (devices such as ventilators/ accessories such as gloves, masks etc