key: cord-0930863-e2hhg6zc
authors: Stone, Emily; Irving, Louis B.; Tonga, Katrina O.; Thompson, Bruce
title: Sustaining the Australian respiratory workforce through the COVID‐19 pandemic: a scoping literature review
date: 2022-04-05
journal: Intern Med J
DOI: 10.1111/imj.15718
sha: 714e72bfb34e87e8c2850a379a613214ea195ff7
doc_id: 930863
cord_uid: e2hhg6zc

The outbreak of the COVID‐19 pandemic in late 2019 and in 2020 presented challenges to healthcare workers (HCW) around the world that were unexpected and dramatic. The relentless progress of infection, starting in China and rapidly spreading to Europe, North America and elsewhere gave more remote countries, like Australia, time to prepare but also time for unease. HCW everywhere had to readjust and change their work practices to cope. Further waves of infection and transmission with newer variants pose challenges to HCW and health systems, even after mass vaccination. Respiratory medicine HCW found themselves at the frontline, developing critical care services to support intensive care units and grappling with unanticipated concerns about safety, risk and the need to retrain. Several studies have addressed the need for rapid changes in the healthcare workforce for COVID‐19 and the impact of this preparation on HCW themselves. In this paper, we present a scoping review of the literature on preparing HCW for the pandemic, explore the Australian experience of building the respiratory workforce and propose evidence‐based recommendations to sustain this workforce in an unprecedented high‐risk environment.

The viral pandemic of COVID-19 emerged in Wuhan, China, in late 2019 and rapidly spread around the world. Reports of intense critical care activity and hard community lockdowns in China foreshadowed the detection of cases in other countries and stimulated rapid pandemic planning for many governments and healthcare communities. Italy and then promptly Spain had little time for preparation before their critical care systems were overwhelmed. However, there was time for Italian physicians to warn of the speed and magnitude of the outbreaks and to emphasise the need for preparation, initially by video recording, 1 a modality that reflected the pace of the pandemic and that heightened the urgency of response. The chaos of outbreak response in countries with relatively sophisticated medical systems, such as the United States and the United Kingdom, presented a sobering front. As the caseload swelled rapidly in many countries, the preparatory efforts intensified in others who were, perhaps, 'behind the curve'. Australia, like New Zealand, benefitted from remote geography and time for planning, but even with this respite, healthcare practitioners faced high levels of initial fear and anxiety, 2 combined with a sense of commitment and responsibility that was, for most, alarming and new. The hardware requirements of pandemic responsepersonal protective equipment (PPE), ventilators, drugs, reorganisation of healthcare serviceswere clear to see. What might have been less apparent was the need for mental preparation. The 2021 outbreaks of newer variants in much of Australia, as well as in other countries, have required healthcare services to adjust again, reintroducing restrictions, alert levels, expansion of isolation wards and additional intensive care unit (ICU) capacity. The pressure on healthcare workers (HCW) has been made evident in Australia through reports (largely in the media) highlighting staff shortages due to furlough, resignations and career change.

In this paper, we have the following aims: to review the literature on HCW preparation for the COVID-19 pandemic; to highlight potential key professional groups and resources for respiratory medicine pandemic preparation; and to explore the evidence base for future pandemic response recommendations.

Scoping literature review on HCW workforce planning A scoping literature review was performed. English language publications in the National Library of Medicine through the PubMed search engine were considered using four search strategies. Papers were included if there was a primary focus on respiratory workforce concerns, HCW preparation, HCW well-being, health services preparation and evaluation of HCW preparedness and ability to cope with the pressures of the pandemic. Papers were excluded if they focussed primarily on parallel issues, such as virological screening of HCW, details of testing or simulation programmes, PPE supply chains and PPE management, impact of the pandemic on other subspecialty areas (such as paediatrics or rheumatology, aged care, anaesthetics, psychiatry, telehealth, rehabilitation, sleep medicine and cardiology), non-healthcare settings, epidemiology, gender issues, data systems, autopsy practices and novel technologies. A small number of papers appeared in more than one search or were derived from ad hoc search findings.

Search strategies were as follows: A. 'COVID-19 pulmonology workforce'; B. 'COVID-19 pandemic workforce respiratory'; C. 'COVID-19 pandemic workforce respiratory preparation'; and D. 'COVID-19 healthcare workers preparation frontline'.

The above search strategies identified the following number of papers in total and papers included, and the remaining papers were excluded as not relevant to the study aim: Search A, 6/35 papers (17%); Search B, 21/ 109 papers (19%); Search C, 1/14 papers (7%); Search D, 23/47 papers (49%). Subsequent ad hoc search strategies added two further papers. 3, 4 The papers included for review were published largely between 21 March 2020 and 15 September 2021. They are summarised in Table 1 and include the following categories: surveys, discussion of health services preparation, commentaries, qualitative research, modelling of preparation strategies and literature reviews.

Surveys covered HCW from China, 6, 8, 18 Pakistan, 9 India, 20 the United Kingdom, 12, 17, 35, 43 Libya, 23, 35, 46 Spain, 32 Singapore, 42 South Africa, 44 9, 17, 20, 23, 44, 46, 48, 55 staff shortages 32, 33, 43 and infection risk. 6, 8, 18, 31, 42, 54 Additional factors contributing to mental health disturbances included lack of supervisor or institutional support, 31, 49, 55 female sex, 6,39 relative youth, 31, 35, 39 isolation from family, 8, 39 family and home stressors 31 and relative inexperience. 35 

The preparation of health services for the pandemic was discussed in papers from the United States, 19, 21, 40, 45 Singapore, 15 the United Kingdom 26 and Cameroon 38 with a strong focus on the ability to rapidly increase intensive care capacity. 15, 19, 21, 38 The daunting lack of intensive care bed capacity on the African continent is highlighted by Metogo and colleagues. 38 Other key health services issues were identified, including the need for rapid development of testing and isolation protocols 15, 19 and retraining, even of very senior staff, to augment the critical care workforce. 15, 19, 26, 45 Commentaries Commentary papers identified critical workforce issues, such as early recognition of the need for HCW protection, 5,7 the speed of the outbreak during wave one in globally recognised early hotspots 5, 16 and aspects of healthcare systems that might have exacerbated outbreaks (such as just-in-time supply chains that limited access to PPE) 34 and that required rapid adaption to manage the surge (including in-hospital physical distancing strategies, HCW screening for infection, rapid uptake of telehealth and prompt redeployment of staff). 13, 29, 30, 47 Qualitative research

Qualitative studies from the United States, 10 Pakistan, 25, 51 China, 27 Canada, 36 South Korea 37 and Denmark 50 involving a range of HCW identified a number of concerns, including infection risk, anticipated overwork, worries about community non-compliance as well as lack of PPE, lack of planning and of trust in institutions.

Three studies modelled preparation strategies for the pandemic, all from the United States. Strategies included survey tools to reduce occupational infection risk, 22 proposals for surge response 24 and scenarios to optimise shift structures that maintained workforce capacity and minimised HCW infection. 28 6 30/3/2020 China Survey Mental health concerns from infection risk Khan et al. 7 2/4/2020 China Commentary Importance of training, support and PPE for HCW Lu et al. 8 4/4/2020 China Survey Fear and anxiety from high-risk setting Khan et al. 9 10/4/2020 Pakistan Survey Concern about lack of preparedness He et al. 10 17/4/2020 United States Qualitative Risk of infection, anticipated overwork Friese et al. 11 22/4/2020 United States Commentary Minimum PPE recommendations Prescott et al. 12 24/4/2020 United Kingdom Survey Need for training and guidance Monica et al. 13 7/5/2020 Singapore Commentary Preparation of nursing workforce Fernandez et al. 14 29 23/7/2020 Europe Commentary Need to protect HCW Blecher et al. 30 9/8/2020 Australia Commentary Workforce flexibility Evanoff et al. 31 25/8/2020 United States Survey Mental health concerns from high-risk setting Alquezar-Arbe et al. 32 1/9/2020 Spain Survey Lack of PPE and training Wahlster et al. 33 11/9/2020 International Survey Lack of PPE and critical care staff Kavanagh et al. 34 7/11/2020 United States Commentary Healthcare system factors that worsened the pandemic Roberts et al. 35 7/11/2020 United Kingdom Survey Anxiety and resilience in nursing staff Brophy et al. 36 11/11/2020 Canada Qualitative Lack of PPE and trust Lee and Lee 37 3/12/2020 South Korea Qualitative Lack of planning Metogo et al. 38 11/12/2020 Cameroon Health service Lack of ICU capacity in Africa Ceri and Cicek 39 15/12/2020 Turkey Survey Mental health risk factors for HCW Wilson et al. 40 4/1/2021 United States Health service Planning for HCW capacity Rieckert et al. 41 6/1/2021 Netherlands Review Practical recommendations for HCW Lau et al. 42 16/1/2021 Singapore Survey Danger at work and responsibility Gemine et al. 43 28 

Review papers included systematic reviews on nursing experience from past viral pandemics 14 and mental health problems in HCW during COVID-19. 52 A scoping review of working conditions in past pandemics developed practical recommendations for both planning periods (education, training) and surge periods (psychosocial support, attend to intensity of work patterns). 41 A retrospective review emphasised the importance of multidisciplinary clinical teams. 53

The Australian COVID-19 pandemic in 2020 had two main waves of infection. The first case was detected on 25 January 2020 in a patient recently returned from China. 56 Cases rose rapidly over the next few weeks, largely in returning travellers and the Australian government shut down borders in a staggered fashion, initially for returnees from China and then Iran and other countries before fully closing the borders to international arrivals in late March 2020. 57 Borders remained closed to international arrivals for many months with mandatory quarantine in place for the small number of returning travellers. At the time of writing, vaccination is mandatory for international arrivals unless a valid medical exemption is held. Hospitals around the country began planning for response in February 2020 with marked acceleration before the shutdown of essential services and elective surgery at the end of March 2020. Sydney in New South Wales was the epicentre of the first wave in April 2020 58 and for many hospital-based respiratory physicians, work requirements changed rapidly, with the introduction of COVID-19 teams to staff COVID-19 wards and government modelling that indicated likely rapid surges in caseload to match international experience. Multiple meetings addressed the pressing issues, such as access to PPE, sufficient training in infection control, the mapping out of 'hot' zones, ICU surge capacity and redeployment of staff. Many hospitals provided upfront psychological support, which surprised us with its value. By the end of May, the curve had flattened and work rosters were returning to previous arrangements. Subsequent outbreaks developed, largely related to leakage from hotel quarantine. These occurred predominantly in NSW where an area of Sydney went into lockdown over December 2020 and January 2021 and in Victoria, where several further lockdowns were instituted in mid-late 2020 and early 2021. Australia's third major wave of COVID-19 cases started in mid-2021, again from quarantine leak. This wave, involving the Delta variant of the SARS-CoV-2 virus, resulted in rapid case escalation, pressure on hospital systems, statewide lockdowns in NSW and Victoria and accelerated vaccination uptake. It also led to a change in long-term strategy in some Australian states, moving from elimination to containment. From the international perspective, Australia has still been lightly hit by the pandemic, a fact well recognised by the local healthcare community and general population. Nonetheless, the impact of preparation and implementation on HCW, concomitant fear and anxiety and the need for retraining (in PPE, infection control and critical care) poses a challenge to the system that warrants evaluation for ongoing and future responses. Additional difficulties with vaccination rollout, including perceived delays to subgroups, such as junior medical officers in the initial phase, lack of supply and complex messaging about options have also contributed to stress, anxiety and controversy. Australia's mass vaccination programme resulted in national levels of adult vaccination above 90% 59 by the end of 2021. However, a further wave of infections related to emerging viral variants and easing of restrictions developed in Australia's eastern states and at the time of writing, has led to further pressure on healthcare systems and HCW, with a distinct shift away from lockdowns and severe restrictions at government policy level.

As the pandemic has progressed, Australia has gone through different phases, including intense rapid preparation (early 2020), management of first and second waves (mid-late 2020), the delta wave (mid-late 2021) 55 2/9/2021 Australia Survey Impact of occupational disruption on HCW mental health † Hill et al. 3 9/9/2021 Australia Survey Factors affecting HCW willingness to work RACP 4 November 2021

Australia Survey Impact of COVID-19 on HCW work and wellbeing †Australian COVID-19 Frontline Healthcare Workers' Study. ED, emergency department; HCW, healthcare workers; ICU, intensive care unit; Int., international; PPE, personal protective equipment; RACP, Royal Australasian College of Physicians; Syst., systematic. (end-2021) . The demands of each phase have called on various areas of subspeciality expertise and service provision. The pandemic has required at different times and in varying intensity such elements as public health measures, expertise in intensive care and respiratory medicine, infection control and governmental social supports. COVID-19 is primarily a respiratory disease, but its high infectivity mandates infection control expertise and training. Initial belief about droplet spread as the main cause of transmission emphasised traditional infectious disease expertise; subsequent evidence for aerosol spread gave more weight to respiratory expertise. 60 Concerns about aerosol spread from routine treatment of respiratory failure (such as non-invasive ventilation and high-flow oxygen) need to be addressed by relevant expertsin respiratory medicine, intensive care and infection control. Given the high risk of severe disease in the elderly, expertise in geriatric medicine is required to address the specific needs of this group, including delirium and appropriate end of life care. 61 As may be the case for other respiratory infections, management of COVID-19 disease and the public health impact of the SARS-CoV-2 pandemic has many strands and requires multidisciplinary teams, strategies and collaboration between craft groups.

From the literature reviewed, we have explored possible directions for future respiratory pandemic responses. The papers reviewed have highlighted the benefits of interaction between multiple disciplines, including redeployment of physician staff and cross-matching of skillsets 47 and tiered staffing models to maximise critical care physician capacity. 45, 53 Availability of clinical resources affected HCW as they adapted to the needs of the pandemic, including PPE, 7, 11, 20, 23, 32, 33, 36 ICU surge capacity 19, 21, 24, 45 and system factors, such as workforce flexibility 30 and shift structure. 28 We anticipate benefits from involving pivotal craft groups, such as respiratory physicians in developing plans for critical clinical resources in this and future pandemics. The need for retraining was made apparent in a number of studies, particularly for critical care skills 15, 26, 53 and infection control. 12, 15, 23 Many of the studies focussed on HCW mental health and well-being, highlighting factors that contributed to anxiety and stress, including the need to work in a high-risk setting, 4, 6, 8, 10, 18, 25, 27, 29, 31 burnout, 43 concerns about preparedness and planning 9, 17, 32, 33, 37, 40, 44, 48 and the need for psychosocial support. 41 

The COVID-19 pandemic presented HCW around the world with new challenges. The rapid re-organisation of the Australian workforce was stressful, worsened by the fear and anxiety generated by initial reports from overseas. The literature on HCW preparedness identifies risk factors for mental health problems, such as anxiety and depression; these include most prominently the risk of infection as well as lack of support and inexperience. In the second year of the pandemic, most HCW have had access to vaccination and have had more time to organise and to prepare mentally. Concerns persist about access to resources, such as PPE and critical care capacity as well as staff shortages and the need for retraining. Many studies identified a combination of fear and commitment within HCW who stayed in their roles despite their worries. The supply of clinical resources, such as PPE, ventilators, drugs, vaccines, are likely best handled at government level, but clear communication with HCW craft groups and professional societies may help improve trust in the periods of intense preparation. Many studies have found that lack of trust with worries about personal and family safety and inadequate training contributed significantly to poor mental health in HCW through the first year of the pandemic. In Australia, as elsewhere, the challenges of mass vaccination have figured highly. HCW may also benefit from greater representation in pandemic response planning, particularly between institutions and in liaison with the government.

Based on this evidence and on experience from the COVID-19 pandemic to date, we make several recommendations for Australia's respiratory workforce to address future pandemic demands:

1 Greater respiratory medicine and multidisciplinary representation in groups that manage demand and supply of clinical resources. 2 Closer liaison between respiratory physicians and healthcare/government leadership in developing pandemic response planning both prior to and during outbreaks. 3 Upfront retraining for respiratory physicians who are prepared to participate in any pandemic response, with an emphasis on infection control and critical care skills. 4 Awareness of mental health requirements for all HCW for future pandemic responses.

These recommendations primarily address HCW concerns about safety in a high-risk work environment as the dominant factor contributing to stress and may apply equally to other groups in other phases of the pandemic around the world. Future pandemic responses will also need to address the impact on usual healthcare activity, diversion of resources, deployment of staff to pandemic responses and HCW shortage due to isolation and furlough. Respiratory physicians, while developing interdisciplinary skills and collaborative links, will continue a likely central role in this and future respiratory pandemics.

Coronavirus in Italy -Report from the Front Lines

High levels of psychosocial distress among Australian frontline healthcare workers during the COVID-19 pandemic: a cross-sectional survey

Willingness to work amongst Australian frontline healthcare workers during Australia's first wave of Covid-19 community transmission: results of an online survey

Results of RACP member survey: "are you COVID-19 safe?" -a full report

COVID-19: protecting health-care workers

Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: a crosssectional study

The spread of novel coronavirus has created an alarming situation worldwide

Psychological status of medical workforce during the COVID-19 pandemic: a cross-sectional study

Is Pakistan prepared for the COVID-19 epidemic? A questionnaire-based survey

Addressing general surgery residents' concerns in the early phase of the COVID-19 pandemic

Respiratory protection considerations for healthcare workers during the COVID-19 pandemic

COVID-19: how prepared are front-line healthcare workers in England?

Preparation and response to COVID-19 outbreak in Singapore: a case report

Implications for COVID-19: a systematic review of nurses' experiences of working in acute care hospital settings during a respiratory pandemic

Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies

Building the pyramids: a perspective on creating and upscaling a critical care workforce at a public hospital during the coronavirus disease

COVID-19: results of a national survey of United Kingdom healthcare professionals' perceptions of current management strategy -a cross-sectional questionnaire study

Posttraumatic stress symptoms of health care workers during the corona virus disease

Hospital preparedness for COVID-19: a practical guide from a critical care perspective

Concerns of frontline doctors in India during COVID-19: a cross-sectional survey

Critical care and emergency department response at the epicenter of the COVID-19 pandemic

Quality improvement tool for rapid identification of risk factors for SARS-CoV-2 infection among healthcare workers

Assessment of healthcare workers' levels of preparedness and awareness regarding COVID-19 infection in lowresource settings

COVID-19 and disruptive modifications to cardiac critical care delivery: JACC review topic of the week

Exploring stress coping strategies of frontline emergency health workers dealing Covid-19 in Pakistan: a qualitative inquiry

Lessons learned and experiences shared from the front lines: United Kingdom

Experiences of frontline nurses combating coronavirus disease-2019 in China: a qualitative Stone et al

Ltd on behalf of Royal Australasian College of Physicians. analysis

Impact of healthcare worker shift scheduling on workforce preservation during the COVID-19 pandemic

Monitoring approaches for healthcare workers during the COVID-19 pandemic

Crisis as opportunity: how COVID-19 can reshape the Australian health system

Work-related and personal factors associated with mental well-being during the COVID-19 response: survey of health care and other workers

Impact of the COVID-19 pandemic on hospital emergency departments: results of a survey of departments in 2020 -the Spanish ENCOVUR study

The coronavirus disease 2019 pandemic's effect on critical care resources and health-care providers: a global survey

COVID-19: through the eyes through the front line, an international perspective

Levels of resilience, anxiety and depression in nurses working in respiratory clinical areas during the COVID pandemic

Sacrificed: Ontario healthcare workers in the time of COVID-19

South Korean nurses' experiences with patient care at a COVID-19-designated hospital: growth after the frontline battle against an infectious disease pandemic

Anaesthesiologistintensivist physicians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective

Psychological well-being, depression and stress during COVID-19 pandemic in Turkey: a comparative study of healthcare professionals and nonhealthcare professionals

Using state licensure data to assess North Carolina's health workforce COVID-19 response capacity

How can we build and maintain the resilience of our health care professionals during COVID-19? Recommendations based on a scoping review

Prepared and highly committed despite the risk of COVID-19 infection: a cross-sectional survey of primary care physicians' concerns and coping strategies in Singapore

Factors associated with work-related burnout in NHS staff during COVID-19: a crosssectional mixed methods study

A health worker knowledge, attitudes and practices survey of SARS-CoV-2 infection prevention and control in South Africa

Adequacy of workforce -are there enough critical care doctors in the US-post COVID?

Psychological distress during the acceleration phase of the COVID-19 pandemic: a survey of doctors practising in emergency medicine

Deploying the physician workforce during a respiratory pandemic: the experience of an academic teaching hospital during the COVID-19 pandemic

Infection control professionals' and infectious diseases physicians' knowledge, preparedness, and experiences of managing COVID-19 in Australian healthcare settings

Well-being and resilience among health care workers during the COVID-19 pandemic: a crosssectional study

On the frontline treating COVID-19: a pendulum experience-from meaningful to overwhelming-for Danish healthcare professionals

Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: an exploratory qualitative study

Mental health outcomes among health-care workers dealing with COVID-19/severe acute respiratory syndrome coronavirus 2 pandemic: a systematic review and meta-analysis

The Mount Sinai Hospital Institute for critical care medicine response to the COVID-19 pandemic

Moral distress and perceived community views are associated with mental health symptoms in frontline health workers during the COVID-19 pandemic

Occupational disruptions during the COVID-19 pandemic and their association with healthcare workers' mental health

Australian Government Department of Health. First confirmed case of novel coronavirus in Australia. Australian Government Department of Health

Australia's COVID-19 response: the story so far. Melbourne: Grattan Institute

Australian Government Department of Health Coronavirus (COVID-19) at a glance. Australian Government Department of Health

Australian Government Department of Health. Vaccination numbers and statistics. Australian Government Department of Health

Airborne or droplet precautions for health workers treating COVID-19?

Commentary: special care considerations in older adults hospitalized with COVID-19

© 2022 The Authors

Open access publishing facilitated by University of New South Wales, as part of the Wiley -University of New South Wales agreement via the Council of Australian University Librarians.