Context.

This phase involved a rapid response by HWs and the healthcare system to the emerging pandemic. It meant rapidly changing ways of working and caring for patients, mostly by reducing contact to prevent transmission and freeing up resources for COVID-19 care (e.g., limiting/stopping non-essential care). It also involved dealing with insufficient pandemic preparedness (e.g., limited PPE), mobilising resources (e.g., redeployment), and significant uncertainties related to the unknown pathogen and unfamiliar situations. This contributed to increased stress from the perceived risks, changing roles, and multiple impacts on the health of patients, HWs and their families.

Everything changed so quickly. [Taren, May ‘20]

It was just at all cost to try and keep these people alive if you can and so, yeah, it felt very–it felt how you could imagine being in a war zone, just get on with it. [Dylan, June ‘20]

Impact on roles and care.

Shifting responsibilities and redeployment. The emergence of the pandemic led to changes in participants’ responsibilities. Those in senior roles focused on planning and managing the response, and reorganising care delivery, and stopped any non-priority tasks (e.g., providing specialty training). There was also a shift in the type of clinical work: non-urgent and routine care was paused, replaced by COVID-related care. General practitioners (GPs) were identifying and contacting clinically vulnerable patients instructed to self-isolate, and ‘correcting’ the lists of those notified centrally by the NHS; dealing with increasing psychological and social (e.g., domestic, alcohol-related) issues during a national lockdown; focusing on palliative care, do-not-resuscitate orders and concerns about ethical issues; and working in COVID-19 clinics/hubs. In emergency departments, clinicians reported shifting to fully clinical work, dealing with administrative and managerial work in their own/extra time. In hospitals, non-urgent care stopped, many patients were discharged, and HWs focused on preparing and then dealing with increasing numbers of patients with COVID-19.

In the absence of usual care, some HWs described having less work and some volunteered, or were selected, for redeployment to support COVID-19 and intensive care. Some participants described working with more responsibility (e.g., covering for shortages of more senior HWs), and some described feeling like they moved into junior roles due to the lack of specific skills needed in the area in which they were redeployed.

I’ve gone from being quite senior and confident in my role and able to do my job quite comfortably to feeling like a student nurse again. (…) I wonder if they could have provided some training to upskill me so I could have been more useful in the clinical area that I am redeployed now. [Carmen, April ‘20]

Those redeployed to intensive care units (ICUs) or COVID-19 wards described significant pressure and stress related to inadequate communication and training, unpredictability of work tasks, and unfamiliarity with the team and environment. For example, Carmen described how, after volunteering for redeployment in a Nightingale hospital and attending required training, she received no communication and ended up waiting at home, feeling anxious about loss of pay, until she asked to return to her previous ward.

New skills and training required. Changed ways of working, social distancing, infection prevention measures, and the new focus of participants’ roles meant that they required new skills and training. GPs required new skills for managing patients remotely, describing concerns about making clinical decisions, risks of missing serious illnesses, and inability to refer patients to specialists. Participants from emergency departments and hospitals reported some (but insufficient) training related to COVID-19 and found managing patients with COVID-19 difficult due to multiple symptoms and little evidence on management. Those redeployed to ICUs perceived training for their new role as inadequate, that their existing skills were not utilised, and that they lacked specialist skills (e.g., using ventilators) which made them depend on guidance from busy ICU nurses which potentially posed risks to patients.

…we were given four hours [of training] and then two supernumerary days and then you were expected to take [a] patient. Now I take an intensive care patient on ventilation and [Extracorporeal membrane oxygenation] when I’ve never had experience in looking after those, so I think people were just worried about the fact that they could possibly harm others, just having to deal with the stress and pressure of essentially keeping someone alive when you don’t really… it’s sort of like flying a plane and not knowing what to do. [Dylan, April ‘20]

Participants also described challenges of communicating with families about end of life care and deaths by telephone and in PPE, which was new to their role.

Challenges in patient care. With reduced contact from patients and suspension of non-urgent care, GPs were concerned about a build-up of unaddressed health issues and how this would be judged in the future. Those in emergency departments described being used to provide care under pressure but then felt helpless with little that they could do to help so many patients and staff with COVID-19 symptoms. They also reported keeping patients longer in the emergency department rather than admitting them to reduce the demand for beds.

In hospitals, nurses were concerned about not being able to provide as high a standard of care during the pandemic as they would like and finding it difficult to prioritise patient dignity; for example, due to caring for multiple patients simultaneously or time pressure.

…it definitely felt that it was potentially unsafe in periods of time, which I know a lot of units are feeling the same and I know we’re essentially trying to almost work in war-like conditions where you’re trying to save lives, but it is quite hard when you’re used to giving really good care to a very high standard with all that holistic care. [Theresa, May ‘20]

They also described the impact of patients being alone in the hospital and relatives unable to visit, increasing loneliness, stress, and communication challenges. Some participants described efforts to compensate for the restrictions by trying to enable communication with families; for example, staff used their own phones to contact families, information centres and equipment were set up to facilitate communication, and then single visitors in PPE (required to self-isolate afterwards) were allowed for dying patients.

…staff were using their own phones to phone the relative of someone who’d just been brought in with an ambulance, to say goodbye to them because they were going to die. …we now have a supply of tablets… [for patients to] stay in contact because we will only allow visitors, because of risk of infection, if someone is truly terminally ill. [Nick, April ‘20]

Impact on health and wellbeing.

Perceived risk of COVID-19 and impact on others. Participants described different influences on their perceived risk of COVID-19. Inadequate PPE and seeing other HWs admitted with, or dying from, COVID-19 seemed to increase a sense of risk, whereas considering themselves young and healthy seemed to mitigate participants’ concerns. Participants assumed that they would get (or had already had) COVID-19 at some point. Some highlighted the variety of responses among fellow HWs related to perceived risk and, consequently, decisions in how they were prepared to care for patients. Some described risk as part of their role (‘vocation’) as HWs but that it should be mitigated by adequate protective equipment.

…we do sign up to risk and that’s why in a sense the healthcare worker deaths in some ways in fact well that’s what we signed up for. But I guess if I was in the military, the irritation was if you didn’t have the right equipment, you’d be pissed off if you all died. Whereas if you have the right equipment, that’s just what you sign up to. [Nick, April ‘20]

Participants described being more concerned about posing a risk to others and accidentally passing COVID-19 at work, home or a supermarket. Some discussed other HWs staying in hotels to protect their families but considered the unknown timescale of the situation as a challenge to such a decision.

Tiredness and emotional weariness. With the increased stress and working hours by mid-April participants described tiredness and emotional weariness among HWs. Some highlighted awareness that this might become a long-term challenge as they expected the pandemic to continue to put pressure on the healthcare system.

It’s hard and [staff] are getting tired. And it has only just started. [Nick, March ‘20]

Hot weather in May caused discomfort and dehydration among HWs working in full PPE, impacting on physical and mental health. Further, while participants reported that some support was available in their organisations (e.g., online resources, ‘wobble’/wellbeing rooms and counselling in hospitals), they described not using these resources due to lack of time or the impracticality of accessing them during work-time. Most referred to relying on support from colleagues (e.g., professional/team ‘WhatsApp’ groups), families, and friends. However, some described avoiding offloading to family/friends because they were also stressed and may not understand HWs’ experience.

I couldn’t even speak to someone without bursting into tears or just the despair of the situation, thinking this is like nothing I’ve ever–I mean I’ve been nursing for 30 years, I’m not new to this business. But it was pretty horrific. [Theresa, May ‘20]

Experiencing patient/public attitudes. Participants experienced patients as understanding of limited services and grateful to HWs. They appreciated, but found unexpected, expressions of gratitude towards and support for HWs (e.g., providing free meals to hospital HWs).

…you’re definitely getting more of a mention or you’re getting more messages of support and things like that which is really nice… I’ve been a nurse for 10 years and I don’t think I’ve ever… two best friends I don’t think I’ve ever got any kind of like ‘oh do a great job’ or whatever, and then now they’re like oh you… so, it’s really quite funny how that’s changed. [Dylan, April ‘20]

Participants described how initially in the pandemic patients seemed to limit contact with healthcare services and wanted to leave the hospital as soon as possible. Later in this phase, GPs reported more patients contacting them and being ‘tetchy’ about reduced care and problems with referrals.

Context.

Following the peak of the first wave of COVID-19 in the UK in April 2020, the numbers of patients in emergency departments and hospitals started to gradually decline, whereas they were increasing in general practice. Participants described being ‘in transition’ between an emergency and a normal state–or rather ‘new normal’ as some measures introduced in phase 1 remained in place. This phase involved reflecting on and consolidating the experiences and lessons from the first phase, and planning and preparing for autumn/winter season driven by concerns about the potential double pressure of COVID-19 and other winter demands on healthcare system.

I’ll be okay in another environment with a week off to try and kind of regroup and get some help, get some strategies in place, and then see where we’re at. [Theresa, end of May ‘20]

It feels normal actually. The only weird bit is another feeling of being in transition so are we transitioning out of being hyper vigilant down to something more relaxed so it’s not static but it’s not uncomfortable. [Bonnie, August ‘20]

Impact on roles and care.

Gradual return to usual care and responsibilities. In this phase the main focus was on safely resuming non-COVID care, specialist referrals and elective surgeries. With the gradual return of usual care, HWs across all settings slowly returned to their typical responsibilities, including administrative tasks and management meetings that stopped during the crisis. Although GPs reported little change in their roles and continuing with primarily remote triage and consultations, they discussed seeing more patients face-to-face if needed (after triage). Emergency departments’ doctors described being back to a more usual type and amount of work, continuing with long clinical shifts. In hospitals, redeployed participants started returning to their old roles, and specialty training was later reintroduced. However, some described the changes as slow due to being ‘on standby’ in case COVID-19 cases surged again, and were concerned about limited communication and access to training.

There’s been I would say much more frustration from people now when they’re feeling like things have been changed aren’t really being reviewed in a timely manner to change back. [Taren, May ‘20]

Sense of professional development and improvement in services and care. Participants reflected on their new skills and confidence developed during the emergency phase. GPs seemed more comfortable combining remote and face-to-face consultations when needed, which helped alleviate their concerns from phase 1 about providing sub-optimal care. Redeployed participants described feeling more confident with new skills and insights; for example, Dylan described realising that he was not suitable for ICU work but with the new confidence and self-awareness he subsequently applied for a new role with more community work.

Participants across settings also described some improvements in services and care resulting from the emergency phase, e.g., in IT systems and use of technology, end-of-life and palliative care, communication between teams, and patient flows. However, some were also concerned that some of the positive changes (e.g., less burdensome paperwork) were waning.

One of the best bits about COVID was just doing it… and not getting stuck around all the bureaucracy, and it feels very much like all the bureaucracy has come back as well. So one lesson that the government need to take away is that organisations drown in the paperwork. [Linda, July ‘20]

Participants described patients as more willing to contact healthcare services with non-COVID issues, and to stay in hospitals longer as needed. In emergency departments and hospitals, with fewer patients with COVID-19, participants reported being able to spend more time with patients and give better care.

I genuinely think that when the numbers got less and it was quieter we were able to do a better standard of care (…) when you slowed down, you gave them more encompassing, like sort of pathway of care for your patient. Things like my documentation and the notes got more detailed, more thorough because I just had more time to do it and so all those things improved. [Kyle, May ‘20]

Learning and preparing for future. Despite some improvements, participants recognised that the pre-pandemic challenges remained or worsened during the pandemic (e.g., staff shortages, delayed referrals). They highlighted the need to reflect on and learn from the experience of the first phase/wave, reporting staff debriefs and resumed quality improvement initiatives. However, some expressed concerns whether the right conclusions were drawn.

We did debrief today… Some of it was interesting because it was learning from what has been done well and what has been done badly, but as always with these senior meetings, there’s an awful lot of, ‘This was all done really well’, and then you’re always slightly careful bringing up what’s done badly so that you don’t piss off the powers that be… [Nick, June ‘20]

Moreover, participants were concerned about the potential impact of COVID-19 (‘small spikes and hopefully not… a second wave’ [Nick, June ‘20]) and seasonal pressures, and the need to plan and prepare for winter. Nevertheless, planning was seen as very challenging due to many uncertainties.

Redeployed participants described the need for training for those who might be redeployed again in the next wave; although some described it as insufficient or unavailable to them. Overall, participants described feeling more prepared to manage surges of COVID-19 given their experiences, and some measures and processes established in phase 1, as well as some preparations undertaken in phase 2.

I think that they’ve prepared a bit better this time. …the people who have been redeployed we’ve got our learning needs and we need to be, they need to be attended to. Whereas in the first time around, I felt that I was thrown into the deep end. [Carmen, November ‘20]

Impact on health and wellbeing.

Frustration with working conditions. Some reported feeling disillusioned with debriefs and frustrated that, despite the appreciation for HWs during the first phase/wave, the working conditions were not improved. They discussed how recognition of HWs was needed in terms of better resources and working conditions rather than symbolic gestures.

I thought that they really didn’t care about us. And that it wasn’t very fair. And like getting shampoo and a toothbrush from charity is wonderful, it’s a very good touch, because they, they bring us like goodie bags… which is brilliant and I really appreciate it, but I just wanna see something essential to us. I mean, I can buy shampoo, yes, it’s a freebie, wow, very nice, I really appreciate it, but it’s not gonna sort my actual problem. [Claire, July ‘20]

Partial recuperation. Over the summer participants described taking short breaks from work, which helped them partially recharge and re-energise. However, insufficient staff to cover absences meant that time off work was too short to fully recover. Participants in management roles described the need to negotiate different priorities, be sensitive about what they can ask of staff, and ensure that there is enough good will and motivation among HWs.

…we can’t give the whole practice an extra week’s leave… if we don’t do that, we’re certainly gonna face the most uncertain future we have with a bunch of staff that we’ve lost all the goodwill from. …it would be a disaster if people start deciding they’re gonna phone in sick anyway because of leave that they haven’t had. [Nathan, September ‘20]

Concerns about risk of complacency and the future. Later in this phase participants described how everything felt almost normal and, consequently, reported some risk of complacency about infection prevention measures among HWs and patients. The latter part of this phase was characterised by expectations of the next wave of COVID-19. Some participants described the stress of this uncertainty and anticipation, and anxiety about the future.

Context.

The third phase started with the increasing numbers of COVID-19 cases in September 2020 leading to the second wave (peaking in November 2020 and January 2021). Initially the main focus was on continuing COVID-19 and non-COVID care. However, due to many COVID-19 cases, as in phase 1, it became impossible to continue with non-COVID care. In January 2021 there were capacity concerns in hospitals, and more patients with COVID-19 presented in settings originally less affected during phase 1 (e.g., obstetrics). There was a sense of disbelief with the situation, which participants described as ‘a mess’, ‘chaos’ and ‘surreal’. There was also a sense of exhaustion as HWs tried to ‘survive’ this phase.

I only started [redeployment to ICU] in the first week of January and by that time it was already chaos. (…) It’s very surreal and sometimes when I finish work and I come out to the street, and I just try to think about what has happened on the previous eight hours, it feels very surreal. [Carmen, January ‘21]

Impact on roles and care.

Shifting responsibilities and redeployment. During this phase participants reported having to juggle an increasing number of responsibilities, trying to avoid the negative impacts on care that had happened in phase 1. GPs reported being very busy with high demand and workload, continuing to provide usual care, and planning and then delivering COVID-19 vaccinations. GPs and emergency departments’ doctors reported dealing with ever-increasing and more severe mental health issues of patients.

Those who were (or volunteered to be) redeployed in phase 1 reported not wanting to be redeployed again due to negative experiences. However, once redeployed again, their experience seemed to be slightly better than in phase 1. For example, Carmen reported being able to work partly in her usual role and partly redeployed to ICU, administering care that she felt more comfortable with. Dylan and Claire also reported being redeployed to ICUs in January but in more-suited roles, upskilled, and on a rotational basis which meant they could get a break from it occasionally.

I have been upskilled to help with ICU, for example, as a dietician, mainly. (…) it’s great for us, we do less on our computer and I guess we help [ICU nurses] out in the meantime, we eyeball patients that we’re worried about, we ask them if there is anyone who is not intubated… So it’s quite good, I think. [Claire, January ‘21]

Balancing COVID-19 and non-COVID care. Unlike in phase 1, participants described intending to continue with providing COVID-19 and usual care.

The big thing that I was afraid of was missing the other stuff that was happening in the community. I don’t know if it’s a lesson learnt so much as an improvement first wave to second wave but we’re able to filter the COVID stuff out and do the normal stuff now. [Fiona, October ‘20]

However, as hospitals filled up with patients with COVID-19, participants reported that non-COVID care became impossible, specialities ‘ceased to exist’ and their focus was again fully on COVID-19 care. Participants described many HWs, and at times whole teams, having to self-isolate due to actual or suspected COVID-19 infections (e.g., through contact tracing). In December and January, there were concerns about capacity and under-staffing.

There was probably a need for extra help about two weeks ago but somehow we sort of managed to get by and survive but I think there were calls for like army to come in and help out because we just needed hands. [Dylan, January ‘21]

The quality and humane aspects of care were again difficult to maintain. HWs had to deal with high death rates, communicating with families about patients’ death remotely, and difficult decisions balancing risks and priorities. Moreover, participants who described their areas as less or little affected in the first phase/wave reported experiencing the impact of COVID-19 more in this phase. For example, Maggie described caring for mothers and babies with COVID-19 in neonatal care, and how new measures needed to be taken to balance risks and complications. In these ways, despite preparation in phase 2, the experience of providing care in phase 3 seemed even worse than in phase 1.

There is nothing that can prepare you for what is happening now… Now it’s totally unmanageable. [Carmen, January ‘21]

Concerns about long-term impact of unceasing pressure. In late January 2021 participants reported declining numbers of patients and easing of the pressure on healthcare services. At the same time, they recognised the need for measures to limit and manage COVID-19 to remain in place longer-term and to consider COVID-19 as endemic rather than an emergent disease.

Challenge? I think it’s going to be neo-normalisation… getting used to managing endemic COVID and non-COVID services at the same time. [Nick, end of January ‘21]

Participants expressed concerns about the impact of continuing long-term high pressure and workload on HWs and healthcare services, and the necessity of some easing of the pressure and rest for HWs (‘People need a break, otherwise people will really break.’ [Nick, January ‘21]).

February is a time where we normally begin to see the end of a winter surge, but in the last few years, there’s been no difference between winter and summer. Last year obviously has skewed that and been different totally, but the worry for me is that we don’t get that down-time and we just carry on at the pace that we’re at now, because I think we won’t survive next winter …if we don’t get some down-time… if people don’t have an opportunity to have a proper holiday, and going into next winter, I think it absolutely is going to have issues for the team. [Linda, February ‘21]

Impact on health and wellbeing.

Changed perceptions of risk of COVID-19. During this phase, participants again reported different factors affecting their sense of personal risk of COVID-19. They perceived the risk as lower due to improved PPE and COVID-19 testing. Most had COVID-19 at some point during the year and this, together with positive antibody test results, made them feel safer. Later in winter, receiving COVID-19 vaccines also contributed to a sense of lower risk. However, they also acknowledged that it was still unclear how to best protect HWs. A higher sense of risk was reported by a participant after their birthday (making them more aware of the age-related risk) and by two participants who became pregnant and thus started to protect themselves by working from home.

Exhaustion and resignation. Under-staffing, many patients, and high workload led to exhaustion during this phase. Participants’ mental health was also impacted by the traumatic experience of phase 1, worry about being redeployed again, and seeing many patients die. For example, Theresa described ‘flashbacks’ from the first redeployment, problems sleeping, and anxiety. While in phase 1 HWs were mobilised by the ‘adrenaline’ of responding to the emergency, during this phase participants described feeling exhausted, and some–depressive.

…where last time we were − you get the adrenaline going, you feel you’ve got work to do, and everyone was going above and beyond and more, but I think now, I’m sure we’ll do that again, but I think the difference is we’re really tired. Really exhausted. A lot of us have very bad memories of that time and don’t really want to go back to that period of time, and I think that’s the big worry. [Theresa, October ‘20].

I feel emotionally and physically exhausted. My patient died on Monday, he was only 44 and then it’s just very tough. [crying] (…) It’s very tough and it’s affecting us. I think we’re all really down. [Carmen, January ‘21]

Participants seemed resigned, describing how they had to continue working while trying to endure—‘self-preserve’ and ‘survive’. Unlike in phase 1, during this phase some participants talked about needing or taking up more formal support, such as counselling.

I’ve reached the point that I do need [support] because I’m waking up in the middle of the night thinking of my patients… There is emotional support but I’m not sure why I’m not accessing it. I think I need to do it now… I need to start off-loading all of this because I’m feeling quite burnt out. I just need to find the time and the space to do it. [Carmen, January ‘21]

Experiencing changed patient/public attitudes and behaviour. Finally, participants described experiencing a change in patients’ attitudes and behaviour: from the initial understanding and appreciation during the first phase/wave, patients increasingly complained about delays, limited services and were less concerned (‘blasé’) about COVID-19 and preventive measures during the second wave (phase 3). Participants expressed feelings of frustration with the public perceived as ‘forgetting’ about COVID-19, and the Government perceived as failing to prevent the high numbers of COVID-19 cases and hospitalisations.

[The Government] waited right up until that last weekend before Christmas and I think the damage was done then already. (…) Last time it was accepted because it came out of nowhere and people were just surprised by it… And then this time round, people are just breaking the rules so then that puts pressure on us and I guess then you build up this kind of different attitude towards how you care for people. You care for them all the same but psychologically you’re just like ‘what is this’. (…) So when you read about people going to lockdown parties, visiting people on Christmas and whichever, I think people are finding it harder to be as empathetic to them. [Dylan, January ‘21]