Work health and safety issues including policies/guidelines

We don’t want to be heroes. We just want protection in line with OHS standards. (GP, Victoria)

HCWs felt that they deserve ‘the same occupational health and safety demanded in any other industry’ (anaesthetist, VIC) and that ‘with community transmission rates climbing, subpar PPE is just unacceptable’ (trainee doctor, VIC). HCWs highlighted the mining and asbestos removal industry where ‘no worker can work without the appropriate respirator’ (nurse, WA). HCWs perceived guidelines derived from the WHO to be ‘woefully inadequate…[with] studies showing the virus to be airborne since March, whereas WHO only got on board in July’ (general practitioner, QLD). This WHO position gave ‘managers and hospital executives an excuse to lower the standard of PPE to a surgical mask, face shield, and apron’ (nurse, WA) with HCWs noting ‘very poor leadership from executive’ (doctor, VIC). Many perceived that guidelines were ‘dictated by resources and not staff safety’ (nurse, QLD) and that Australia has ‘waited until our own staff got sick and intubated before we very gradually changed the PPE quality supplied to staff in Australia’ (doctor, VIC).

HCWs decried that ‘staff becoming sick is unacceptable’ (nurse, TAS) and ‘having any fellow HCWs at the same health network with confirmed COVID is far too many’ (doctor, VIC). They asked, ‘since when was it acceptable for miners to die from preventable OHS accidents? Never - so don't make it acceptable for HCWs’ (doctor, VIC) noting that ‘We give everything for our patients, but we don't expect to have to give our lives’ (nurse, TAS).

The approach to occupational safety was, ‘reactive not proactive as numbers began to grow’ (nurse, VIC). Instead of introducing ‘PPE appropriate for airborne transmission, and scale back if required’ (doctor, VIC), policies dismissed precaution and were ‘dragging their heels … Adopting the cheapest PPE instead of the most suitable’ (paramedic, VIC). Respondents drew a comparison with SARS, where ‘respiratory protection was upgraded well before the evidence-based studies regarding respiratory protection “proved” that aerosol spread was occurring which saved hundreds of HCW lives’ (physician, TAS).

Opportunities had been squandered given, ‘Australia had so much time to learn from the experiences overseas’ (nurse, TAS). Instead we ‘lost valuable time to prepare for this pandemic due to government and department effective obstructiveness’ and did not consult broadly enough, ‘occupational medicine doctors should have been involved in expert groups from start to prevent workplace outbreaks’ (occupational medicine physician, WA). HCWs recognised the threat to health system functionality where asymptomatic patients who had ‘moved across many areas of the hospital’ could cause an outbreak ‘affecting hospital flow and productivity’ (midwife, VIC).

Issues with PPE: access, quality, appropriateness and training

Protect us PROPERLY so we can protect you! (Nurse, Western Australia)

Despite HCWs being ‘essential’, a lack of or limited supply of PPE was reported across Australia. Respondents emphasised that they ‘need PPE in our practice consult rooms, not in a “National Stockpile” thousands of kilometres away!’ (doctor, QLD). The lack of availability of PPE had led to rationing, with PPE being ‘locked in cupboards’ (doctor, NSW) and respondents being ‘directed to store surgical masks in a plastic bag and reuse them for the same patient on multiple occasions’ (doctor, NSW). PPE had quality issues with ‘gowns that tear easily, surgical mask quality is often poor’ (nurse, WA), masks that ‘often require a tremendous amount of “MacGuyver-ing”’ but still ‘slid down, exposing my nose’ (trainee doctor, VIC), ‘poorly fitting ear loop ones’, which affected critical manoeuvres where ‘several colleagues had to remove eye protection as they kept fogging up’ (surgeon, NSW).

Fit for purpose PPE was important particularly for first responders where they ‘do not function in a controlled environment’ and ‘face wind, weather, manual handling of infected patients, difficult extrications, patient lifts, carries, and sit centimetres from patients in confined spaces’. Gowns were prone ‘to billowing in the wind, spreading droplets, contaminating faces and surfaces, as well as providing no protection to legs when bending, lifting, sitting’ (paramedic, WA). Proceduralists encountered PPE failures, ‘on a patient who had suffered a cardiac arrest, the mask developed a major leak and fogged up the face shield which meant I was exposed to viral aerosol and had poor visibility. It is incredibly stressful. Make fit testing mandatory and provide us state of the art PPE.’ (anaesthetist, VIC). Even anaesthetists, who are at high risk due to intubation responsibilities are being asked ‘to use cheap N95 duckbill masks without formal fit testing… intubators’ face shields are fogging so badly that it is almost impossible to see. Full face Respirators must be made available’ (anaesthetist, VIC). Guideline variability resulted in mask confusion with the need ‘to juggle between different masks based on the interventions we use to treat patients’ where ‘we are not able to predict these decisions until we are already on scene’ (paramedic, NSW).

HCWs were angered by a lack of internal support: ‘My hospital’s Chief Medical Officer has been silent on this issue, even when it was raised in a public forum’ (trainee doctor, VIC), citing that the inadequacy of PPE ‘runs contrary to OH&S regulations in every other facet of working life’ (trainee doctor, QLD). The lack of representation in policy making meant that, ‘General Practice is under-represented in the decision-making process and the allocation of PPE, despite our high profile in the early presentations’ (nurse, WA). Consequently, HCWs are ‘purchasing their own masks, at extreme cost’ (nurse, SA) including non-approved items such as ‘an elastomeric P3 filter mask but I would be disciplined if I wore it to work despite it likely being superior to a non-fit tested N95/P2 respirator’ (doctor, VIC).

In addition to fit testing, PPE training was required. ‘Donning and doffing correctly, needs education and compliance monitoring! I’ve seen so many nurses do it incorrectly’ (surgical nurse, VIC). There were calls for ‘a nationwide respiratory protection programme incorporating the training, use and centralised cleaning of PAPRs and reusable elastomeric respirators for those who do not fit disposable P2/N95 masks’. Without this level of oversight, ‘Governments and healthcare organisations are currently failing in their duty of care to provide a safe working environment for HCWs’ (anaesthetist, NSW).

Fit testing

We were horrified by the mismatch in different people’s faces to various brands of P2/N95. (GP, Tasmania)

The provision of respirators is not a one-size-fits-all matter. Respiratory protection is only effective if HCWs ‘have quantitative Fit Testing’ (anaesthetist, VIC) ‘to ensure that they provide an adequate seal. Without proper fitting, these masks provide no additional protection over and above a standard surgical mask’ (anaesthetist, NSW). One surgeon recounted how they ‘had to apply strips of Micropore tape around the mask to achieve an adequate seal. … It beggars belief that HCWs are expected to jury-rig N95 masks to achieve a life-protecting air-tight seal’ (surgeon, WA).

In-house fit testing was occurring, with alarming results, where ‘around 40% of women failed a quantitative fit test on the disposable P2/N95 masks’ (anaesthetist, NSW), noting that ‘women and non-Caucasian faces appear at greatest risk of failure. They also appear to be disproportionately the HCWs exposed and dying in the UK’ (anaesthetist, QLD). Arranging fit testing was not easy, with HCWs having to ‘fight to even be fit-tested for N95 masks’ and having to ‘to pay for that fit-testing myself before the hospital relented and tested the rest of the department’ (doctor, TAS). HCWs were bewildered as to ‘why certain industry sectors make it mandatory for their workers to have such rigorous testing performed and others such as healthcare, where lives matter just as much, do not seem to be implementing this’ (anaesthetist, VIC). ‘Supply issues’ was the reason cited for organisational resistance to fit testing even when there were ‘multiple HCW infections despite adhering to the current policy for PPE’ (emergency department doctor, VIC).

Reusable respirators such as powered air-purifying respirators were seen as viable alternatives to disposable respirators ‘as it provides superior protection in those who cannot achieve adequate seal with N95 or P2 masks’ (anaesthetist, WA) and had a proven track record in safety during SARS: ‘I owe my life to the wearing of the 3M Jupiter Hood System with ventilatory filters… issued by the hospital administration’ (physician, WA). However, there was resistance to reusables even when ‘none of the N95 masks fit my face and my hospital won't let me wear my own 3M respirator, so how do I minimise my risk?’ (anaesthetist, NSW).

Fear for self and others, bullying and censure

I have not been sleeping well for a long time. I am likely to be called up for active service on the COVID-19 wards and this fear is playing on my mind. (Physician, Victoria)

HCWs described being bullied and victimised in their workplaces, being told they were ‘not a team player’ (ED doctor, NSW) and ‘face shaming tactics from colleagues’ (GP, WA), in a workplace that ‘has actively tried to silence me’ (allied health, QLD) for expressing concerns about their safety. HCWs were ‘threatened to be stood down for requesting an N95 mask’ (paediatrician, NSW), having ‘N95 masks taken out of our hands before going into see positive COVID-19 patients’ (physician, VIC) and of being ‘bullied by admin staff who don’t want us to ask for appropriate PPE, and lied to’ (anaesthetist, QLD).

Senior managers had told staff that they ‘need to toughen up’ (ED doctor, QLD), while infection control nurses were ‘chastising front-line ED nurses caring for suspected COVID-19 patients for wearing N95s, saying they should only use surgical masks’ (trainee doctor, TAS). Requests for use of personal higher grade PPE was discouraged by infectious diseases experts as it may ‘set a precedent and that the optics of not following the [Department of Health and Human Services] guidelines were not good’ (nurse, VIC). Infection control was ‘very poor in backing up the HCWs’ and preferred to ‘toe the executive line rather than evidence-based practice’ (ED physician, NSW), creating a very bad taste in our department (ED physician, NSW). HCWs were angry that infectious diseases experts had determined N95 masks were only needed for aerosol generating procedures in COVID-19patients and accused them of expressing ‘hubris when they were asked about HCW infections’ implying ‘that the high rate of HCW infections and deaths was due to incorrect donning and doffing rather than the grade of the PPE itself’ (physician, VIC).

Concerns about workplace safety had ‘caused increased anxiety’ (nurse, WA), leading to withdrawal from family noting that being ‘away from my family and my pets is hard emotionally, but I do this so I can serve my community and protect my family’ (doctor, WA). HCWs were ‘mentally exhausted stressing about the possibility of bringing home the virus’ (trainee Doctor, WA), with ‘growing burnout … We are losing sleep at unprecedented levels due to worry’ (GP, NSW). They felt ‘threatened coming to work and seeing COVID suspected patients with inadequate PPE’ (doctor, WA).

Self-disclosed HCW infections

I was denied N95 masks, informing me they are ‘unnecessary’ when caring for COVID19 positive patients. I am now COVID19 positive, and won’t see my baby for weeks. All because of trying to care for people, when no one cared for me’. (Nurse, VIC)

HCWs stated that COVID-19 infections were ‘almost certainly contracted in my workplace’ (doctor, COVID-19 clinic, VIC) as ‘evidenced in 10% of cases being HCWs. Rates in the community are far lower than 10%. HCWs are acquiring this infection in their places of employment’ (anaesthetist, VIC). Many felt that they contracted COVID-19 despite ‘wearing the correct PPE, and yet it still wasn’t safe enough’ (nurse, VIC). PPE guidelines were ineffective as ‘three nurses on our ward tested positive to COVID-19, only surgical masks were provided to nurses when caring for suspected positive patients’ (nurse, VIC). Similar stories were evident for community-based HCWs: ‘my colleague looked after two COVID-19 patients in their home wearing the current PPE and is now at home isolating as he is COVID-19 positive’ (physician, VIC). ‘The risk is real and it is too great not to act’ said an infected ED doctor (VIC) especially with a ‘close friend in ICU after contracting COVID-19 working in ED’ (GP, VIC).

Poor consultation and loss of trust in leadership

We have the knowledge and skills required to sort this out. The bureaucracy is getting in the way of safety. (Anaesthetist, NSW)

Underlying the themes was a loss of trust in leadership at service, state and national levels. ‘We use our judgement and analyse situations as part of our daily work. Do not lie to us and gaslight us when we assess the situation to be unacceptably risky’ (ED doctor, WA). Throughout the pandemic ‘there is one thing which is constant and consistent, which is no transparency and no honesty reflected in the leadership’s policies’ (ED doctor, NSW). ‘We have had very poor leadership from executive, they have cut corners with our safety at every turn’ (physician, VIC), such that ‘I have lost faith in leadership that sees risk to my safety at work as acceptable’ (trainee doctor, VIC). Directives were top-down with little consultation with HCWs because ‘Hospital admin only take advice from the health department despite requests and recommendations by local physicians’ (physician, NSW). Requests for extra precautions were ‘not responded [to] at all despite repeated requests and lobbying’ (physician, VIC). HCWs found ‘it hard to trust leadership’, which ‘makes already low morale, even lower’ (physician, VIC) and were ‘seriously thinking of leaving nursing due to the lack of leadership, support and respect within the system’ (nurse, NSW). The lack of precaution was short sighted with a HCW wondering ‘what happens when we’ve infected all our staff and don’t have adequate staffing levels to provide care’ (anaesthetist, NSW).