The study results highlight the challenges for ODPs during the COVID-19 pandemic. Until now, there is no research focussing on this group of healthcare personnel in times of the COVID-19 pandemic available, although it is a vulnerable subgroup. ODPs are low to middle income earners and many have entered the profession with only secondary school degrees. Due to their underprivileged background, they are particularly vulnerable to infection burden from household locality. Within our study, ten themes were discovered which highlighted the problems that ODPs faced in delivering services and securing patient safety during the pandemic and otherwise.
The first finding was related to training for COVID-19. There was a misunderstanding that previous overall training for infectious disease control would be sufficient. Although no study participant had received any advanced training, some had at least a briefing from a senior health professional. Overall, there was reliance on social media and on-the-job experience for training. However, it is essential to provide extended COVID-19-specific training (e.g. hand washing procedure, donning and doffing protective gear, face mask guidelines) to ensure practitioner and patient safety . Worldwide the most difficult issue for hospitals and health sectors has been the allocation of resources and time for training of healthcare practitioners (HCPs) , especially emergency surgical teams . A large amount of ODPs within our study have received only secondary schooling. Thus, it is important that ODPs in Pakistan and other developing regions from lower educational backgrounds receive more support in continuous training and skill development . For that reason, training for skill development and professional convergence is needed, along with a focus on non-technical skill development and team-building to improve communication and patient safety. Simulation training is encouraged for ODPs and surgical teams to avoid adverse events in emergency settings and support improved communication between practitioners coming from highly diverse skill backgrounds. Training for COVID-19 must not be limited to prevention and protective gear management, but also include updated information about epidemiology of and testing for the disease.
A second finding was with relation to COVID-19 testing. Globally, there were challenges with regard to emergency patients not being able to be tested in time and thus placing the theatre and hospital staff at risk of infection . ODPs were not being supported with regular testing by the employer and had to pay for testing themselves and visit other hospitals for consultancy. In some cases, paying for COVID-19 testing amounted to one-third of the monthly salary of ODPs. Other recent research argues that unless healthcare staff are supported with easy access to diagnostics and medical support they will be unable to provide optimal services to critical patients seeking emergency care . Another issue of concern was that ODPs had inadequate knowledge about tests results and believed that a negative result in nonspecific antibody tests (like IgG) indicated that lenient preventive protocols could be adopted. This is an issue of inadequate knowledge of tests, but also of non-standardized policies across hospital structures and practitioners .
A third finding was about the critical supply shortages and poor quality of PPE. Reasons for limited supply not only include shortages from suppliers and contractors, but also discrimination in supply by administration. Also previous research has highlighted that supply issues and shortages exist even in developed countries . However, special attention is needed for the discrimination in distribution between HCPs in Pakistan and other developing regions. Such discrimination may be a result of status discrepancy between providers .
A fourth area was the challenge of maintaining physical distance and preventive protocols. The nature of the job and workplace routines for ODPs meant that they were unable to maintain physical distance from patients and co-workers. There were also issues of inability to secure complete cleaning of the theatre or maintain protective gear from patient to patient in emergencies due to a lack of time and high work burden. ODPs also highlighted that in some hospitals no modifications in protocols for disinfection and sterilization have been adopted since the COVID-19 pandemic. Recent research confirms that complete and appropriate use of PPE kits is essential for HCPs who cannot avoid frequent and close physical contact with patients. Furthermore, there should be enough staffing and time for preventive practices . Proper knowledge of different processes and agents for sterilization and disinfection are essential to secure patient safety in the theatre . Sterilization and disinfection protocols must be standardized and made consistent across hospitals settings.
A fifth area was that of shortages in human resources and role burden of ODPs. It was highlighted that there is a serious shortage of ODPs, which leads to additional work burden and lack of time for prevention during the pandemic. There was no extra remuneration for the additional responsibilities allocated during the pandemic for disinfection and sterilization. It has been emphasized that equitable compensation of HCPs leads to an improvement in job satisfaction and patient care . We also found that in some cases COVID-19 positive ODPs who remained asymptomatic were asked by the employer to continue work due to shortages. Increasing ODP staffing in the theatre has advantages of assisting in the distribution of responsibility, cooperation in processing information related to the patient, and managing infection control .
A sixth finding is that of problems with hospital administration. ODPs are unable to communicate with the administration or solicit a response from them as they were considered non-significant team members. Research suggests that health service quality and patient safety is dependent on efficient and responsive hospital administration . We also found that ODPs are hampered by the unsafe planning of theatre design and lack of safe avenues for waste disposal. Design of the operation theatre and waste disposal paths are critical supportive characteristics needed to build an environment of safety . There is need for immediate re-construction of theatres to provide avenues for waste disposal and prevention of cross-contamination. Waiting areas for family must be located at a reasonable distance and overall random construction must be prohibited in the future while observing international recommendations for theatre construction and patient safety. ODPs also levelled criticism about the turning away of critical obstetric patients who were not registered with the hospital, which has implications for maternal and new-born safety. Local research confirms that the public health sector needs more funding and capacity to cater to the need of critical obstetric patients from primary to tertiary sector .
A seventh theme of problems related to exclusion and hierarchy. ODPs complained about a lack of inclusion in matters of governance and compensation. Research suggests that ODPs and AHPs who are not provided involvement in governance are less likely in assuming responsibility for patient safety . Local research confirms that AHPs in Pakistan, despite being regular government employees, have unsatisfactory salaries and employment benefits . The inferior position of ODPs was described through examples of discrimination in supply of protective gear and training opportunities, in comparison to colleagues like physicians and nurses. Other literature corroborates that ODPs across the world suffer from exclusion due to their historical enlistment as untrained support staff . ODPs are also known to suffer from long-standing power politics and hierarchal bullying in the theatre, with the surgeons and anaesthesiologists on the top, the nurses in next line, and the ODPs last .
The eighth theme was of problems related to teamwork and communication. ODPs faced coordination barriers with pre- and post-operative as well as intra-operative teams. Study participants also complained that they did not receive collective training with the surgical team preventing team-building. Patient safety in the surgical setting is highly dependent on the non-technical aspects of theatre processes, such as team development and communication skills . In fact, some research argues that evidence-based best practices for infection prevention are less valuable, compared to collaboration and communication between practitioners . Therefore, regular team briefing and consultation meetings between the entire surgical team and administration are necessary to secure perioperative safety. Issues of hierarchy and lack of communication must be resolved, through team-building workshops and punitive measures against workplace bullies, in order to encourage sharing of information for patient safety.
There were also issues of poor communication with patients from various backgrounds and the inability to manage family attendants and even face aggression from them. Language and literacy barriers with patients from various socio-demographic backgrounds can contribute to adverse events . Although the number of visiting family attendants has been limited to one during COVID-19, informal cultural norms and fear of surgical errors, malpractice or negligence drive multiple family members to accompany patients in hospitals of Pakistan . Furthermore, aggression by family attendants during COVID-19 may have augmented due to: (i) fear of inadequate sterilization maintenance, and (ii) belief that the government is falsely diagnosing people as COVID-19 positive, and in some cases even killing them, to receive more funding .
The ninth theme of problems related to error management. ODPs highlighted the types of errors including breaches during emergency surgeries due to work overburden, inability to maintain protective gear in emergency and hurried circumstances, and failure to understand surgeon instructions. Errors and efficiencies are grounded in system and administrative limitations . In Pakistan, there is no error reporting system for protocol violation or surgical error for ODPs or other hospital team members . ODPs in the study rationalized that most errors were unintentional and due to the nature of the job. International literature advocates that there is need for constant monitoring and strategy development to prevent situational violations during surgery . ODPs also maintained that they were unable to share errors and safety concerns with doctors and management. Other research confirms that junior practitioners are unable to share patient safety concerns and errors due to fears of job loss and litigation .
The tenth and final theme related to anxiety and fear. ODPs remained in fear of getting infected with COVID-19 despite safety measures, catching the virus in the closed setting of the theatre, and the close proximity of theatre staff and patients. There was also fear of carrying the virus home and passing it to family members. These fears are also linked to adverse effects on mental health. Other local research confirms that healthcare staff is facing significant mental health challenges due to the pandemic . Other research verifies that ODPs can suffer from stress and perceptions of inefficiencies due to interprofessional failure and lack of teamwork in the theatre . The anxiety about contracting COVID-19 and shortage in preventive gear supply or maintenance has led to reliance on religious beliefs for protection. However, misconceptions can encourage stigma, discrimination and lapses in preventive protocols .
We were successful in interviewing ODPs working in emergency surgeries during the COVID-19 pandemic. The limitations of this study include perception-based responses and a small sample size. We were also only able to gain permission to sample public sector teaching hospitals in Lahore. However, the advantage is that all sampled hospitals are regulated by the same health sector body, which prevents problems of differences in comparison. Furthermore, it is the first study of its kind to investigate the concerns of an invisible health workforce, who are a fountain of information regarding the closed surgical theatre environment. This study has also helped to identify critical gaps in the delivery of emergency surgical services and infection control during pandemics. We believe this study has presented salient qualitative findings to help generate hypotheses about practices that need improvement in government hospital settings and future research can now target hypothesis testing in representative quantitative studies.