Challenges of primary health care leadership during the COVID-19 pandemic in Sweden: a qualitative study of managers' experiences.

PURPOSE: At the outbreak of the COVID-19 pandemic, health care was at the centre of the crisis. New demands made existing organizational practices and services obsolete. Primary health care had a great deal of responsibility for COVID-19-related care. The pandemic demanded effective leadership to manage the new difficulties. This paper aims to explore experiences and perceptions of managers in primary health care in relation to their efforts to manage the COVID-19 crisis in their everyday work. DESIGN/METHODOLOGY/APPROACH: The authors used a qualitative approach based on 14 semi-structured interviews with managers in primary health care from four regions in Sweden. The interviews were conducted during September to December 2020. Data were analysed using conventional qualitative content analysis. FINDINGS: Data analysis yielded three categories: lonely in decision-making; stretched to the limit; and proud to have coped. The participants felt lonely in their decision-making, and they were stretched to the limit of their own and the organization's capacity. The psychosocial working conditions in primary care worsened considerably during the pandemic because demands on leaders increased while their ability to control the work situation decreased. However, they also expressed pride that they and their employees had managed the situation by being flexible and having a common focus. ORIGINALITY/VALUE: Looking ahead and using lessons learnt, and apart from making wise decisions under pressure, an important implication for primary health-care leaders is to not underestimate the power of acknowledging the virtues of humanity and justice during a crisis. Continuing professional education for leaders focusing on crisis leadership could help prepare leaders for future crises.

Working conditions in primary healthcare during the COVID-19 pandemic: an interview study with physicians in Sweden.

OBJECTIVE: The aim of this study was to explore how the COVID-19 pandemic changed the working conditions of physicians in Swedish primary healthcare. DESIGN: This is a descriptive, qualitative study with individual semistructured interviews. Data were analysed using inductive content analysis. SETTING: Swedish primary healthcare units in both rural and urban areas. PARTICIPANTS: A total of 11 primary care physicians fulfilled participation. RESULTS: Two main categories emerged: 'work organisation and routines' and 'psychosocial work environment', containing three and five subcategories, respectively. The pandemic enforced changes in work organisation and routines. Increased flexibility, including more patient-oriented delivery of care, and novel means of interorganisational and intraorganisational interactions were perceived as positive by physicians. The pandemic also caused several changes in physicians' psychosocial work environment. Increased workload, information overload, as well as ethical considerations and feelings of uncertainty made the work environment stressful for physicians. CONCLUSIONS: The COVID-19 pandemic affected the working conditions of physicians in Swedish primary healthcare in numerous ways. The pandemic enforced changes in work organisation and routines for physicians in primary healthcare. Further research is needed to investigate how the pandemic will affect primary healthcare in the longer term. Learning from the pandemic is important because this will not be the last crisis that primary care and its healthcare professionals will face.

From chaos to control - experiences of healthcare workers during the early phase of the COVID-19 pandemic: a focus group study.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic has caused overwhelming challenges to healthcare systems worldwide. Healthcare workers (HCWs) have faced particular challenges: being exposed to the coronavirus SARS-CoV-2 and caring for patients having a new and potentially life-threatening disease. The aim of this study was to explore how HCWs in the Swedish healthcare system perceived their work situation during the first phase of the COVID-19 pandemic in 2020. METHODS: Focus group discussions and interviews with HCWs were performed from June to October 2020 in one Swedish healthcare region. A purposeful sampling approach was used to select a variety of professions (physicians, nurses, nurse aides and cleaners) and workplaces (hospital inpatient wards, emergency department, nursing home and home care service). Qualitative content analysis was used for data analysis. RESULTS: In total, 51 HCWs participated in eight focus group discussions and one HCW participated in an individual interview. The content analysis identified two main categories: 'Concerns about the risk of infection and transmission of infection to others', and 'Transition from chaos to managing in a new and challenging work situation'. The findings revealed how HCWs perceived working conditions, including experiences of fear for personal health, confusion and uncertainty regarding personal protective equipment and infection prevention and control (PPE/IPC), and fear of infecting others. Both fearful and appreciating attitudes were achieved from the surrounding community. Helpful strategies for transition from chaos to control were lifted i.e. present and supportive leadership, and finding comfort and strength in the working team. Both helplessness and meaningfulness were described when caring for COVID-19 patients. CONCLUSIONS: This study provides unique insights into HCWs experiences of an extremely challenging work situation during the first phase of the COVID-19 pandemic, including feelings of stress and insecurity in a chaotic and hazardous working environment. But there is also mitigation of these challenges and even positive experiences including feelings of safety and meaningfulness. To enhance safety among HCWs in healthcare crises such as the COVID-19 pandemic, the findings highlight the importance of avoiding confusion about PPE/IPC, having a supportive healthcare leadership and ensuring accurate information provision about virus transmission to the public.

Lung Ultrasound for Identification of Patients Requiring Invasive Mechanical Ventilation in COVID-19.

OBJECTIVES: Indication for invasive mechanical ventilation in COVID-19 pneumonia has been a major challenge. This study aimed to evaluate if lung ultrasound (LUS) can assist identification of requirement of invasive mechanical ventilation in moderate to severe COVID-19 pneumonia. MATERIALS AND METHODS: Between April 23 and November 12, 2020, hospitalized patients with moderate to severe COVID-19 (oxygen demand ≥4 L/min) were included consecutively. Lung ultrasound was performed daily until invasive mechanical ventilation (IMV-group) or spontaneous recovery (non-IMV-group). Clinical parameters and lung ultrasound findings were compared between groups, at intubation (IMV-group) and highest oxygen demand (non-IMV-group). A reference group with oxygen demand <4 L/min was examined at hospital admission. RESULTS: Altogether 72 patients were included: 50 study patients (IMV-group, n = 23; non-IMV-group, n = 27) and 22 reference patients. LUS-score correlated to oxygen demand (SpO2 /FiO2 -ratio) (r = 0.728; p < .0001) and was higher in the IMV-group compared to the non-IMV-group (20.0 versus 18.0; p = .026). Based on receiver operating characteristic analysis, a LUS-score of 19.5 was identified as cut-off for requirement of invasive mechanical ventilation (area under the curve 0.68; sensitivity 56%, specificity 74%). In 6 patients, LUS identified critical coexisting conditions. Respiratory rate and oxygenation index ((SpO2 /FiO2 )/respiratory rate) ≥4.88 identified no requirement of invasive mechanical ventilation with a positive predictive value of 87% and negative predictive value of 100%. CONCLUSIONS: LUS-score had only a moderate diagnostic value for requirement of invasive mechanical ventilation in moderate to severe COVID-19. However, LUS proved valuable as complement to respiratory parameters in guidance of disease severity and identifying critical coexisting conditions.