The responsibility to care: lessons learned from emergency department workers' perspectives during the first wave of the COVID-19 pandemic in Canada.

BACKGROUND: This study's objective was to examine emergency department (ED) workers' perspectives during the Canadian COVID-19 first wave. METHODS: This qualitative study included workers from nine Canadian EDs who participated in 3 monthly video focus groups between April and July 2020 to explore (1) personal/professional experiences, (2) patient care and ED work, (3) relationships with teams, institutions and governing bodies. Framework analysis informed data collection and analysis. RESULTS: Thirty-six focus groups and 15 interviews were conducted with 53 participants (including 24 physicians, 16 nurses). Median age was 37.5 years, 51% were female, 79% had more than 5 years' experience. Three main themes emerged. (1) Early in this pandemic, participants felt a responsibility to provide care to patients and solidarity toward their ED colleagues and team, while balancing many risks with their personal protection. (2) ED teams wanted to be engaged in decision-making, based on the best available scientific knowledge. Institutional decisions and clinical guidelines needed to be adapted to the specificity of each ED environment. (3) Working during the pandemic created new sources of moral distress and fatigue, including difficult clinical practices, distance with patients and families, frequent changes in information and added sources of fatigue. Although participants quickly adapted to a "new normal", they were concerned about long-term burnout. Participants who experienced high numbers of patient deaths felt especially unprepared. INTERPRETATION: ED workers believe they have a responsibility to provide care through a pandemic. Trust in leadership is supported by managers who are present and responsive, transparent in their communication, and involve ED staff in the development and practice of policies and procedures. Such practices will help protect from burnout and ensure the workforce's long-term sustainability.

RéSUMé: CONTEXTE: Cette étude avait pour objectif d'examiner le point de vue des travailleurs des services d'urgence pendant la première vague de la COVID-19 au Canada. MéTHODES: Cette étude qualitative a inclus des travailleurs de neuf services d'urgence canadiens qui ont participé à 3 groupes de discussion monsuels par visioconférence entre avril et juillet 2020, pour explorer: (1) leurs expériences personnelles/professionnelles, (2) les soins aux patients et le travail au service d'urgence, (3) leurs relations avec les équipes, les institutions et instances dirigeantes. Le "framework analysis" a guidé le receuil et l'analyse des données. RéSULTATS: Trente-six groupes de discussion et 15 entretiens individuels ont été menés avec 53 participants (dont 24 médecins et 16 infirmières). L'âge médian était de 37,5 ans, 51% étaient des femmes, 79% avaient plus de 5 ans d'expérience. Trois thèmes principaux sont ressortis. (1) Au début de cette pandémie, les participants se sont sentis responsables de prodiguer des soins aux patients et solidaires envers leurs collègues et leurs équipes des urgences, tout en cherchant à équilibrer la gestion de nombreux risques et leur protection personnelle. (2) Les équipes des services d'urgence souhaitaient participer aux prises de décision, informées par les meilleures connaissances scientifiques disponibles. Les décisions institutionnelles et les lignes directrices cliniques doivent être adaptées à la spécificité de chaque salle d'urgence. (3) Travailler pendant la pandémie a créé de nouvelles sources de détresse morale et de fatigue, notamment des pratiques cliniques difficiles, la distance avec les patients et les familles, les changements fréquents d'information. Bien que les participants se soient rapidement adaptés à une « nouvelle normalité¼, ils étaient préoccupés par l'épuisement professionnel des travailleurs au long terme. Les participants qui ont vécu un nombre élevé de décès de patients à l'urgence se sentaient particulièrement mal préparés. INTERPRéTATION: Les travailleurs des services d'urgence estiment qu'ils ont la responsabilité de fournir des soins en cas de pandémie. Un sentiment de confiance dans les décideurs peut être soutenu par des gestionnaires qui sont présents et réactifs, transparents dans leur communication, et qui impliquent le personnel des services d'urgence dans le développement des politiques et procédures cliniques. De telles pratiques aideront à protéger contre l'épuisement professionnel pour garantir le bien-être des travailleurs d'urgence.

A survey of Canadian emergency physicians' experiences and perspectives during the COVID-19 pandemic.

BACKGROUND: The objective of this study was to explore Canadian emergency physicians' experiences, concerns, and perspectives during the first wave of the coronavirus disease (COVID-19) pandemic. METHODS: This cross-sectional survey of physician members of Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians explored: personal safety/responsibility to care; patient interactions; ethical issues in pandemic care; institutional dynamics and communication practices. Data analysis was descriptive: categorical data were summarised with frequency distributions, continuous data [100 mm visual analog scales (VAS)] were analysed using measures of central tendency. Short open-ended items were coded to identify frequencies of responses. RESULTS: From June 29 to July 29, 2020, 187 respondents (13% response rate) completed the survey: 39% were from Ontario and 20% from Quebec, trained in general (50%) or pediatric (37%) emergency medicine. Respondents reported a high moral obligation to care for patients (97/100, IQR: 85-100, on 100 mm VAS). Fear of contracting COVID-19 changed how 82% of respondents reported interacting with patients, while 97% reported PPE negatively impacted patient care. Despite reporting a high proportion of negative emotions (84%), respondents (59%) were not/slightly concerned about their mental health. Top concerns included a potential second wave, Canada's financial situation, worldwide solidarity, and youth mental health. Facilitators to provide emergency care included: teamwork, leadership, clear communications strategies. CONCLUSION: Canadian emergency physicians felt a strong sense of responsibility to care, while dealing with several ethical dilemmas. Clear communication strategies, measures to ensure safety, and appropriate emergency department setups facilitate pandemic care. Emergency physicians were not concerned about their own mental health, requiring further exploration.

RéSUMé: CONTEXTE: L'objectif de cette étude était d'explorer les expériences, les préoccupations et les perspectives des médecins urgentistes canadiens pendant la première vague de la pandémie de coronavirus (COVID-19). MéTHODES: Cette enquête transversale auprès des médecins membres de Pediatric Emergency Research Canada et de l'Association canadienne des médecins d'urgence a permis d'explorer les aspects suivants : sécurité personnelle/responsabilité de soigner ; interactions avec les patients ; enjeux éthiques liés au soin en temps de pandémie ; dynamique institutionnelle et pratiques de communication. L'analyse des données était descriptive : les données catégorielles ont été résumées par des distributions de fréquence, les données continues [échelles visuelles analogiques (EVA) de 100 mm] ont été analysées à l'aide des indicateurs de tendance centrale. Les réponses ouvertes courtes ont été codées pour déterminer la fréquence des réponses. RéSULTATS: Du 29 juin au 29 juillet 2020, 187 répondants (taux de réponse de 13 %) ont répondu à l'enquête : 39 % provenaient de l'Ontario et 20 % du Québec, fet étaient formés en médecine d'urgence générale (50 %) ou pédiatrique (37 %). Les répondants ont rapporté une obligation morale élevée de s'occuper des patients (97/100, IQR : 85-100, sur une EVA de 100 mm). Quatre-vingt deux pourcent des répondants ont déclaré que la peur de contracter le COVID-19 avait modifié leurs intéractions avec les patients, tandis que, 97 % ont déclaré que l'EPI avait un impact négatif sur les soins aux patients. Bien qu'ils aient rapporté une forte proportion d'émotions négatives (84 %), les répondants (59 %) n'étaient pas/légèrement préoccupés par leur santé mentale. Parmi les principales préoccupations figuraient la possibilité d'une deuxième vague, la situation financière du Canada, la solidarité mondiale et la santé mentale des jeunes. Les facilitateurs chargés de fournir des soins d'urgence comprenaient : le travail d'équipe, le leadership et des stratégies de communication claires. CONCLUSION: Les médecins urgentistes canadiens ont ressenti un fort sentiment de responsabilité envers les soins, tout en faisant face à plusieurs dilemmes éthiques. Des stratégies de communication claires, des mesures visant à assurer la sécurité des professionnels d'urgence et une organisation appropriée des services d'urgence facilitent les soins en cas de pandémie. Les médecins urgentistes n'étaient pas préoccupés par leur propre santé mentale, ce qui mériterait une étude une étude plus approfondie.

Paediatric palliative care in practice: Perspectives between acute and long-term healthcare teams.

AIM: To explore and compare acute and long-term care professionals' perspectives about paediatric palliative care. METHODS: Focus group interviews were conducted in 2016-2017 with professionals from acute (Emergency Department, Intensive Care Unit) and long-term care (Complex Care Service, Palliative Care) teams. RESULTS: Fifty-eight participants were enrolled. Palliative care definitions were similar throughout groups: to provide active care early in the illness, focusing on the child as a whole and supporting families. Each group perceived a different role in the patient's illness trajectory, reflecting their own culture of care. They demonstrated important differences in their approach to palliative care. Disagreements regarding when or how to discuss goals of care were expressed. Acute care professionals reported discomfort when having to introduce these discussions for the first time, while long-term care professionals perceived negative judgements about their patients' quality of life by acute care teams during health events. Personalised care, communication with families and continuity of care were thought to be key elements to improve care. CONCLUSION: Paediatric palliative care is well recognised throughout specialties, yet continuity of care is challenged by groups' roles and interventions in a patient's illness. A reflective and mutual clinical approach is needed to improve quality of care and professionals' satisfaction.

Palliative Care in the Pediatric Emergency Department: Findings From a Qualitative Study.

STUDY OBJECTIVE: Children with medical complexity represent a fragile population and account for the majority of patients followed in pediatric palliative care. Little is known in regard to the role of the emergency department (ED) in caring for the families of children with medical complexity. METHODS: Semistructured focus groups were held with health care professionals from pediatric emergency medicine, palliative care, complex care, and intensive care to explore their perspective on pediatric palliative care in the ED. Data were transcribed and analyzed with NVivo software, and thematic analysis and theoretic sampling were performed. RESULTS: From January to October 2016, 58 participants were interviewed. Difficulties providing pediatric palliative care in the ED are related on the one hand to characteristics specific to the ED, such as its culture and its health care professionals' strong emotional responses when caring for children with medical complexity, and on the other hand to factors extrinsic to the ED; mainly, lack of continuity of care. For critically ill children with unknown goals of care and potential for end of life, professionals in the ED should evaluate the clinical situation, contact known health care teams, remain open to families' preferences, alleviate distressing symptoms, and create a caring environment. Communication between teams is targeted by health care professionals to facilitate and improve patient flow and care. CONCLUSION: Although perspectives differ in regard to how to provide care for pediatric palliative care patients in the ED, several barriers to providing high-quality emergency pediatric palliative care can be overcome.