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A mixed-methods sequential explanatory design comparison between COVID-19 infection control guidelines’ applicability and their protective value as perceived by Israeli healthcare workers, and healthcare executives’ response

A mixed-methods sequential explanatory design comparison between COVID-19 infection control... Background: Healthcare workers (HCWs) are on the front line of the COVID-19 outbreak, and their constant exposure to infected patients and contaminated surfaces puts them at risk of acquiring and transmitting the infection. Therefore, they must employ protective measures. In practice, HCWs in Israel were not fully prepared for this sudden COVID-19 outbreak. This research aimed to identify and compare: (1) Israeli HCWs’ perceptions regarding the official COVID-19 guidelines’ applicability and their protective value, and (2) HCWs executives’ response to HWCs’ concern regarding personal protective equipment (PPE) shortage. Methods: A mixed-methods sequential explanatory design consists of: (1) An online survey of 242 HCWs about the application of the guidelines and PPE, and (2) Personal interviews of 15 HCWs executives regarding PPE shortage and the measures they are taking to address it. Results: A significant difference between the perceived applicability and protective value was found for most of the guidelines. Some of the guidelines were perceived as more applicable than protective (hand hygiene, signage at entrance, alcohol rub sanitizers at entrance, and mask for contact with symptomatic patients). Other were perceived as less applicable than protective (prohibited gathering of over 10 people, maintaining a distance of 2 m’, and remote services). Conclusions: HCWs need the support of the healthcare authorities not only to provide missing equipment, but also to communicate the risk to them. Conveying the information with full transparency, while addressing the uncertainty element and engaging the HCWs in evaluating the guidelines, are critical for establishing trust. Keywords: COVID-19, Infection control guidelines, Healthcare workers, Applicability and protective value, Perception * Correspondence: ageser@univ.haifa.ac.il School of Public Health and the Health and Risk Communication Research Center, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel Head of Health Promotion Program, School of Public Health, Founding Director of the Health and Risk Communication Research Center, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 2 of 7 Background Methods COVID-19 is a contagious viral infection, caused by Research design newly identified virus [1]. Presentation can range from This research is based on mixed-methods sequential ex- no symptoms to severe illness including pneumonia, planatory design [8]. The quantitative research is the main respiratory failure, septic shock, and multi-organ failure, research, conducted through an online survey of 242 which may result in death [1]. HCWs concerning the application of the guidelines and There is a dispute as to how the virus is transmitted from protective measures. The secondary qualitative research one person to another (droplet or airborne transmission). examined 15 healthcare executives’ perceptions of the Recently, the World Health Organization (WHO) declared HCWs’ reports of a PPE shortage, and the actions they that current information indicated that transmission is took to address that issue using personal interviews [8]. usually by droplets [2]. Droplet transmission occurs when a person is in close contact (within 1 m’)withsomeone who Sampling and data collection has respiratory symptoms (e.g., coughing or sneezing) and An online questionnaire was designed using the Qualtrics is therefore at risk of having his/her mucosae (mouth and XM software for a deliberate nonprobability sampling [9] nose) or conjunctiva (eyes) exposed to potentially infective of the population of HCWs. This method was selected respiratory droplets. However, the organization declares because the COVID-19 crisis requires social distancing, there is still uncertainty about airborne contagion, and preventing face-to-face interviews. Furthermore, HCWs concludes that “these initial findings need to be interpreted are the busiest population at this time. carefully” [2]. Therefore, some countries and organizations, The survey was distributed in March 2020 to HCWs including the US and European Centers for Disease Control using three main social media platforms: Facebook, and Prevention recommend airborne precautions for any WhatsApp, and Instagram. The first stage was deliberate situation involving the care of COVID-19 patients [3, 4]. intensive sampling through posts on specific social On 30 January 2020, the WHO Director-General media forums for healthcare workers, such as the forum declared that the current outbreak constituted a public of nurses in Israel, the forum of Arab doctors in Israel, health emergency of international concern. Avoidance of and more. Meanwhile, the questionnaire was sent to exposure is the single most important measure for directors of health funds and hospitals and from there preventing COVID-19, so-called “social distancing.” In was distributed to their employees on WhatsApp. The the case of HCWs, they must wear PPE including gloves, second stage was snowball sampling [10] to reach medical masks, goggles or a face shield, and gowns, as well broader circles of healthcare workers. as for specific procedures, respirators and aprons [1, 3]. In the qualitative research, we performed intensive At the end of February 2020, the WHO published rec- sampling of health executives and senior physicians. The ommendations for the rational use of PPE in healthcare study was advertised through WhatsApp groups, and and community settings that aims to provide informa- executives and physicians who agreed to participate in tion about when PPE use is most appropriate [1, 5]. the study contacted the researchers to schedule tele- In Israel theMinistryofHealth (MOH) at the beginning phone interviews. Each interview lasted 20–30 min. of March published “Guidelines for dealing with COVID-19 for health professionals in healthcare settings” [6]Even Study population though Israel was one of the first countries to understand A total of 292 HCWs filled out the online questionnaire, the severity of the epidemic, and the MOH had taken drastic however 50 (17%) questionnaires were not fully measures to close the country’sborders[7], the State Comp- completed. Those questionnaires were taken out of the troller’s report declared that Israel is not prepared for the sample, leaving 242 HCWs (Table 1) who fully completed COVID-19 epidemic and that the MOH has no organized the questionnaire. That was done only after verifying that plan to mitigate the shortage gaps in inpatient beds, medical the main research findings did not differ when the whole teams, and PPE. set of questionnaires (292) was included in the statistical Considering the critical issues regarding guidelines for analysis. dealing with COVID-19 for healthcare professionals in In the qualitative research 15 health executives and healthcare settings and the lack of evaluation studies senior physicians participated, including 6 (40%) hospital regarding the implications of the formal guidelines, this directors, 3 (20%) healthcare fund directors, 3 (20%) article seeks to: (1) Identify the attitudes and perceptions of directors of medical organizations, and 3 (20%) senior Israeli HCWs regarding official guidelines (their applicabil- physicians. ity, protection of HCWs, and spread prevention); (2) Present behavioral practices proposed by the front-line The research process HCWs; and (3) present senior health executives’ response The quantitative questionnaire consisted of questions on to the PPE shortage. sociodemographic details and questions on the guidelines Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 3 of 7 Table 1 Healthcare workers socio-demographic characteristics Wilcoxon Signed-Ranks test for dependent measures. (N = 242) Furthermore, Friedman’s test was conducted in order to Characteristic N (%) check for efficacy differences among the guidelines. In the second stage, the findings of the open questions Sector in the questionnaire were coded into categories on the Physician 34 (14) additional protective measures that do not exist in the Nurse 109 (45) guidelines. In the third stage the report of missing PPE Paramedic 61 (25) was integrated with a content analysis of the personal in- Administration 38 (16) terviews with the HCWs executives about their response Location to the PPE shortage. Hospital 113 (47) Reliability and validity Community 129 (53) Before the questionnaire was distributed, a pilot study Gender was conducted among 20 participants in order to refine Male 71 (29) the questions and prevent information bias. The ques- Female 171 (71) tions were written in Hebrew and translated into Arabic Age and later re-translated to Hebrew in order to check their wording. In addition, in order to test the validity of the < =30 69 (29) guidelines we presented in the questionnaire, and in 31–40 100 (41) order to check for sectorial differences (physicians, 41–50 37 (15) nurses, paramedics and administrative workers) 51–60 29 (12) concerning perceptions of the protection guidelines, 61+ 7 (3) Kruskal-Wallis tests were performed on each guideline. Three perceptions were examined for each guideline; its for HCWs for the COVID-19 crisis based on MOH guide- level of applicability, its protectiveness for the healthcare lines [6]. The questions about the MOH guidelines worker, and its preventive level against the public’s con- included questions about the applicability of each tagion. No significant differences were found between guideline and the protection it offers the worker and the 4 sectors on all these comparisons, which eliminates the public against contagion with the COVID-19 (See the need to consider this parameter in further analysis of Additional file 1). For each guideline, the participants these data (See Additional file 2). were asked to rank its level of applicability, and the The brief qualitative interviews with the directors were way they perceive its protection against their own conducted in the Arabic and Hebrew languages. All of contagion and the public’s. The ranking was based on the interviews were recorded, transcribed, and translated a Likert scale from 1 (not at all) to 5 (very much). into Hebrew. The transcription of the interviews in the Thenextpartofthe questionnaireincludedopen Arabic language was performed by two Arabic-speaking questions about the PPE and a question about other researchers who speak both languages. protective practices HCWs perform, which are not in the official guidelines. Results After finishing collecting the quantitative data, an The comparison between the applicability of each guide- interesting issue emerged from the open question in the line and its protective value was done using a Wilcoxon qualitative research, about a shortage of PPEs on the Signed-Ranks test for dependent measures (Table 2). ground. Therefore, in the personal interviews with A significant difference between applicability and hospital directors and senior officials, the two following protective value was found for several guidelines, except questions were included: (1) How do you perceive the for three guidelines (using gloves and gown, mask for issue of PPE shortage? and (2) What actions are you symptomatic patients, and questioning at entrance). taking to address this issue? Some of the guidelines are perceived as more applicable than protective (hand hygiene, signage at entrance, alco- Analysis hol rub sanitizers at entrance, and mask for contact with In the first stage, we performed a statistical analysis to symptomatic patients). Three guidelines are perceived as test the difference between the applicability of the guide- less applicable than protective (prohibited gathering over line and its degree of protection/contagion prevention 10 people, maintaining a distance of 2 m’, and remote for each of the MOH guidelines. The comparisons be- services). tween the applicability of the guidelines and the degree Friedman’s test was conducted in order to check for of protection and contagion prevention were made by a efficacy differences among the guidelines. The different Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 4 of 7 Table 2 Guidelines applicability average degree compared to its protective value (“protecting me” and “prevent contagion”)(N = 242) a b Guideline Applicable Protect/Prevent Contagion Test Statistic (S) p-value Adjusted p Hand hygiene 4.5 4.0 4122.5 <.0001 <.0001 Gloves and gown 3.9 3.7 960.0 0.02 0.20 Signage at entrance 4.4 3.8 3190.5 <.0001 <.0001 Alcohol rub sanitizers at entrance 4.3 4.0 1593.5 <.0001 <.0001 Mask for symptomatic patients 3.8 3.9 − 446.0 0.20 0.89 Mask for contact with symptomatic patients 4.3 3.9 1923.5 <.0001 <.0001 Prohibited gathering over 10 people 3.6 3.8 − 1020.5 0.004 0.04 Maintaining a distance of 2 m’ 3.0 3.7 − 3470.5 <.0001 <.0001 Questioning at entrance 3.5 3.6 − 754.5 0.08 0.58 Remote services 3.9 4.4 − 2277.0 <.0001 <.0001 Wilcoxon Signed-Ranks tests Sidak adjustment for multiple testing guidelines were examined using an overall measure of situation because my staff members are afraid of efficacy which averages the applicability and the protect- contagion during treatment.” ive value of each guideline. Test results (Table 3) show significant differences (χ2(9) = 553.5, P < 0.0001) between “Right now, I as a physician and the medical personnel the guidelines. around me are very exposed to the disease. They are Additional practices that do not appear in the official barely protected, and it disturbs me. When a patient guidelines against COVID-19, were suggested by the comes to my room, I don't know anything about them, HCWs (Table 4). what their condition is, whether they were exposed or The HCWs also reported a shortage of PPEs. The main not, infected or not. Our chances of contagion are very shortages reported (by rate of respondents) are of face- high. There is not sufficient protective gear, there are masks (19%), gowns (16%), general protective gear (10%), not even temperature checks.” disinfectant (10%), gloves (7%), and surgical masks (7%). The response of the HCWs executives to the HCWs’ “There is a feeling that protection of the human concern over PPE shortages included three main themes, resource is insufficient, there is neither a health nor that are present with their selected quotes. an economic safety net.” (1) HCWs’ fears of contagion (2) Adjusting expectations and resource allocation “As deputy director I see a tremendous shortage of “There is tremendous anger among the staff about equipment. It is extremely difficult to deal with the the equipment shortage. I try to solve it by setting Table 3 A comparison of guideline applicability and protective value using an overall measure of efficacy (N = 242) a b Guideline Overall measure of efficacy Chi-Square DF p-value Hand hygiene 4.2 317.52 9 < 0.001 Remote services 4.2 Alcohol rub sanitizers at entrance 4.2 Signage at entrance 4.1 Mask for contact with symptomatic patients 4.1 Mask for symptomatic patients 3.8 Gloves and gown 3.8 Prohibited gathering over 10 people 3.7 questioning at entrance 3.5 Maintaining a distance of 2 m 3.3 Averages the applicability and the protective value of each guideline Friedman’s test Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 5 of 7 Table 4 Additional practices suggested by the HCWs that do guidelines and the protection of HCWs against conta- not appear in the official guidelines against COVID-19 gion and infecting the public. These findings indicate Practice No. Practice description the gap that has been documented in the literature, not only in the COVID-19 epidemic, between the official 1 Eating healthy, vitamin C-fortified food, and drinking a lot of water infection prevention guidelines and what happens on the 2 Rinsing nostrils with water and soap after shift ground [14]. The findings of the present study indicate that three 3 Disinfecting personal belongings before going home guidelines are perceived as less applicable than protect- 4 Disinfecting cell phone, keyboard, mouse, and other ive: prohibited gathering of over 10 people, maintaining equipment throughout the day a distance of 2 m’, and remote services. 5 Changing clothes and disinfecting shoes when entering the house A possible interpretation to that is that the Israeli healthcare system has fewer staff positions and man- 6 Washing work clothes separately power than the Organisation for Economic Co-operation 7 Opening doors with elbow and Development (OECD) countries [15]. Israel has a 8 Thorough cleaning of surfaces and chairs tremendous overload on its healthcare system that is 9 Cleaning steering wheel and car door handles reflected by long lines [15–17]. The HCWs feel they 10 Showering at the end of shift before going home cannot question the people who come in during the cor- onavirus crisis because they do not have enough time an optimal protection level for use per team. The and there is a personnel shortage. In addition, since the idea is to control the amounts and not let the hospitals and health funds are at full capacity all the workers go crazy...” time, during the COVID-19 crisis the pressure increases, and it is difficult to reduce the congregating and main- “I sat with all the teams, from all the departments in tain a distance between people. Another possible explan- the clinic, we developed a work procedure, which ation for the difficulty to maintain a distance is the team members need to be protected, and then cultural component. Israeli society has a culture of social together we came up with a “portion” of PPE based intimacy where it is not common to keep a physical dis- on the number of staff members, the number of tance. Moreover, there are geographical areas in Israel patients, and which needs or cases they deal with. with high population density where people congregate, Every morning each team gets its portion. It will such as the Arab and ultra-Orthodox communities. In prevent misunderstandings and help the team the COVID-19 crisis in Israel certain populations have understand the situation better.” reportedly had difficulty following the guidelines, making (3) Remote services. it hard for the HCWs to maintain the specific guidelines concerning social distancing. For example, the ultra- “We use videoconferencing in the treatment room, Orthodox community in Israel found it difficult to fol- to reduce to a minimum the medical staff's exposure low the guidelines and suffered from some of the highest to patients and contagion.” infection rates in the country [18, 19]. The findings also indicated that some guidelines were “Currently the communication between the medical perceived as more applicable than protective, such as staff and the COVID-19 patients in the departments hand hygiene, and alcohol rub sanitizers at entrance. is remote, the communication is by intercom. The Hand hygiene (HH) is the single most effective way to medical staff is not exposed to the confirmed reduce the spread of germs that cause respiratory disease patients.” [20]. HH after removing PPE is particularly important to remove any pathogens that might have been transferred Discussion to bare hands during the removal process [3]. HCWs are on the front line of the COVID-19 outbreak, and One explanation for the findings of the present study their constant exposure to infected patients and contami- that HCWs view HH as less protective of them might be nated surfaces puts them at risk for acquiring and transmit- the cognitive bias that exists among many of them, as it ting the infection. Current global stockpiles of PPE are does in the general public, whereby they perceive PPE as insufficient, driven not only by the number of COVID-19 a solution but forget to perform HH in the course of cases but also by misinformation, panic buying and stockpil- their work [21]. ing [1, 11, 12]. Major distributors in the United States have This interpretation is consistent with other research in already reported shortages of PPE [3, 13]. the literature about the prevention of hospital-acquired The findings of the present study point to the gap the infections, which indicates that despite a variety of inter- HCWs perceive between the applicability of the existing ventions conducted for HCWs, the levels of compliance Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 6 of 7 with HH still remain low at 50–60% [22–24]. during the Limitations COVID-19 crisis Reports from China indicate that The research limitation is that this is not a representative suboptimal HH after contact with patients was linked to sample of all HCWs in Israel. However, the questionnaire COVID-19 [25, 26]. Long exposure time to large was filled out by diverse sectors of the Jewish and Arab numbers of infected patients directly increased the risk populations working in the Israeli healthcare system, both of HCW infections [11, 12]. in the community and in hospitals. Follow-up studies Another guideline perceived as applicable but less might examine HCWs’ perceptions concerning the guide- protective is masks for contact with symptomatic pa- lines for treating COVID-19 patients: guidelines about tients. The professional literature indicates uncertainty care, their level of applicability, and suggestions from the about the effectiveness of wearing masks. Some say staff can contribute important information to the health- that wearing a mask can lead to false confidence [27]. care system. It is possiblethat thedisputeabout the degreeof protection from masks led the respondents to indicate Conclusions a gap between applicability and protection. It is also The HCWs on the front line of this global crisis need possible that the uncertainty that still exists about the the support of the authorities not only to provide transmission of the coronavirus (droplet or airborne) missing equipment, but also to communicate the risks to also contributed to the gap found in regard to masks them. Emerging infection diseases communication [34] between its applicability and the degree of its protec- is a critical strategy not only for conveying information tion against contagion [2]. to the general public, but also for HCWs [35–37]. Recent studies in the field of infection control indicate Furthermore, including the personnel, while discussing that the official guidelines focus on the temporal order with them the level of applicability of the guidelines and of actions in their broadest sense and cannot be totally the way they perceive the risks, can help the authorities comprehensive as exigency situations arise from the communicate with their staff effectively and adjust the dynamic nature of the work, that exist in the care guidelines to the reality on the ground. Furthermore, continuum [28, 29]. including the HCWs and enabling them to contribute Respectively, in a crisis such as the COVID-19 epi- additional solutions that can prevent infection is signifi- demic, the staff faces new situations they did not con- cant and can help the overall effort. ceive of before, as the virus spreads. Therefore, in the study we asked the respondents to share with us add- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. itional practices they perform that cannot be found in 1186/s13756-020-00812-8. existing guidelines. The HCWs raised creative practices that indicate the importance of including the staff when Additional file 1: Table S5. Questionnaire for healthcare workers. confronting an epidemic crisis. Guidelines that are Additional file 2: Table S6. Guideline applicability and protective value: handed down from above are insufficient in a changing a comparison between sectors (Kruskal-Wallis Tests) (N=242). reality and it is important to hear the staff and accom- modate them. Abbreviations This study indicates there is a PPE shortage of for HCWs: Healthcare workers; HH: Hand hygiene; MOH: Ministry of Health; PPE: Personal protective equipment; WHO: World Health Organization HCWs in Israel like in other countries [30]. Many of the HCWs (69%) noted the PPE shortage. The HCWs Acknowledgements executives interviewed for this research noted that the The authors would like to thank all the participants of this study. PPE shortage led to feelings of anger and frustration Authors’ contributions among the HCWs. During the crisis in Israel due to the AGE is the principal investigator and she has conceptualized the study, data PPE shortage for its employees, the MOH issued a state- analysis written the manuscript and taken full responsibility for the study. RC, ment at a press conference in mid-March, saying that NAES and RH are co-researchers who participated in the conceptualized of the study, data analysis and written the manuscript. The author(s) read and HCWs do not need to wear PPE regularly but rather approved the final manuscript consider the situations in which they should do so [31]. Following the MOH statement, senior doctors from Funding None. across the country came together and sent a letter to the government stating that their voices were not being Availability of data and materials heard, and that the state was abandoning them due to Requests for more detailed information regarding the study can be addressed to the corresponding author. the severe shortage of PPE [32, 33]. The MOH statement was perceived as an excuse to cover up the inadequacy Ethics approval and consent to participate of the Israeli healthcare system, of which the PPE This study was approved by the ethics committee of The Faculty of Social shortage is only one example [7]. Welfare and Health Sciences at the University of Haifa (confirmation number Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 7 of 7 08/22). All the study participants gave their consent to participate in the 21. Sani Y. Stop wearing gloves. 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A mixed-methods sequential explanatory design comparison between COVID-19 infection control guidelines’ applicability and their protective value as perceived by Israeli healthcare workers, and healthcare executives’ response

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Abstract

Background: Healthcare workers (HCWs) are on the front line of the COVID-19 outbreak, and their constant exposure to infected patients and contaminated surfaces puts them at risk of acquiring and transmitting the infection. Therefore, they must employ protective measures. In practice, HCWs in Israel were not fully prepared for this sudden COVID-19 outbreak. This research aimed to identify and compare: (1) Israeli HCWs’ perceptions regarding the official COVID-19 guidelines’ applicability and their protective value, and (2) HCWs executives’ response to HWCs’ concern regarding personal protective equipment (PPE) shortage. Methods: A mixed-methods sequential explanatory design consists of: (1) An online survey of 242 HCWs about the application of the guidelines and PPE, and (2) Personal interviews of 15 HCWs executives regarding PPE shortage and the measures they are taking to address it. Results: A significant difference between the perceived applicability and protective value was found for most of the guidelines. Some of the guidelines were perceived as more applicable than protective (hand hygiene, signage at entrance, alcohol rub sanitizers at entrance, and mask for contact with symptomatic patients). Other were perceived as less applicable than protective (prohibited gathering of over 10 people, maintaining a distance of 2 m’, and remote services). Conclusions: HCWs need the support of the healthcare authorities not only to provide missing equipment, but also to communicate the risk to them. Conveying the information with full transparency, while addressing the uncertainty element and engaging the HCWs in evaluating the guidelines, are critical for establishing trust. Keywords: COVID-19, Infection control guidelines, Healthcare workers, Applicability and protective value, Perception * Correspondence: ageser@univ.haifa.ac.il School of Public Health and the Health and Risk Communication Research Center, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel Head of Health Promotion Program, School of Public Health, Founding Director of the Health and Risk Communication Research Center, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 2 of 7 Background Methods COVID-19 is a contagious viral infection, caused by Research design newly identified virus [1]. Presentation can range from This research is based on mixed-methods sequential ex- no symptoms to severe illness including pneumonia, planatory design [8]. The quantitative research is the main respiratory failure, septic shock, and multi-organ failure, research, conducted through an online survey of 242 which may result in death [1]. HCWs concerning the application of the guidelines and There is a dispute as to how the virus is transmitted from protective measures. The secondary qualitative research one person to another (droplet or airborne transmission). examined 15 healthcare executives’ perceptions of the Recently, the World Health Organization (WHO) declared HCWs’ reports of a PPE shortage, and the actions they that current information indicated that transmission is took to address that issue using personal interviews [8]. usually by droplets [2]. Droplet transmission occurs when a person is in close contact (within 1 m’)withsomeone who Sampling and data collection has respiratory symptoms (e.g., coughing or sneezing) and An online questionnaire was designed using the Qualtrics is therefore at risk of having his/her mucosae (mouth and XM software for a deliberate nonprobability sampling [9] nose) or conjunctiva (eyes) exposed to potentially infective of the population of HCWs. This method was selected respiratory droplets. However, the organization declares because the COVID-19 crisis requires social distancing, there is still uncertainty about airborne contagion, and preventing face-to-face interviews. Furthermore, HCWs concludes that “these initial findings need to be interpreted are the busiest population at this time. carefully” [2]. Therefore, some countries and organizations, The survey was distributed in March 2020 to HCWs including the US and European Centers for Disease Control using three main social media platforms: Facebook, and Prevention recommend airborne precautions for any WhatsApp, and Instagram. The first stage was deliberate situation involving the care of COVID-19 patients [3, 4]. intensive sampling through posts on specific social On 30 January 2020, the WHO Director-General media forums for healthcare workers, such as the forum declared that the current outbreak constituted a public of nurses in Israel, the forum of Arab doctors in Israel, health emergency of international concern. Avoidance of and more. Meanwhile, the questionnaire was sent to exposure is the single most important measure for directors of health funds and hospitals and from there preventing COVID-19, so-called “social distancing.” In was distributed to their employees on WhatsApp. The the case of HCWs, they must wear PPE including gloves, second stage was snowball sampling [10] to reach medical masks, goggles or a face shield, and gowns, as well broader circles of healthcare workers. as for specific procedures, respirators and aprons [1, 3]. In the qualitative research, we performed intensive At the end of February 2020, the WHO published rec- sampling of health executives and senior physicians. The ommendations for the rational use of PPE in healthcare study was advertised through WhatsApp groups, and and community settings that aims to provide informa- executives and physicians who agreed to participate in tion about when PPE use is most appropriate [1, 5]. the study contacted the researchers to schedule tele- In Israel theMinistryofHealth (MOH) at the beginning phone interviews. Each interview lasted 20–30 min. of March published “Guidelines for dealing with COVID-19 for health professionals in healthcare settings” [6]Even Study population though Israel was one of the first countries to understand A total of 292 HCWs filled out the online questionnaire, the severity of the epidemic, and the MOH had taken drastic however 50 (17%) questionnaires were not fully measures to close the country’sborders[7], the State Comp- completed. Those questionnaires were taken out of the troller’s report declared that Israel is not prepared for the sample, leaving 242 HCWs (Table 1) who fully completed COVID-19 epidemic and that the MOH has no organized the questionnaire. That was done only after verifying that plan to mitigate the shortage gaps in inpatient beds, medical the main research findings did not differ when the whole teams, and PPE. set of questionnaires (292) was included in the statistical Considering the critical issues regarding guidelines for analysis. dealing with COVID-19 for healthcare professionals in In the qualitative research 15 health executives and healthcare settings and the lack of evaluation studies senior physicians participated, including 6 (40%) hospital regarding the implications of the formal guidelines, this directors, 3 (20%) healthcare fund directors, 3 (20%) article seeks to: (1) Identify the attitudes and perceptions of directors of medical organizations, and 3 (20%) senior Israeli HCWs regarding official guidelines (their applicabil- physicians. ity, protection of HCWs, and spread prevention); (2) Present behavioral practices proposed by the front-line The research process HCWs; and (3) present senior health executives’ response The quantitative questionnaire consisted of questions on to the PPE shortage. sociodemographic details and questions on the guidelines Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 3 of 7 Table 1 Healthcare workers socio-demographic characteristics Wilcoxon Signed-Ranks test for dependent measures. (N = 242) Furthermore, Friedman’s test was conducted in order to Characteristic N (%) check for efficacy differences among the guidelines. In the second stage, the findings of the open questions Sector in the questionnaire were coded into categories on the Physician 34 (14) additional protective measures that do not exist in the Nurse 109 (45) guidelines. In the third stage the report of missing PPE Paramedic 61 (25) was integrated with a content analysis of the personal in- Administration 38 (16) terviews with the HCWs executives about their response Location to the PPE shortage. Hospital 113 (47) Reliability and validity Community 129 (53) Before the questionnaire was distributed, a pilot study Gender was conducted among 20 participants in order to refine Male 71 (29) the questions and prevent information bias. The ques- Female 171 (71) tions were written in Hebrew and translated into Arabic Age and later re-translated to Hebrew in order to check their wording. In addition, in order to test the validity of the < =30 69 (29) guidelines we presented in the questionnaire, and in 31–40 100 (41) order to check for sectorial differences (physicians, 41–50 37 (15) nurses, paramedics and administrative workers) 51–60 29 (12) concerning perceptions of the protection guidelines, 61+ 7 (3) Kruskal-Wallis tests were performed on each guideline. Three perceptions were examined for each guideline; its for HCWs for the COVID-19 crisis based on MOH guide- level of applicability, its protectiveness for the healthcare lines [6]. The questions about the MOH guidelines worker, and its preventive level against the public’s con- included questions about the applicability of each tagion. No significant differences were found between guideline and the protection it offers the worker and the 4 sectors on all these comparisons, which eliminates the public against contagion with the COVID-19 (See the need to consider this parameter in further analysis of Additional file 1). For each guideline, the participants these data (See Additional file 2). were asked to rank its level of applicability, and the The brief qualitative interviews with the directors were way they perceive its protection against their own conducted in the Arabic and Hebrew languages. All of contagion and the public’s. The ranking was based on the interviews were recorded, transcribed, and translated a Likert scale from 1 (not at all) to 5 (very much). into Hebrew. The transcription of the interviews in the Thenextpartofthe questionnaireincludedopen Arabic language was performed by two Arabic-speaking questions about the PPE and a question about other researchers who speak both languages. protective practices HCWs perform, which are not in the official guidelines. Results After finishing collecting the quantitative data, an The comparison between the applicability of each guide- interesting issue emerged from the open question in the line and its protective value was done using a Wilcoxon qualitative research, about a shortage of PPEs on the Signed-Ranks test for dependent measures (Table 2). ground. Therefore, in the personal interviews with A significant difference between applicability and hospital directors and senior officials, the two following protective value was found for several guidelines, except questions were included: (1) How do you perceive the for three guidelines (using gloves and gown, mask for issue of PPE shortage? and (2) What actions are you symptomatic patients, and questioning at entrance). taking to address this issue? Some of the guidelines are perceived as more applicable than protective (hand hygiene, signage at entrance, alco- Analysis hol rub sanitizers at entrance, and mask for contact with In the first stage, we performed a statistical analysis to symptomatic patients). Three guidelines are perceived as test the difference between the applicability of the guide- less applicable than protective (prohibited gathering over line and its degree of protection/contagion prevention 10 people, maintaining a distance of 2 m’, and remote for each of the MOH guidelines. The comparisons be- services). tween the applicability of the guidelines and the degree Friedman’s test was conducted in order to check for of protection and contagion prevention were made by a efficacy differences among the guidelines. The different Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 4 of 7 Table 2 Guidelines applicability average degree compared to its protective value (“protecting me” and “prevent contagion”)(N = 242) a b Guideline Applicable Protect/Prevent Contagion Test Statistic (S) p-value Adjusted p Hand hygiene 4.5 4.0 4122.5 <.0001 <.0001 Gloves and gown 3.9 3.7 960.0 0.02 0.20 Signage at entrance 4.4 3.8 3190.5 <.0001 <.0001 Alcohol rub sanitizers at entrance 4.3 4.0 1593.5 <.0001 <.0001 Mask for symptomatic patients 3.8 3.9 − 446.0 0.20 0.89 Mask for contact with symptomatic patients 4.3 3.9 1923.5 <.0001 <.0001 Prohibited gathering over 10 people 3.6 3.8 − 1020.5 0.004 0.04 Maintaining a distance of 2 m’ 3.0 3.7 − 3470.5 <.0001 <.0001 Questioning at entrance 3.5 3.6 − 754.5 0.08 0.58 Remote services 3.9 4.4 − 2277.0 <.0001 <.0001 Wilcoxon Signed-Ranks tests Sidak adjustment for multiple testing guidelines were examined using an overall measure of situation because my staff members are afraid of efficacy which averages the applicability and the protect- contagion during treatment.” ive value of each guideline. Test results (Table 3) show significant differences (χ2(9) = 553.5, P < 0.0001) between “Right now, I as a physician and the medical personnel the guidelines. around me are very exposed to the disease. They are Additional practices that do not appear in the official barely protected, and it disturbs me. When a patient guidelines against COVID-19, were suggested by the comes to my room, I don't know anything about them, HCWs (Table 4). what their condition is, whether they were exposed or The HCWs also reported a shortage of PPEs. The main not, infected or not. Our chances of contagion are very shortages reported (by rate of respondents) are of face- high. There is not sufficient protective gear, there are masks (19%), gowns (16%), general protective gear (10%), not even temperature checks.” disinfectant (10%), gloves (7%), and surgical masks (7%). The response of the HCWs executives to the HCWs’ “There is a feeling that protection of the human concern over PPE shortages included three main themes, resource is insufficient, there is neither a health nor that are present with their selected quotes. an economic safety net.” (1) HCWs’ fears of contagion (2) Adjusting expectations and resource allocation “As deputy director I see a tremendous shortage of “There is tremendous anger among the staff about equipment. It is extremely difficult to deal with the the equipment shortage. I try to solve it by setting Table 3 A comparison of guideline applicability and protective value using an overall measure of efficacy (N = 242) a b Guideline Overall measure of efficacy Chi-Square DF p-value Hand hygiene 4.2 317.52 9 < 0.001 Remote services 4.2 Alcohol rub sanitizers at entrance 4.2 Signage at entrance 4.1 Mask for contact with symptomatic patients 4.1 Mask for symptomatic patients 3.8 Gloves and gown 3.8 Prohibited gathering over 10 people 3.7 questioning at entrance 3.5 Maintaining a distance of 2 m 3.3 Averages the applicability and the protective value of each guideline Friedman’s test Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 5 of 7 Table 4 Additional practices suggested by the HCWs that do guidelines and the protection of HCWs against conta- not appear in the official guidelines against COVID-19 gion and infecting the public. These findings indicate Practice No. Practice description the gap that has been documented in the literature, not only in the COVID-19 epidemic, between the official 1 Eating healthy, vitamin C-fortified food, and drinking a lot of water infection prevention guidelines and what happens on the 2 Rinsing nostrils with water and soap after shift ground [14]. The findings of the present study indicate that three 3 Disinfecting personal belongings before going home guidelines are perceived as less applicable than protect- 4 Disinfecting cell phone, keyboard, mouse, and other ive: prohibited gathering of over 10 people, maintaining equipment throughout the day a distance of 2 m’, and remote services. 5 Changing clothes and disinfecting shoes when entering the house A possible interpretation to that is that the Israeli healthcare system has fewer staff positions and man- 6 Washing work clothes separately power than the Organisation for Economic Co-operation 7 Opening doors with elbow and Development (OECD) countries [15]. Israel has a 8 Thorough cleaning of surfaces and chairs tremendous overload on its healthcare system that is 9 Cleaning steering wheel and car door handles reflected by long lines [15–17]. The HCWs feel they 10 Showering at the end of shift before going home cannot question the people who come in during the cor- onavirus crisis because they do not have enough time an optimal protection level for use per team. The and there is a personnel shortage. In addition, since the idea is to control the amounts and not let the hospitals and health funds are at full capacity all the workers go crazy...” time, during the COVID-19 crisis the pressure increases, and it is difficult to reduce the congregating and main- “I sat with all the teams, from all the departments in tain a distance between people. Another possible explan- the clinic, we developed a work procedure, which ation for the difficulty to maintain a distance is the team members need to be protected, and then cultural component. Israeli society has a culture of social together we came up with a “portion” of PPE based intimacy where it is not common to keep a physical dis- on the number of staff members, the number of tance. Moreover, there are geographical areas in Israel patients, and which needs or cases they deal with. with high population density where people congregate, Every morning each team gets its portion. It will such as the Arab and ultra-Orthodox communities. In prevent misunderstandings and help the team the COVID-19 crisis in Israel certain populations have understand the situation better.” reportedly had difficulty following the guidelines, making (3) Remote services. it hard for the HCWs to maintain the specific guidelines concerning social distancing. For example, the ultra- “We use videoconferencing in the treatment room, Orthodox community in Israel found it difficult to fol- to reduce to a minimum the medical staff's exposure low the guidelines and suffered from some of the highest to patients and contagion.” infection rates in the country [18, 19]. The findings also indicated that some guidelines were “Currently the communication between the medical perceived as more applicable than protective, such as staff and the COVID-19 patients in the departments hand hygiene, and alcohol rub sanitizers at entrance. is remote, the communication is by intercom. The Hand hygiene (HH) is the single most effective way to medical staff is not exposed to the confirmed reduce the spread of germs that cause respiratory disease patients.” [20]. HH after removing PPE is particularly important to remove any pathogens that might have been transferred Discussion to bare hands during the removal process [3]. HCWs are on the front line of the COVID-19 outbreak, and One explanation for the findings of the present study their constant exposure to infected patients and contami- that HCWs view HH as less protective of them might be nated surfaces puts them at risk for acquiring and transmit- the cognitive bias that exists among many of them, as it ting the infection. Current global stockpiles of PPE are does in the general public, whereby they perceive PPE as insufficient, driven not only by the number of COVID-19 a solution but forget to perform HH in the course of cases but also by misinformation, panic buying and stockpil- their work [21]. ing [1, 11, 12]. Major distributors in the United States have This interpretation is consistent with other research in already reported shortages of PPE [3, 13]. the literature about the prevention of hospital-acquired The findings of the present study point to the gap the infections, which indicates that despite a variety of inter- HCWs perceive between the applicability of the existing ventions conducted for HCWs, the levels of compliance Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 6 of 7 with HH still remain low at 50–60% [22–24]. during the Limitations COVID-19 crisis Reports from China indicate that The research limitation is that this is not a representative suboptimal HH after contact with patients was linked to sample of all HCWs in Israel. However, the questionnaire COVID-19 [25, 26]. Long exposure time to large was filled out by diverse sectors of the Jewish and Arab numbers of infected patients directly increased the risk populations working in the Israeli healthcare system, both of HCW infections [11, 12]. in the community and in hospitals. Follow-up studies Another guideline perceived as applicable but less might examine HCWs’ perceptions concerning the guide- protective is masks for contact with symptomatic pa- lines for treating COVID-19 patients: guidelines about tients. The professional literature indicates uncertainty care, their level of applicability, and suggestions from the about the effectiveness of wearing masks. Some say staff can contribute important information to the health- that wearing a mask can lead to false confidence [27]. care system. It is possiblethat thedisputeabout the degreeof protection from masks led the respondents to indicate Conclusions a gap between applicability and protection. It is also The HCWs on the front line of this global crisis need possible that the uncertainty that still exists about the the support of the authorities not only to provide transmission of the coronavirus (droplet or airborne) missing equipment, but also to communicate the risks to also contributed to the gap found in regard to masks them. Emerging infection diseases communication [34] between its applicability and the degree of its protec- is a critical strategy not only for conveying information tion against contagion [2]. to the general public, but also for HCWs [35–37]. Recent studies in the field of infection control indicate Furthermore, including the personnel, while discussing that the official guidelines focus on the temporal order with them the level of applicability of the guidelines and of actions in their broadest sense and cannot be totally the way they perceive the risks, can help the authorities comprehensive as exigency situations arise from the communicate with their staff effectively and adjust the dynamic nature of the work, that exist in the care guidelines to the reality on the ground. Furthermore, continuum [28, 29]. including the HCWs and enabling them to contribute Respectively, in a crisis such as the COVID-19 epi- additional solutions that can prevent infection is signifi- demic, the staff faces new situations they did not con- cant and can help the overall effort. ceive of before, as the virus spreads. Therefore, in the study we asked the respondents to share with us add- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. itional practices they perform that cannot be found in 1186/s13756-020-00812-8. existing guidelines. The HCWs raised creative practices that indicate the importance of including the staff when Additional file 1: Table S5. Questionnaire for healthcare workers. confronting an epidemic crisis. Guidelines that are Additional file 2: Table S6. Guideline applicability and protective value: handed down from above are insufficient in a changing a comparison between sectors (Kruskal-Wallis Tests) (N=242). reality and it is important to hear the staff and accom- modate them. Abbreviations This study indicates there is a PPE shortage of for HCWs: Healthcare workers; HH: Hand hygiene; MOH: Ministry of Health; PPE: Personal protective equipment; WHO: World Health Organization HCWs in Israel like in other countries [30]. Many of the HCWs (69%) noted the PPE shortage. The HCWs Acknowledgements executives interviewed for this research noted that the The authors would like to thank all the participants of this study. PPE shortage led to feelings of anger and frustration Authors’ contributions among the HCWs. During the crisis in Israel due to the AGE is the principal investigator and she has conceptualized the study, data PPE shortage for its employees, the MOH issued a state- analysis written the manuscript and taken full responsibility for the study. RC, ment at a press conference in mid-March, saying that NAES and RH are co-researchers who participated in the conceptualized of the study, data analysis and written the manuscript. The author(s) read and HCWs do not need to wear PPE regularly but rather approved the final manuscript consider the situations in which they should do so [31]. Following the MOH statement, senior doctors from Funding None. across the country came together and sent a letter to the government stating that their voices were not being Availability of data and materials heard, and that the state was abandoning them due to Requests for more detailed information regarding the study can be addressed to the corresponding author. the severe shortage of PPE [32, 33]. The MOH statement was perceived as an excuse to cover up the inadequacy Ethics approval and consent to participate of the Israeli healthcare system, of which the PPE This study was approved by the ethics committee of The Faculty of Social shortage is only one example [7]. Welfare and Health Sciences at the University of Haifa (confirmation number Gesser-Edelsburg et al. Antimicrobial Resistance and Infection Control (2020) 9:148 Page 7 of 7 08/22). All the study participants gave their consent to participate in the 21. Sani Y. Stop wearing gloves. 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Published: Sep 4, 2020

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