Bríd Phillips // For those of you who have never had to wonder about Western Australia (WA) or indeed Australia itself beyond the beautiful beaches, kangaroos, and Crocodile Dundee, here are a few facts to help you put the country and its people into context. The population of Australia sits just under 26 million, and around 2.5 million of those live in the vast state of WA. WA accounts for 33% of the Australian continent and is four times the size of Texas, and twelve times bigger than the United Kingdom. 79% of Western Australians live in the capital, Perth. These demographics point to a state that is vulnerable in a crisis, as there are no easy means of getting manpower, equipment, or general supplies into the state. In January this year, the only sealed road between Western Australia and South Australia was closed for 12 days due to bushfires. This caused supply issues for many goods, including basics such as fruit and vegetables.
Recovering from a devastating bushfire season, the country is threatened by a global pandemic. As of April 21, 2020, 71 people have died from COVID-19 in Australia, with the majority of cases having contracted the disease overseas. Modeling released on April 7, 2020, shows peak daily ICU bed demand under 3 different scenarios in the current pandemic: Uncontrolled spread, 35,000; isolation and quarantine, 17,000; isolation, quarantine and social isolation, below 5,000. Australia has the ability to boost intensive care unit (ICU) bed capacity to around 7, 000 beds, which means the toughest measures needed to be put in place.
The government of Western Australia declared a state of emergency on March 15, 2020. The state border was closed at 11:59 p.m. April 5, 2020, which means that you cannot enter WA unless an exemption has been granted. Exemptions include government officials, active military personnel, and urgent and essential medical treatment. Travel within the state is restricted to avoid bringing COVID-19 to indigenous communities or remote towns without a single case of infection. All Western Australians are asked to stay at home unless shopping for food, attending to medical or health care needs, exercising in groups of no more than two, and working or studying if unable to undertake these activities remotely.
Perhaps surprisingly, in WA, the main employment in 2011 was healthcare and social assistance, which has perhaps been a factor in our ability to respond to COVID-19. At present, the health system has capacity due to fewer influenza cases, fewer serious injuries including car accidents, and reduced elective surgery. However, there is a dissonance between the statistics and the emotional reality of staff on the frontline. In five short weeks, lives have been turned upside down and frontline workers live COVID-19 twenty-four hours a day. Although the disease trajectory is vastly different here in WA, there is still an emotional cost. An emergency nurse leader said, “It has been like watching a tsunami coming so slowly towards us while the rest of the world is at war.” And after a frantic period of preparation, there is a sense of waiting for things to go off.
I spoke to a range of clinical staff* and some recurring emotional responses appear. Anxiety and fear figure largely with everyone I spoke to. Anxieties focused initially on how to deal with the constant onslaught of information from a variety of news and professional sources. An emergency consultant noted that “there was high anxiety around the uncertainty, but we have had an opportunity to figure it out, which has been good to help manage the anxiety.” There is also nervousness around going from work to home, and the possibility of infecting loved ones. Have I washed and wiped, donned and doffed to perfection? With this virus there seems to be no room for error.
Anxieties soon escalated to fear, which initially was provoked by the some of the same triggers. A senior ICU nurse said that “initially we … were so scared, we watched TV (news) and that frightened us. Staff were very scared, we all thought we would get sick and infect our families. Lots of staff cried, myself included (at home). … Senior nursing staff were very brave and led by example and fear lessened.” Even in the midst of a fearful time, there have been heartening leadership moments of courage and strength which have not gone unnoticed.
There is fear now in the everyday. For example, when a patient comes in with chest pain, staff are alert for any sign of a cough or fever: could they have COVID as well? Does the febrile expectorating patient have a post-operative chest infection or should we suspect COVID? After initial frantic preparations, another concern is being raised by several staff working across different clinical fields: if restrictions are relaxed, will there be a rebound of COVID cases undoing all the hard work that has been put in so far to keep our state safe? A physiotherapist remarked, “I am worried that we haven’t had the winter months. Lots of influenza patients to come. It could go either way.” In the southern hemisphere, people are worried that our winter flu season could herald a second wave of viral attack. This is an unknown globally as the northern hemisphere greets spring and a lessening of the viral stranglehold.
Stress is heightened by a lack of escape for frontline workers from COVID. One health professional noted that, “even when having virtual catch-ups or drinks with friends, there are constant questions directed at me about COVID. I can’t get away from it.” Socializing with non-healthcare staff seems to be adding to the emotional burden suffered by those working in health.
Other staff have noticed a possible generational difference when it comes to stress. Those with young families appear stressed about potential risks to themselves and their families, while those who are older find the volume of electronic information overwhelming: constant emails, Microsoft team meetings, WhatsApp, Zoom, etc. Once the initial, fevered activity settled into a new norm, however, the volume of information decreased and this stress lessened.
One physiotherapist noted that younger staff became more stressed, but “maybe that is because they have not been through anything like this before: they do not remember 9/11 or even swine flu.” Meanwhile, those who had treated swine flu patients are getting flashbacks to that experience now. And despite everyone’s best efforts, there have been communication issues, which has led to stress around evolving policies and procedures, the COVID-19 status of patients, and the correct PPE for each clinical situation. Such stressors are difficult to mitigate in the fast-paced pandemic environment.
There is tension when staff on the floor do not understand the sheer amount of work that goes on behind the scenes. “In just six weeks,” one educator said, “we got turned upside down and education planning that could take months has been done in 1-2 days to roll out COVID-19 education.” Some new ways of practice are horrifying to clinicians who always put the patient first, but now it is the safety of staff that has to come first. Otherwise staff risk sickness or even death. There is also a sense of frustration: “We have done all this preparation work and we are ready and just waiting.” Time is being marked and there is worse to come. The clinical routine has changed: continuing education, team meetings, and elective surgeries have been cancelled. Emergency wards continue to be busy, but routine surgical wards are quiet—the eye of the storm, perhaps?
A lot of our clinical staff from overseas are directly affected by events happening to family and former colleagues. Guilt becomes compounded by feelings of helplessness when we live so far away. Staff feel much guilt that across the globe there are terrifying occurrences of the virus. There is also a strong feeling of empathy for international healthcare workers working in tragic circumstances. All healthcare workers are our colleagues. We are learning from their mistakes and successes. We feel both lucky and guilty for having the gift of time to prepare. Frontline staff in WA thought at the beginning that we could be in the same situation as hotspots such as Italy or New York, but this has not happened. So there has been further guilt when the community started sending us support, such as food, because “we have not done anything to deserve that.” There is a feeling of inadequacy around living up to the image of the hard-working frontline worker, when the surge has not yet happened.
Having the time to prepare has been felt as a real gift in WA. For many staff, stress management has been focused on practical work measures and good communication. Sometimes there can be the impression that the critical care worker is an adrenaline junkie, but that persona is changing and we are aware that not all of our junior staff may be built that way. Practical departmental measures such as regular Zoom meetings where staff on and off-duty can take part have been hugely beneficial. Additionally, a lot of frontline staff take a break from media outlets when they get home. One worker noted, “I have stopped focusing on the news as it was freaking me out.” Giving ourselves a mental break is a recurrent theme. Some staff are focusing on small pleasures such as crime novels, exercising at home, and jigsaw puzzles. Some have put energy into learning to compartmentalize work and leave it behind at the end of the day. These strategies have had varying degrees of success, but there is a consistent acknowledgement that we all need to look after both our mental and physical well-being.
While the abnormal has been normalized to a certain extent, there are underlying concerns. Will we face a rebound when restrictions are lifted? Will developing countries suffer devastations? Will junior staff get the best teaching they could have? However, despite present upheavals, clinical staff have put some critical thought into the shape of healthcare in the future. Concepts include researching emotional responses and how we can manage those, regular team downtime exercises such as narrative medicine group sessions, and an increased focus on staff safety. The reality that frontline staff may suffer from PTSD is a key concern, while communication, kindness, leadership, and wellness for staff are considered ways to positively recover in the months and years to come.
The emotion words highlighted in this piece reflect common reactions and point to an emotional community which is operating in a different way to other social groups in the wider community. Naming or expressing emotions has helped some to organize and process their experience (Scheer 212). Every healthcare worker I spoke with has taken time out to consider fully their experiences and their emotional responses. The lived experiences of those behind the lines needs to be heard. Discussions have revealed the dissonances between the buoyant public mood towards the results that containment has achieved, and the emotional reality amongst WA healthcare staff. Actively listening to their experiences will point to ways we can support the workers who will always support us.
*Staff who generously took time to be part of my discussions include an ICU consultant, ICU nurse, ED Consultant, ED senior nurse, ED Clinical Nurse, speciality physiotherapist, and staff development nurse. My sincere thanks to them for their kindness and strength while sharing their experiences.
Note: All facts were correct at the time of writing, but in a rapidly evolving situation information will change from hour to hour.
“COVID-19 at a glance.” Australian Government, Department of Health, www.health.gov.au/sites/default/files/documents/2020/04/coronavirus-covid-19-at-a-glance-coronavirus-covid-19-at-a-glance-infographic_17.pdf Accessed 21 April 2020
“COVID-19 coronavirus: Latest Updates.” Government of Western Australia, Department of the Premier and Cabinet, www.wa.gov.au/organisation/department-of-the-premier-and-cabinet/covid-19-coronavirus-latest-updates Accessed 18 April 2020
“Declaration of State of Emergency.” Government of Western Australia, www.wa.gov.au/sites/default/files/2020-03/Declaration%20of%20State%20of%20Emergency.pdf Accessed 14 April 2020
“FluTracking Tracking COVID-19.” info.flutracking.net/about/ Accessed 14 April 2020
“Modelling how COVID-19 could affect Australia.” Australian Government, Department of Health, www.health.gov.au/news/modelling-how-covid-19-could-affect-australia Accessed 12 April 2020
Moussalli, Isabel, and Jarrod Lucas. “Eyre Highway Reopens.” ABC News, www.abc.net.au/news/2020-01-10/eyre-highway-reopens-after-bushfire-threat-blocks-road/11857678 Accessed 14 April 2020
“Population Clock.” Australian Bureau of Statistics, www.abs.gov.au/AUSSTATS/abs@.nsf/Web+Pages/Population+Clock?opendocument&ref=HPKI Accessed 15 April 2020
“Western Australia, Region Summary.” Australian Bureau of Statistics, itt.abs.gov.au/itt/r.jsp?RegionSummary®ion=5&geoconcept=REGION&dataset=ABS_REGIONAL_ASGS&datasetLGA=ABS_NRP9_LGA&datasetASGS=ABS_REGIONAL_ASGS®ionLGA=REGION®ionASGS=REGION Accessed 18 April 2020
Scheer, M. “Are Emotions a kind of practice (And is that what makes them have a history)?” History and Theory, vol. 51, 2012, pp. 193-220.