Discussion

This research identified that during the first wave of COVID-19 in Australia, frontline HCWs surveyed in April 2020 had several concerns impacting their willingness to work. Compared to pre-pandemic circumstances, over 40% of HCWs were less inclined to work. By April 20, 2020 (the last day the online survey was open for completion) Australia had recorded 6798 cumulative cases, substantially less than the 28000+ recorded by the latter end of January 2021. ² It is uncertain if more HCWs would be disinclined to work the longer the pandemic lasts. Organizational processes and procedures are likely to be more streamlined now than they were at the start of the pandemic, weighed against factors such as fatigue and burnout.

As the pandemic continues, the risks of ongoing physical, psychological, and emotional toll on frontline workers, and their families is of great concern. ^{Reference Raudenská, Steinerová and Javůrková47} The prevalence of traumatic stress in HCWs during the pandemic has been reported as ranging from 7.4–35% with women, nurses, and frontline workers particularly at risk. ^{Reference Benfante, Di Tella, Romeo and Castelli48} It has been recommended that organizations recognize early symptoms of psychological trauma in order to establish appropriate interventions and protective factors to prevent or help alleviate conditions such as severe depression, post-traumatic stress disorder, and substance abuse from developing. ^{Reference Benfante, Di Tella, Romeo and Castelli48} A 2019 investigation of American nurses concluded burnout was likely to impact on work performance. ^{Reference Dyrbye, Shanafelt, Johnson, Johnson, Satele and West49} A third of participants reported at least 1 symptom of burnout (35%), 30% had symptoms of depression, and 16% disclosed absenteeism. Work performance was self-rated as ‘poor’ in 10% of nurses without burnout, and 27% of nurses with burnout. ^{Reference Dyrbye, Shanafelt, Johnson, Johnson, Satele and West49} Factors such as burnout and depression could potentially impact on the quality of patient care. The investigation was conducted prior to COVID-19 and raises concerns regarding the ability of HCWs to maintain adequate standards of patient care during periods of heightened workplace stress such as the COVID-19 pandemic.

With regard to Social distancing from family, Social distancing from community members, or Caring responsibilities, the extent to which these factors impacted willingness to work were no different between professions (Table 1), although paramedics had a lower mean score for all 3 categories than nurses and MDs. With respect to Concern expressed by family members, this impacted nurses significantly more than paramedics. This survey did not explore family and parental commitments extensively, but occupational exposure to COVID-19 could be a concern to family members of HCWs, particularly if children are part of the family unit. Influenza pandemics have shown childcare obligations can significantly affect frontline HCWs willingness to work, and even young children can be aware of the risks of their HCW parents being exposed to COVID-19 in the workplace. ^{Reference Aoyagi, Beck, Dingwall and Nguyen-Van-Tam34,Reference Skokauskas, Leventhal, Cardeli, Belfer, Kaasbøll and Cohen50}

Some HCWs with pre-existing medical conditions reported feeling unsupported by their employers (Table 2). While there is no current evidence that pregnant HCWs are at elevated risk of infection from COVID-19, ^{Reference Hanna, Hanna and Sharma51} the psychological impact from anxiety cannot be ignored. ^{Reference Moyer, Compton, Kaselitz and Muzik52} A recent Austrian study found that the pandemic was having a profoundly negative effect on the psychological health of pregnant women, with nearly 50% of their participants working in essential services or as HCWs. This demonstrates the need for workplaces to consider employees’ physical and mental well-being and scrutinize existing policies concerning employee welfare. Various HCWs expressed a desire to work in a role away from the frontline, as they or their family members were in a ‘high risk’ category. It is possible some organizations are unable to do this, lacking alternative roles and suitable replacements for frontline work. However, there should be appropriate communications and policies in-situ to manage these challenges. Research has underscored the need for suitable pre-pandemic preparedness guidelines from organizations in order to handle such disasters appropriately. ^{Reference Anderson, Pooley, Mills, Anderson and Smith42} Employer discontent was a frequently mentioned factor regarding willingness to work amongst our sample, with 45 open-text box comments. An additional 11 comments expressed discontent with the government’s response to the pandemic. Requests for open and honest communication and timely information were frequently noted.

An important consideration for HCWs was the availability of PPE. MDs and nurses suggested Access to PPE was impacting their willingness to work more so than paramedics; however, paramedics still recorded an elevated level of concern with a mean response of 4.14 out of a possible 7 (with 7 representing ‘high impact’). The reason for paramedics being less concerned than other HCWs is unclear. Many possible reasons exist, including knowledge of pre-existing stock levels within their own organization, a higher risk threshold concerning exposure to COVID-19 or potentially clearer messaging from management about how PPE supplies were going to be managed. PPE shortages have been recorded worldwide, ^{Reference Cohen and Rodgers53,Reference Burki54} and Australian HCWs have also had difficulty with access to sufficient PPE. ^{Reference Halcomb, McInnes and Williams31} It has been reported that during Australia’s second wave of COVID-19 cases, up to 70% of COVID-19 infected HCWs acquired the virus through their occupation. ^{Reference Smith55}

Provision of adequate PPE covers multiple aspects of willingness to work: increased occupational exposure and risk of infection, greater risk of transmission to colleagues and family, as well as impacting perceived support from the employer. MDs were significantly more concerned regarding exposure to COVID-19 compared to paramedics, with both MDs and nurses recording higher mean scores (4.87 and 4.67 respectively) compared to paramedics (4.26). In Australia, under the Health and Safety Legislation, the responsibility to appropriately protect employees with PPE falls on organizations. ^{Reference Weekes56}

HCWs being less willing to work during COVID-19 when compared with pre-pandemic times must take a toll on the workplace. Staff morale, physical, and mental health could become eroded over time, as the COVID-19 pandemic continues. Staff shortages from illness, quarantining or absence due to caregiver responsibilities reduce the pool of available workers, potentially affecting care quality, and patient outcomes. ^{Reference Propper, Stoye and Zaranko57} HCWs availability and willingness to work is therefore directly related to capacity within the healthcare system, ^{Reference Rajbhandari and Maharjan36,Reference Foley, Kirk, Jepp, Brophy-Williams, Tong and Davis58} and surge planning will need to incorporate contingencies for HCW availability, and adjust resources and maximum capacity ratings accordingly. ^{Reference Tumlinson, Altman, Glaudemans, Gleckman and Grabowski59}

Clearly, there is a need for open honest communications from management, and timely information on matters such as PPE supplies. The link between perceived organizational support and job performance is clear. ^{Reference Ahmed and Nawaz60} Policies and guidelines for public health emergencies need to include considerations on ‘just in time’ supply chains and sufficient training in infection control appropriate to the disease outbreak. ^{Reference Shokrani, Loukaides, Elias and Lunt61,Reference Miroudot62} HCWs need to feel valued and supported in their role which is becoming increasingly stressful and complex.