In March 2020 the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. Management of this pandemic had significant implications for clinical departments across the world. Healthcare systems were urgently required to reorganise and redesign patient care as well as repurpose staff.
We will share the lived experience of our response as speech therapy and audiology (STA) clinicians to the COVID-19 pandemic.
This study adopted an autoethnographic approach within Bronfenbrenner’s bioecological model to describe STA clinicians’ response to the COVID-19 pandemic.
Adaptations to practice were made to continue service provision whilst adhering to COVID-19 regulations. We assisted in other areas to meet the immediate needs of the hospital. Service delivery strategies consisted of a review of clinical and quality assurance protocols. We developed a telehealth service package which included a hybrid approach, within a context of digital poverty. We created resources to ensure continuity of care. Collaboration within our systems facilitated innovative solutions. Mental health and well-being of staff members were key to the response developed.
South African healthcare systems’ inequalities were highlighted by the pandemic. The response showed that the needs of vulnerable populations were not accounted for when developing this public health response. Lessons learnt included the importance of adaptability, becoming comfortable with uncertainty and maintaining open and transparent communication. Consultation and collaboration within various levels of our healthcare system were critical in responding to the needs of patients. Commitment to compassionate leadership and staff well-being were crucial.
South Africa detected its first case of the coronavirus disease 2019 (COVID-19) in March 2020 (Moonasar et al.,
Our response to the COVID-19 pandemic within a tertiary academic hospital’s STA department in South Africa is narrated using an autoethnographic approach (Dercon et al.,
In fact, Roy and Uekusa (
Bronfenbrenner’s bioecological model provides a systemic, integrated approach that facilitates the understanding of the individual’s experience in a specific context and time within an interdependent system (Bronfenbrenner,
Outline of Bronfenbrenner’s process-person-context-time model.
The STA Department had a staff complement of 47 therapists and 10 auxiliary staff members during this period. The staff profile within our department consisted of white therapists, African therapists, Indian therapists and coloured therapists, with only four men in the group. More than 55% of staff members had less than five years’ experience, with 13 members having just started their community service year. Fifty-three per cent of staff members lived away from their families who resided in other provinces. Our immediate microsystem during the COVID-19 pandemic consisted of a diverse group of people who did not have extensive experience within the public healthcare sector.
The reciprocal interactions between people within the STA Department and the environment within which they function are connected through these various processes (Barach & Johnson,
Microsystems co-exist within a macrosystem (Tudge et al.,
Speech Therapy and Audiology falls under Allied Health with Occupational Therapy, Physiotherapy, Dietetics, Podiatry, Social Work and Orthotics. The heads of these departments, who are not directly involved in hospital management structures, meet monthly and mainly discuss operational issues. The STA Department is interconnected with the broader healthcare system within the province. At a provincial level, we are represented on the executive committee for STA as well as the Rehabilitation Forum which has representation from Occupational Therapy, Physiotherapy and STA. These structures fall under the directorate for Oral Health and Therapeutic Services in Gauteng. The STA Department is therefore integrally linked and accountable to broader structures within the hospital and province. Furthermore, the STA Department provides a clinical platform for STA students from the University of the Witwatersrand and hosts students doing their electives or observations from other universities in the country. Our microsystem is therefore extensive, with our mesosystem consisting of varied levels of interaction and engagement. At a macrosystem, services are informed and planned in accordance with the burden of disease, sociodemographic conditions (Pillay, Tiwari, Kathard, & Chiktay,
Time as defined within the PPCT model will be highlighted in our discussion through identifying the activities that took place within a specific time period, March 2020 to December 2021. The continuous adaptations to processes within the microsystem were also defined by changes within the macrosystem at a particular time, e.g., adapting to the changes in legislature and its impact on services.
The clinical microsystem assessment tool in
Clinical microsystem assessment tool.
Characteristic | Description |
---|---|
Leadership | The role of leaders is to balance setting and reaching collective goals, and to empower individual autonomy and accountability, through building knowledge, respectful action, reviewing and reflecting. |
Organisational support | The larger organisation looks for ways to support the work of the microsystem and coordinate the hand-offs between microsystems. |
Staff focus | There is elective hiring of the right kind of people. The orientation process is designed to fully integrate new staff into culture and work roles. Expectations of staff members are high regarding performance, continuing education, professional growth and networking. |
Education and training | All clinical microsystems have responsibility for the ongoing education and training of staff and for aligning daily work roles with training competencies. Academic clinical microsystems have the additional responsibility of training students. |
Interdependence | The interaction of staff members is characterised by trust, collaboration, willingness to help each other, appreciation of complementary roles, respect and recognition that all contribute individually to a shared purpose. |
Patient focus | The primary concern is to meet all patient needs: caring, listening, educating, responding to specific requests, innovating to meet the patients’ needs and smooth service flow. |
Community focus | The microsystem is a resource for the community; the community is a resource to the microsystem; the microsystem establishes excellent and innovative relationships with the community. |
Performance results | Performance focuses on patient outcomes, avoidable costs, streamlining delivery, using data feedback and frank discussion about performance. |
Process improvement | An atmosphere for learning and redesign is supported by the continuous monitoring of care, use of benchmarking, frequent tests of change and a staff that has been empowered to change. |
Information and information technology | Technology facilitates effective communication and multiple formal and informal channels are used to keep everyone informed all the time, listen to everyone’s ideas and ensure that everyone is connected on important topics. |
Adhering to
A crisis requires ‘positive leadership amid unprecedented change, to lead and function as active, authentic, aware, adaptive, flexible, as well as trusted, engaged and compassionate communicators’ (Hill, Butnoris, Dowling, Macolino, & Patel,
Vision, mission and values of the Speech Therapy and Audiology Department.
Vision | Mission | Values |
---|---|---|
To be the centre of excellence in providing services that enrich the lives of its community | To improve the quality of life for people with and affected by communication, hearing, balance, feeding and swallowing difficulties guided by the principles of best practice, research and national priorities | Patient-centred care Accountability Empowerment Transparency Efficiency Integrity |
According to Heath, Sommerfield and Von Ungern-Sternberg (
Mather (
Research has shown an increase in levels of stress, anxiety and depression of healthcare professionals during the COVID-19 pandemic (Feijt, De Kort, Bongers, Bierbooms, Westerink, & IJsselsteijn,
Healthcare professionals should be provided with evidence-based knowledge and tools to cope with the impact of COVID-19 (Rana, Mukhtar, & Mukhtar,
Speech Therapy and Audiology training and development programme.
Clinical evidence | Staff well-being | Staff safety |
---|---|---|
COVID-19 research: disease profile and clinical presentation | Coping during a pandemic | National regulations |
Ethical decision-making in the public health sector during COVID-19 | Toolkit for emotional coping for healthcare staff | Donning and doffing |
Clinical guidelines, webinars and courses | Mindfulness | Mask usage |
Telehealth | Mental health matters in the workplace: navigating the tsunami of mental health | Hand washing |
A disability inclusive response to COVID-19 | Managing stress | Hospital occupational health and safety training: symptom monitoring, isolation and risk assessments |
Human rights and ethics: was this compromised during COVID-19? | Destigmatising mental health in the workplace | COVID vaccine roll-out |
Providing a safe work environment is a matter of social justice, and healthcare professionals need to be safe to provide care for others (Zungu et al.,
Promoting a safety culture through the development of organisational policies is important for contributing to a better mental health in the workplace (Devaraj,
During the pandemic, a shortage of sanitisers, medical masks and toilet paper and the absence of guidelines on the use of PPE increased anxiety-related behaviours amongst healthcare professionals (Corkery & Maheshwari,
Research has highlighted that the pandemic will have far-reaching psychological impacts including burnout, fatigue, moral injury, depression, increased anxiety and post-traumatic stress for healthcare professionals (Blake, Bermingham, Johnson, & Tabner,
We created a space to share information on events such as online music festivals and ideas on self-care activities, movies, recipes and reading lists. Our well-being activities included mindfulness practice such as adult colouring, beadwork and gratitude practice by making gratitude jars, practising meditation and yoga. A graduation ceremony was hosted for our community service therapists who were denied this opportunity because of COVID-19. Research by Teo et al. (
Stigmatisation of healthcare professionals by their colleagues was rife during the early stages of COVID-19 (Grover, Singh, Sahoo, & Mehra,
Interdependence within the clinical microsystem refers to the interaction of staff, characterised by collaboration, a willingness to help and a recognition that all contribute individually to a shared purpose (Johnson,
Our services were aligned to the different levels of lockdown as indicated on the timeline in
STA Department timeline.
Initial prioritisation guideline.
Level of priority | Speech therapy In and outpatients | Audiology In and outpatients |
---|---|---|
High priority | Swallowing assessment and management of severe oral and pharyngeal phase dysphagia Deep-partial, full-thickness and chemical facial burns at risk of contractures Laryngectomy patients if unable to be assisted telephonically (leaking speech valve, difficulty breathing or swallowing) Tracheostomised patients (blue dye assessments and speech valve trials were stopped) |
Hearing assessment and management of patients with drug-resistant tuberculosis and meningitis Inpatients with severe-profound communication difficulty related to hearing loss Urgent repairs for all hearing devices Patients requiring emergency ENT surgical intervention Ototoxicity monitoring Cochlear implant workup and management of paediatrics, recently implanted patients and those with hearing loss secondary to meningitis |
Medium priority | Communication disorders impacting patients’ abilities to indicate their needs in their immediate environment Oral dysphagia without risk of aspiration in newly diagnosed patients |
Occupational audiology for patients at risk of losing employment Patients with chronic middle ear pathologies requiring baseline audiograms Baseline audiograms required for oncology initiation Neonatal hearing screening Workup of adult cochlear implant candidates and management of all cochlear implant recipients |
Low priority | Oral dysphagia without risk of aspiration in previously diagnosed patients Patients who had at least one established mode of communication (e.g. AAC) Videofluoroscopy studies Patients who were able to implement home and ward exercise programmes independently or with caregiver assistance |
Presbycutic hearing loss Patients previously fitted with a hearing device Annual cochlear implant follow-up |
AAC, alternate and augmentative communication.
The above guidelines were continuously reviewed and adjusted according to emerging evidence and levels of lockdown. Risk reduction strategies included stopping high-risk procedures like speech-valve trials and modified Evans blue-dye tests (Cameron, Reynolds, & Zuidema, 1973 as cited in Swigert,
Outpatient care was severely restricted because of lockdown regulations; however, our commitment to patient-centred care continued to motivate us to investigate other means of reaching our patients. The team regrouped to strategise approaches on how we could identify and meet the urgent needs of patients to maintain function in their home environments. We developed a proposal to obtain permission from the hospital to conduct home visits. However, because of the level of lockdown and concerns around staff safety, our request was denied. Missed opportunities to engage and partner with communities during COVID-19 were also reported by Rispel, Marshall, Matiwane and Tenza (
Numerous research studies have shown that people with disabilities have lower incomes and are at a heightened risk of food insecurity compared to people without disabilities (Banks et al.,
Children’s exposure to formal and informal learning opportunities was limited because of lockdown restrictions (Murray,
COVID-19 required us to investigate new and additional methods of service provision (Cacciante et al.,
Many studies have identified digital poverty as a barrier to the implementation of telehealth (Baker-Smith, Sood, Prospero, Zadokar, & Srivastava,
A study conducted by Signal, Martin, Leys, Maloney and Bright (
Asynchronous intervention has an advantage over synchronous intervention by removing scheduling issues (Hill & Breslin,
A strategic planning session with staff members identified the resources, processes and support that were required to provide services to patients who indicated a preference for face-to-face sessions. The adherence to non-pharmaceutical interventions to reduce the risk of infections was critical. These measures included patient screening, hand hygiene, booking fewer patients and increasing the time between patients to allow for cleaning. The number of people per room was limited and disinfection protocols were strictly followed (Agarwal et al.,
At a macro level, the needs of people with disabilities should be visibly accounted for when planning a country’s response to a pandemic (De Biase et al.,
This article provided us with an opportunity to tell our story of adaptation, teamwork and resilience in a period of uncertainty. Storytelling allowed us to understand the meaning of our actions, our values and principles, ‘our fears and vulnerability, and the connective tissue that binds us together’ (Kumagia & Baruch,
Stories are being increasingly recognised for their potential as creators of change as they guide small, everyday decisions and practices (Essebo,
The authors acknowledge the dedication, commitment and passion of their colleagues at the Speech Therapy and Audiology Department at Chris Hani Baragawanath Academic Hospital. A special thanks to everyone who discussed, read and reviewed their work in progress.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
S.B., A.L.V. and S.C.P. all conceptualised the idea for this research, wrote the first draft and made the editorial input, with S.B. as the main author.
This article followed all ethical standards for research without direct contact with human or animal subjects.
The authors thank the National Institute for the Humanities and Social Sciences (NIHSS) for providing financial assistance for the publication of this article.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.