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, 2006). The STA Department is organised into five clinical teams, where each team has a designated team leader and clinic coordinators who ensure the smooth flow of services at an operational level. Inpatient and outpatient services across the lifespan are provided to patients with communication, hearing, balance and swallowing disorders. Statistics from 2019 indicated that there were a total of 35 019 contact sessions for STA. Contact sessions refer to clinical contact with patients. The Head of Department and team leaders form an executive leadership committee that engages in strategic decision-making, planning and monitoring. Our department’s functioning is guided by a strategic plan, a comprehensive annual performance plan, departmental protocols, clinical guidelines and hospital and provincial policies. Quality assurance roles, responsibilities and activities in these protocols are outlined to ensure that service standards are upheld. This includes areas such as infection control and occupational health and safety. The STA Department facilitates various activities to build a dynamic, transformative, committed and well-cared-for team with a strong sense of purpose.

Microsystems co-exist within a macrosystem (Tudge et al., 2009). The macrosystem includes legislature, government departments, social policies, economic systems, media and cultural values that influence social contexts (Newman & Newman, 2020). Our hospital is classified as a central hospital in the public healthcare sector where highly specialised, multispeciality clinical services are offered by multidisciplinary teams in an environment that fosters innovation and research (Department of Health, 2017). There are seven business units in the hospital, each under the management of a senior clinical executive who reports to the hospital’s Chief Executive Officer.

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, 2020) and the linguistic and cultural diversity of our patients (Khoza-Shangase & Mophosho, 2018).

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.

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, 2020, p. 294). At the onset of Level 5 lockdown, we were instructed by hospital management to stop all nonessential services, which included all outpatient STA services. This sudden change in operations required us to rethink our purpose and function within the hospital. Mather (2020) recommended that leaders should go back to their core values and purpose at a time of crisis. Our vision and mission as a department, as displayed in Table 2, therefore guided our decision-making during this period.

According to Heath, Sommerfield and Von Ungern-Sternberg (2020), keeping staff informed serves the purpose of building resilience through a sense of increased control over one’s environment and displays a commitment to engage and support staff directly. An urgent staff meeting was called by the Head of Department to relay information about the directive received and its impact on services and staff. Staff members communicated their fears about COVID-19 in this meeting but added that they wanted to contribute to the hospital’s response. Unfortunately, at this initial stage the hospital’s response was not clearly communicated by management. Organisational support in the hospital (Barach & Johnson, 2013) was activated only a few weeks later through the development of a steering committee under the leadership of the Head of Internal Medicine. This committee met biweekly via the Microsoft Teams platform. Statistics on the number of COVID-19 admissions, staff positivity rates, logistical challenges, personal protective equipment (PPE) and ward reallocations were some of the areas discussed. These meetings facilitated improved relations with various stakeholders within the hospital and continued to build the identity of rehabilitation. The Head of the STA Department attended these meetings and provided feedback to staff members on a regular basis. These sessions provided an opportunity for staff to be informed and to participate in decision-making. In a crisis, employees depend on organisational leaders for information, and effective communication of critical decisions (Sanders, Ngugen, Boukenogne, Rafferty, & Schwarz, 2020). Initially, all information received through various platforms was shared with staff members to reduce the anxiety associated with COVID-19. However, this influx of information became very overwhelming. We refined our communication strategy as our knowledge, skills and understanding of COVID-19 improved. We agreed on a set of principles to guide our communication in terms of the nature, frequency, time and platforms that would be used.

Mather (2020) and Bronfenbrenner (2005) stated that during a crisis or a specific historical event, there is a need to act with urgency as wasted time and delays can be damaging. During this period there was no communication received from the National and Provincial Rehabilitation Directorates about the role of rehabilitation personnel in and during COVID-19. It was therefore critical for decisions to be made at an STA departmental level to ensure that we continued functioning with a sense of purpose within the health system. We engaged with our exosystem to review material generated by international and national associations and the Health Professions Council of South Africa. This facilitated the development of standard operating procedures, adaptation of protocols and creation of resources to guide clinical practice. Because of the urgency of this response, our protocols were developed in a silo and did not include consultation with other disciplines in the hospital. Upon reflection, it was evident that to ensure a unified approach, this process should have been guided by the leadership of National and Provincial Rehabilitation structures to ensure a more comprehensive and integrated response. Adaptable, transparent and compassionate leadership (De Zulueta, 2016; Poorvakos, 2016) was key in helping us lead during a period marked with uncertainty.

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, 2020; Prasad et al., 2021; Zhang et al., 2020). A valued member of the microsystem is one that feels that their needs are taken into consideration by the organisation (Johnson, 2010). The STA Department therefore focused on the well-being of our staff. This was achieved through training and development, creation of a supportive and safe environment and a culture that facilitated trust, transparency, empathy, open-communication and teamwork (Barach & Johnson, 2006).

Our services were aligned to the different levels of lockdown as indicated on the timeline in Figure 2. Rehabilitation is a human right (United Nations, 2006) and is identified as a key health strategy by the WHO (2019). The rehabilitation needs of persons with disabilities were not considered in many countries’ responses to the COVID-19 pandemic (Eskytė, Lawson, Orchad, & Andrews, 2020), as services were either stopped or curtailed (Negrini et al., 2020). Vulnerable people became even more vulnerable during this pandemic (Castelyn, Viljoen, Dhai, & Pepper, 2020). Our outpatient services were immediately stopped after the State of Disaster was declared in March 2020 (Dlamini Zuma, 2020; Moonasar et al., 2021). Our inpatient load was affected by the hospital’s decision to discharge all medically stable patients in order to free beds and increase staff availability for COVID-19 patients. This reprioritisation within the hospital for COVID-19 patients necessitated a meeting with medical heads of units to clarify referrals, discharge procedures and plan the clinical management of patients already in the hospital. Communication channels between teams were also discussed to improve the understanding of expectations and patient flow within and through the various units. Our protocols were adjusted to include prioritisation criteria and risk reduction strategies for the inpatient population. The criteria were based on guidelines developed by the Royal College of Speech and Language Therapists (2020) and recommendations made by West, Kevin and Welling (2020). Three levels of priority as indicated in Table 4 were developed and instituted to guide decision-making in Levels 5 and 4 of lockdown.

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, 2003). The time spent with inpatients was reduced and the frequency of treatment was determined by the risk of transmission. All multidisciplinary joint treatment sessions were stopped to maintain social distancing. Other adjustments included the positioning of the therapist and ensuring that the appropriate PPE was used. Initially, the staff entering COVID-19 wards was restricted because of PPE and uncertainty about treatment protocols. Screening algorithms and augmentative and alternative communication boards were developed for doctors and nurses to facilitate communication with patients and safe eating and drinking practices. Note-writing templates were developed to reduce the time spent in wards. Research has shown that there was an increased need for information from family members of patients during this period as the levels of worry and uncertainty were high (Hugelius, Harada, & Marutani, 2021). Limited family contact because of visiting restrictions impacted family and caregiver training, education and counselling and obtaining relevant patient information. Despite the barriers discussed above, the STA Department continued clinical care and maintained a total of 17 310 contact sessions with speech and audiology inpatients.

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 (2021). A non-governmental organisation was contacted to enquire if they were able to conduct the visits on our behalf. Care packages were developed for patients who required consumables and equipment to facilitate continued access. These included home programmes, batteries for patients with hearing aids, consumables for patients with head and neck cancer, Transpore tape and specialised feeding equipment for children with cleft lip and/or palate. Information for families and caregivers on how to stimulate communication at home, pamphlets on COVID-19 and mindfulness activities were included in the packs. The non-governmental organisation reported that they were well-received by patients who expressed their gratitude for the visit.

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., 2020; Park, Kim, Kim, Jeoung, & Park, 2020; The Lancet, 2020). Lockdown was especially difficult for already vulnerable groups (Abrahams, Boisits, Schneider, Prince, & Lund, 2021); some of the adult patients reported that they had limited access to food and others lived alone without familial support. The non-governmental organisation arranged food parcels for these patients and placed them on their database for follow-up visits. Feyisayo, Olufunke and Lambert (2021) found that an increasing number of South Africans became dependent on food parcels during the pandemic. Whilst the Gauteng Provincial Government identified social relief as a key response, it is evident that this may have been inaccessible to more vulnerable groups (Gauteng Provincial Government, 2020). The elderly and people with disabilities were expected to compete with others for limited resources within a context of restricted movement (De Groot & Lemanski, 2021).

Children’s exposure to formal and informal learning opportunities was limited because of lockdown restrictions (Murray, 2021). The disruption of rehabilitation services for children with disabilities negatively impacted their physical and mental well-being as well as their behavioural development (Allison & Levac, 2021; Rao, 2021). Because of these identified risks, we collaborated with Soweto TV to run a segment on how to stimulate language, literacy and play in the home during COVID-19. The segment was aired as part of the news bulletin of the day.

COVID-19 required us to investigate new and additional methods of service provision (Cacciante et al., 2021; Dixit et al., 2021). Our service package included face-to-face intervention, telehealth (asynchronous, synchronous and remote monitoring) or a hybrid model of incorporating the two. A study conducted by Camden and Silva (2021) across 76 countries showed that the use of telehealth by therapists had increased from 4% pre-COVID-19 to 70% by May 2020. The STA Department’s overall use of telehealth increased from 0% pre-COVID to 46% in 2021. Speech therapy for hearing-impaired children reached 88% during Level 5 lockdown and maintained 70% in 2021, with many patients electing to follow a hybrid model. A total of 520 synchronous and 632 asynchronous interventions were conducted from June 2020 until December 2021. An upward trend was noted in all other clinical areas in the STA Department.

Many studies have identified digital poverty as a barrier to the implementation of telehealth (Baker-Smith, Sood, Prospero, Zadokar, & Srivastava, 2016; Clare, 2021; The Lancet, 2020). Barriers include internal factors such as the lack of awareness and scepticism about change, technical readiness and external challenges such as costs, limited technical resources, data privacy issues and unclear liability of rehabilitation providers (Camden & Silva, 2021). Furthermore, Dixit et al. (2021) identified limited access to telehealth in patients with low income, limited English proficiency, low health, computer literacy and those accessing public healthcare. To understand our patients’ needs and preferences, we conducted a telehealth access questionnaire. This included questions related to data and Internet access, availability of smartphones, laptops and tablets as well as establishing if patients were interested in telehealth. These interviews highlighted the reality of digital poverty within our context, as most patients indicated their lack of data and internet. Whilst the identified barriers were overwhelming, we continued to look for solutions to overcome these. Internet access for both staff members and patients was the main challenge. We developed funding proposals to various private organisations but received no response. We also developed a comprehensive motivation to the hospital for improved Internet access as well as supporting equipment. Our proposal was rejected; however, this did not deter us. The high level of motivation and drive amongst staff members ensured that other creative solutions were developed; this included the use of personal resources and a mapping exercise to identify community centres and places that offered free Wi-Fi. We developed a roster for staff members to conduct telehealth sessions from home. Relevant accountability mechanisms were introduced to ensure transparency (e.g. the use of Google Calendars) and appropriate use of time. The Health Professionals Council of South Africa was contacted to discuss our plan to ensure compliance with the ethical rules and regulations. We developed telehealth record-keeping forms and created password-protected storage for videos sent in by patients for asynchronous sessions as well as recorded therapy sessions. Logistical issues such as patient payment for these sessions were discussed with our finance and patient affairs department.

A study conducted by Signal, Martin, Leys, Maloney and Bright (2020) found that most patients were unfamiliar with telehealth and sceptical of its value, but their attitudes changed once they received telehealth services. We are still refining our skills in providing synchronous telehealth sessions; however, many lessons have already been learnt, which have assisted in improving services. We have learnt that presession planning is important. This includes setting up the device, checking Internet stability, ensuring that all therapy resources are within the reach, communicating with patients and families on expectations for the session as well as what material would be required. Correct positioning and lighting are crucial and family routines and schedules must be accommodated. Patient and family feedback after each session is critical for continuity of care and achievement of goals. Effective implementation of telehealth requires organisational change and support (James et al., 2021). Sustainable telehealth implementation in the public health sector requires commitment of resources and logistical support from the Department of Health. We should continue to fine-tune, monitor and evaluate the implementation of telehealth (Abdel-Wahab, Rosenblatt, Prajogi, Zubizarretta, & Mikhail, 2020) in the public health sector.

Asynchronous intervention has an advantage over synchronous intervention by removing scheduling issues (Hill & Breslin, 2016). The efficiency of therapy can also be improved within a context of infrastructure limitations and language variability (Bhat, Kant, Vachhani, Rautara, & Kopparapu, 2020). Our asynchronous sessions required the development of digital learning resources, therapy programmes and educational material. We consulted an expert in digital health literacy who provided us with critical feedback on health literacy, high-impact messaging and technical aspects to improve the quality of our videos. These resources were shared through WhatsApp, email and short message service (SMS). Our overall goal of service delivery was to maintain patient-centred care in a safe environment for patients and therapists.

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., 2020; Cho et al., 2020). It was imperative that these infection control measures become a part of our routine clinical practice.