Challenges Faced by Dialysis Unit Staff During COVID-19 Times: A Qualitative Study

The COVID-19 pandemic sweeping across the whole globe has affected everyone in diverse ways. Chronic kidney disease patients have been affected in a very big way as they continue to visit the hospitals and hemodialysis units for continuity of care and to get regular dialysis sessions. The dialysis patients visit their dialysis center at least twice or traditionally thrice a week. The dialysis staff has also been working hard during these challenging times. Health care workers in the United States have expressed concerns about working with patients during the active pandemic (1). These challenges are complex and interact with each other. Hence, to prioritize the intervention and understand its complexity and interaction, we did a qualitative evaluation to understand the problem from team members’ point of view. Although qualitative research is increasingly used in many health care fields, it is underused and rarely reported in nephrology high-impact journals (2).

The objective of the present study was to look at the problems afflicting the hemodialysis staff during the current COVID-19 pandemic in a rural medical setting.

Setting- The study setting was the hemodialysis unit of Sri Manakula Vinayagar Medical College Hospital, Pondicherry, India. Accreditation of the unit: This dialysis unit has been audited on a regular basis by an external nephrology consultant auditor for the last six years. It has also passed step ½ of the NABH accreditation process.

Out of 12 respondents, five were nurses, five were technicians, and two were doctors. Among them, three were males, and the remaining nine were females. Table 1 shows a free listing of twelve salient items in descending order of salience. As seen in Appendix 1 in Supplementary File, the structure of the cognitive domain of challenges faced by staff consisted of three sub-groups – (1) operational problems, (2) the major group consisted of items related to lack of personal safety for staff, and (3) concerns for lack of personal safety equipment for the staff. Appendix 2 in Supplementary File shows the Algorithm (flow chart) followed in the study.

The main finding, as shown in Appendix 1 in Supplementary File, was about the issue of shortage of personal safety equipment (ie, lack of sanitizer, soap solutions, lack of hot water in the unit, lack of PPEs, and face mask shortage), which stood apart closely together despite repeated modeling a number of times on the software of the computer. The second finding as a cluster was that of the danger to the personal safety of the staff (incorrect history given by patients, relatives not following isolation rules, patients and relatives not wearing masks, unavailability of testing for RT-PCR, and fear/possibility of COVID-19 positivity. The third finding as a cluster highlighted was the logistics and operational issues (patient lacking public transport, difficulty in the scheduling of patients, and financial stringency)

In prioritizing the different clusters, the first cluster chosen was the one dealing with shortages of personal safety equipment for the dialysis staff. As a result of the information gathered from the dialysis staff, we immediately talked to the various stakeholders in the institution's hierarchy, apprised them of our findings, and showed them the results of the cluster mapping. They agreed to immediately order fresh standard masks, PPEs, and sanitizers and provide hot water for the unit. The dialysis staff was very appreciative of the immediate outcomes. There were remarkable transformation and positivity in the behavior and the work culture of the unit members.

The second group of clusters as regards the patients and their relatives not adhering to infection control practices, didactic meetings were held with them, and the wearing of face masks and following isolation and infection control measures were stressed upon. The issues touched upon in the above two clusters were within our purview, and we were able to address them successfully.

The problems regarding RT-PCR testing were the hospital management to ponder upon, which they readily agreed to discuss and act upon, and they stated that they will get the RT-PCR machine.

The third cluster of issues pointed out was really beyond our control, ie, regarding the lack of public transport owing to lockdowns, disarray in the scheduling of patients (again due to lack of transport), and the general financial depression. This was under the domain of the government and other official authorities. The patients successfully petitioned the collector and government officials to get them dropped to the hospital using government ambulances.

Nowadays, most people are usually more concerned about the RT-PCR and antibody testing, but our results showed that the concerns of dialysis staff were mainly centered upon protecting themselves (personal safety) by means of proper PPEs while caring for their patients.

The best strategy to prevent COVID-19 transmission is frequent hand washing, maintaining physical distancing, proper cough and sneeze etiquette, and regular environmental disinfection in the dialysis unit (12-14). Finding of the real issues bothering our health care staff was not a technical ability but was actually an elective, focused bonding towards them! The main direction of our outlook was to consider the staff working with us as an individual and not to just treat them like some stereotype. Finally, it was our job to consider them as our fellow human beings facing the fear of the unknown and uncertainity (15) and not to consider it serousely (16).

The challenges of COVID-19 in a rural health care facility has their own multidimensional impact, such as the lack of testing services, poor surveillance, and acute shortage of equipment and PPEs (17). Also, the financial burden during these challenging times casts a shadow on the smooth functioning of the dialysis units directly affecting patient care.

In challenging and high-pressure environments, the burnout rates are very high, like in busy dialysis units. The burden of the moral dilemmas afflicting the health care staff due to lack of equipment can easily lead to stress, depression, anxiety, post-traumatic stress disorder, and even suicide. Hence, as a clinical director of a dialysis unit or as a dialysis manager, it is our foremost duty to make sure the staff is provided with evidence-based care and support materials (18). Appreciation of the staff and expressing gratitude for their work during stressful times can raise their confidence levels and improve resilience (19).

Health care workers constantly face an ethical dilemma, which is fueled by the lack or inequitable distribution or even reusage of PPEs or masks (20). The similar challenges faced by staff in some health care centers across Africa are of gargantuan proportions because of global jostling (21), lack of low-cost face masks, and even lack of water for handwashing (22). Invaluable lessons were learned at the time of Ebola in Africa and even in HIV control, where dispelling myths and support to health care workers led the way forward (23).

A recent qualitative study from China using semi-structured in-depth interviews (empirical phenomenological approach) reported challenges faced by health care workers in COVID-19 wards, exhaustion, fear of getting infected, and infecting others (especially family).They suggest comprehensive support in the form of adequate protective gear, effective communication, monitoring, and surveillance of infection control (24).