HCWs are on the front line of the COVID-19 outbreak, and their constant exposure to infected patients and contaminated surfaces puts them at risk for acquiring and transmitting the infection. Current global stockpiles of PPE are insufficient, driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling [1, 11, 12]. Major distributors in the United States have already reported shortages of PPE [3, 13].
The findings of the present study point to the gap the HCWs perceive between the applicability of the existing guidelines and the protection of HCWs against contagion and infecting the public. These findings indicate the gap that has been documented in the literature, not only in the COVID-19 epidemic, between the official infection prevention guidelines and what happens on the ground [14].
The findings of the present study indicate that three guidelines are perceived as less applicable than protective: prohibited gathering of over 10 people, maintaining a distance of 2 m’, and remote services.
A possible interpretation to that is that the Israeli healthcare system has fewer staff positions and manpower than the Organisation for Economic Co-operation and Development (OECD) countries [15]. Israel has a tremendous overload on its healthcare system that is reflected by long lines [15,16,17]. The HCWs feel they cannot question the people who come in during the coronavirus crisis because they do not have enough time and there is a personnel shortage. In addition, since the hospitals and health funds are at full capacity all the time, during the COVID-19 crisis the pressure increases, and it is difficult to reduce the congregating and maintain a distance between people. Another possible explanation for the difficulty to maintain a distance is the cultural component. Israeli society has a culture of social intimacy where it is not common to keep a physical distance. Moreover, there are geographical areas in Israel with high population density where people congregate, such as the Arab and ultra-Orthodox communities. In the COVID-19 crisis in Israel certain populations have reportedly had difficulty following the guidelines, making it hard for the HCWs to maintain the specific guidelines concerning social distancing. For example, the ultra-Orthodox community in Israel found it difficult to follow the guidelines and suffered from some of the highest infection rates in the country [18, 19].
The findings also indicated that some guidelines were perceived as more applicable than protective, such as hand hygiene, and alcohol rub sanitizers at entrance. Hand hygiene (HH) is the single most effective way to reduce the spread of germs that cause respiratory disease [20]. HH after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process [3].
One explanation for the findings of the present study that HCWs view HH as less protective of them might be the cognitive bias that exists among many of them, as it does in the general public, whereby they perceive PPE as a solution but forget to perform HH in the course of their work [21].
This interpretation is consistent with other research in the literature about the prevention of hospital-acquired infections, which indicates that despite a variety of interventions conducted for HCWs, the levels of compliance with HH still remain low at 50–60% [22,23,24]. during the COVID-19 crisis Reports from China indicate that suboptimal HH after contact with patients was linked to COVID-19 [25, 26]. Long exposure time to large numbers of infected patients directly increased the risk of HCW infections [11, 12].
Another guideline perceived as applicable but less protective is masks for contact with symptomatic patients. The professional literature indicates uncertainty about the effectiveness of wearing masks. Some say that wearing a mask can lead to false confidence [27]. It is possible that the dispute about the degree of protection from masks led the respondents to indicate a gap between applicability and protection. It is also possible that the uncertainty that still exists about the transmission of the coronavirus (droplet or airborne) also contributed to the gap found in regard to masks between its applicability and the degree of its protection against contagion [2].
Recent studies in the field of infection control indicate that the official guidelines focus on the temporal order of actions in their broadest sense and cannot be totally comprehensive as exigency situations arise from the dynamic nature of the work, that exist in the care continuum [28, 29].
Respectively, in a crisis such as the COVID-19 epidemic, the staff faces new situations they did not conceive of before, as the virus spreads. Therefore, in the study we asked the respondents to share with us additional practices they perform that cannot be found in existing guidelines. The HCWs raised creative practices that indicate the importance of including the staff when confronting an epidemic crisis. Guidelines that are handed down from above are insufficient in a changing reality and it is important to hear the staff and accommodate them.
This study indicates there is a PPE shortage of for HCWs in Israel like in other countries [30]. Many of the HCWs (69%) noted the PPE shortage. The HCWs executives interviewed for this research noted that the PPE shortage led to feelings of anger and frustration among the HCWs. During the crisis in Israel due to the PPE shortage for its employees, the MOH issued a statement at a press conference in mid-March, saying that HCWs do not need to wear PPE regularly but rather consider the situations in which they should do so [31].
Following the MOH statement, senior doctors from across the country came together and sent a letter to the government stating that their voices were not being heard, and that the state was abandoning them due to the severe shortage of PPE [32, 33]. The MOH statement was perceived as an excuse to cover up the inadequacy of the Israeli healthcare system, of which the PPE shortage is only one example [7].
Limitations
The research limitation is that this is not a representative sample of all HCWs in Israel. However, the questionnaire was filled out by diverse sectors of the Jewish and Arab populations working in the Israeli healthcare system, both in the community and in hospitals. Follow-up studies might examine HCWs’ perceptions concerning the guidelines for treating COVID-19 patients: guidelines about care, their level of applicability, and suggestions from the staff can contribute important information to the healthcare system.
