Outcomes of rapid digital transformation of large-scale communications during the COVID-19 pandemic

. Objective. This study examined the content and impact of a new digital communication medium, called a VIDCAST, implemented at a large hospital and health service when the COVID-19 pandemic was announced, and the key concerns held by staff at the time when the health service was preparing for the COVID-19 pandemic to arrive in this health service. Methods. A mixed-methods approach was used. Thematic What are implications for New digitised communication methods provided an effective vehicle to inform and support staff in the early stages of pandemic preparation.


Introduction
In January 2020, news of the COVID-19 virus emerged in reports from Wuhan, China. A major Australian metropolitan hospital and health service (HHS) set a clear strategic and operational objective to prevent the spread of COVID-19 while planning for potential increased hospital admissions. Many aspects of the hospital operating systems and clinical care models were digitally transformed to facilitate social distancing and reduce the chance of nosocomial acquisition of COVID-19 for patients and staff, including the virtualisation of work, clinical consultations and staff forums.
Work during the 2009 H1N1 influenza pandemic indicated that front-facing healthcare workers in Birmingham, UK were worried about the wellbeing of their families and themselves. 1 Such fears were not without reason: the intrahousehold secondary transmission of H1N1 influenza in Melbourne, Australia was 14.8%. 2 Up to 53% of hospital staff at a major hospital in Gold Coast, Australia reported that they would not attend work if there were multiple admissions of affected patients. 3 At the beginning of the COVID-19 pandemic, two international publications emphasised the need to understand and proactively support the physical and emotional wellbeing of healthcare staff. 4,5 The HHS in this study made it a priority to support its workforce and be working at full capacity while preparing for the anticipated growth in COVID-19 admissions. It enacted a proactive and coordinated initiative to support the HHS's most valued asset, its workforce. Previously, staff communication was via traditional staff forums, with hundreds of staff filling auditoriums, obviously not possible with new social distancing edicts. Instead, the HHS rapidly implemented a virtual model to allow direct, real-time, bidirectional communication between the Chief Executive (CE) Team, the CE and staff.
Commencing on 30 March 2020, the CE and leadership team commenced daily weekday, 1-h VIDCAST sessions that could be streamed live by all staff or viewed later as recordings. The name 'VIDCAST' was coined to combine 'video' and 'live cast', representing the session format, but also as a play on words as a shortened version of 'COVID video cast'. The last VID-CAST session in this analysis was on 24 April 2020, when the HHS had a total of 29 COVID-19 cases, 459 recovered cases and three reported deaths, whereas the national death toll was 79. 6 In contrast, on the same day in the US, the death toll had passed 50 000. 7 This study was designed to understand the impact of the daily VIDCASTS and the key concerns held by staff during initial stages of the COVID-19 pandemic.

Design
A mixed-methods approach was used. Descriptive analysis of staff feedback from a brief anonymous online survey was conducted in parallel with thematic analysis of the VIDCAST transcripts recorded between 30 March and 24 April 2020. The COREQ (COnsolidated criteria for REporting Qualitative research) checklist was used to guide write-up. 8

Setting
The HHS is a large Australian health service with an annual turnover of more than A$3 billion and 19 500 staff. The patient catchment covers a geographical area of .4000 km 2 and delivers a full range of health services to over 1 million people.

Intervention
Each day, staff were emailed the link for the live videoconference held via Microsoft Teams (Microsoft Corporation). Before and during the live VIDCASTS, staff could submit questions (anonymously by default) using the third-party platform Slido (https://www.sli.do). During each VIDCAST, a leadership team member, infectious diseases consultant or infection control nurse provided information updates, and paraphrased and answered staff questions. Table 1 contains a snippet of how one VIDCAST unfolded with the information and question-andanswer sequence.

Materials
Responses to a 12-item SurveyMonkey (Momentive) questionnaire emailed to staff were captured in a spreadsheet. The VIDCAST recordings were transcribed into Microsoft Word files by a professional transcription service.

Data analysis
Survey data were summarised using frequencies for categorical variables and the mean AE s.d. for continuous data. Quotes were extracted from the open-ended survey question asking participants' thoughts about the VIDCASTS. Thematic analysis using an interpretative approach was used to understand and identify patterns in the transcript data; the interpretative role of the researcher is critical in qualitative analysis. 9 The thematic analysis process articulated by Braun and Clarke 10 was used, whereby the first investigator (JS) immersed herself in the transcript data and manually coded the first transcript. A second investigator (BL) independently coded the first transcript, and the two met to review and discuss the extracted codes. After discussion, as per O'Connor and Joffe's 11 recommendations regarding inter-coder reliability in qualitative analyses, the first and second coders coded a further four transcripts, yielding an acceptable 25% double coding. 11 To ensure maximum variability, because the first VIDCAST was by the CE and the Chief Operations Officer, the other four double-coded transcripts were of an infection control nurse consultant, an infection diseases physician, a human resources (HR) officer and a digital agency officer (one each). Further discussion was then held between the two coders, and the coded items were grouped into themes. The first investigator individually coded the remaining 15 transcripts using the coding framework. The themes and data extraction process were then shared and discussed with the broader research team.

Ethical considerations
The project was granted ethics clearance by Royal Brisbane and Women's Hospital Human Research Ethics Committee (LNR/ 2020/QRBW/63933) and The University of Queensland Human Research Ethics Committee (2020002967).

Results
The online survey was completed by 322 staff members (mean age 44 AE 12 years; 84% female). Survey respondents were from nursing/midwifery, medical, allied health, oral health, administration and corporate services across nine different geographic sites in the HHS.
The survey questions and descriptive data are contained in Tables 2 and 3. Almost 94% of staff agreed or strongly agreed that the VIDCASTS were an effective communication method, whereas 85% agreed or strongly agreed there was value in having anonymous questions answered by the CE team. Most respondents (98.4%) recommended this type of communication be continued. Staff responding to the survey found the sessions informative and reported that the sessions helped allay some of their anxieties and enabled them to feel connected, supported and included in this time of crisis.
The 20 VIDCAST sessions generated 149 863 words of transcribed text, with 128 216 (86%) of the words generated from the question-and-answer portions of the VIDCASTS. The proportion of words from the question-and-answer portion varied between the daily VIDCASTS, ranging from 48% to 99%. Between 300 and 400 staff members watched each VIDCAST live.
Three themes were derived from the transcripts: 'Accurate Information', 'Reassurance and Support' and 'Innovation'. Illustrative quotations from VIDCAST transcripts are provided in Table 4.

Theme 1: accurate information
Accurate information was the dominant theme. This was especially important given the rapid spread of the pandemic worldwide in March and April 2020.

On COVID-19
Information ranged from HHS capacity to manage the anticipated COVID-19 surge to current case numbers, COVID-19 care plans and the safety of staff caring for COVID-19 patients, as well as state and nation-wide information. Modelling on the COVID-19-curve, how the virus is spread, the time course of the virus and testing criteria were also covered. This information was delivered in a timely manner, so staff were aware of the latest advice.
On personal protective equipment Personal protective equipment (PPE) information was shared in 16 of the 20 VIDCASTS, with questions focused on the HHS's supply of PPE and the adequacy of the PPE to keep staff safe. There was noticeable anxiety that staff would be asked to care for sick COVID-19 patients without proper PPE (reported in other countries 12 ); they were reassured that this was not the case in this HHS and that PPE stocks were being built up.
The HHS's innovations to supplement existing PPE supplies were explained, such as three-dimensional printing of masks and shields, and sourcing of alternative fabric for gowns. Guidelines for what PPE to wear and when to wear it were shared, in addition to demonstrations of donning and doffing PPE.

On infection control
Staff expressed concerns they would become ill with COVID-19. The VIDCAST presenters calmly spoke about normal infection control procedures that are the bread and butter of routine hospital practice: good hand hygiene and cough etiquette. Extending these principles to non-work settings was recommended (e.g. public transport, shopping). Social distancing was a novel control strategy, so it was helpful to have the infectious diseases consultants explain the rationale based upon respiratory secretion droplets that a person infected with COVID-19 spreads when they cough or sneeze.

On workforce issues
During this time of uncertainty, staff had concerns about working conditions and job security. Some areas of hospital business were being scaled down, such as procedural work; at the same time, recruitment of clinical and cleaning staff was increasing. Questions about government job subsidies, continuation of employment contracts and reallocation to alternative duties were frequent. Staff were advised of new HR initiatives, including an expression of interest job portal, resources on the COVID-19 HR website and a 7-day HR hotline.
Other areas of concern were vulnerable staff and family members, and staff who needed to supervise home schooling.
Staff were advised that all HHS staff were essential workers, and so had access to schooling and childcare during the pandemic. Leave arrangements during the pandemic were explained (sick leave, pandemic leave, recreation leave, long service leave). Staff were advised to speak with their line manager and HR personnel for specific circumstances. There were many questions about the HHS's flexible working arrangements and working from home policies, which were changing throughout the pandemic.

On hospital business
The CE and team provided insights into behind-the-scenes activities of the organisation, including logistics and supply of equipment, patient workflows and models of patient care. Because the expected peak in case numbers did not eventuate, See Table 3 for examples of open-ended responses 173 planning for recommencement of elective surgeries and other business was described.

Theme 2: reassurance and support
The VIDCASTS contributed to a sense of reassurance and provided support for staff.

Managing emotions of fear, anxiety and uncertainty
Anticipatory anxiety is a well-documented phenomenon, whereby uncertainty about a real or imagined future threat can disrupt a person's adaptive functioning. 13 The VIDCASTS were an important part of reassuring and supporting a large workforce during a trying time. Staff were told about developing guidelines on patient care prioritisation in the event of a surge like the one occurring overseas. Knowing that planning was in train regarding deeply important ethical issues to allocate scant resources was reassuring for staff.
The VIDCAST team acknowledged their own emotions and were able to bracket these emotions with the knowledge that the plans of the HHS were keeping everyone safe.

Promoting staff wellbeing
The CE team highlighted its determination to support staff wellbeing by recruiting a chief wellness officer and rolling out a staff wellness program across the HHS. This wellness program identified four domains of emotional, physical, social and financial wellbeing and support. Considerable resources were provided for an 'R U OK?' program (https://www.ruok.org.au/).

Building connectedness
The VIDCASTS provided a COVID-safe and effective mechanism for the Executive to build human connections with its community through a virtual platform. The VIDCAST presenters did this by sharing their own situation when it mirrored staff concerns. For example, those who had children shared concerns about how they would manage if they got sick or referred to their own elderly grandparents and the decision to stop face-to-face contact for their protection. The presenters also shared positive messages about the great work everyone in the HHS was doing.

Adapting to fast changing situation
Over the period these VIDCASTS were run, rapid changes occurred in the organisation. In January 2020, the HHS established emergency operation control centres to coordinate the emergency response to the pandemic. As knowledge about the virus emerged from overseas, matters such as the testing criteria changed. COVID-19 was referred to as 'an evolving beast'. The balancing act between HHS preparedness for the anticipated COVID-19 patient admissions and the reintroduction of paused clinical services was shared with staff, underpinned by modelling of PPE availability.

Theme 3: innovation
The final theme was innovation.

HHS digital agency
The HHS digital agency was established in 2018 to lead digital transformation; many of the innovations implemented for the anticipated COVID-19 surge were underpinned by the work of this agency. The HHS digital agency provided support for staff to work socially distanced or from home and developed a suite of apps to enable many aspects of the HHS's business, including public health tracing orders, an HR app to model absenteeism and a PPE dashboard.
Virtual models for patient care were increased, requiring more information technology (IT) bandwidth and hardware resources. Telehealth was increased, and new virtual models, such as the virtual COVID-19 ward, the virtual emergency department (ED) and virtual family meetings, were established.

New ways of working
The pandemic and preparation for the surge in COVID-19 patients resulted in many changes across the HHS. Virtual wards

Communication
The VIDCASTS enabled staff to get to know the team leading them through this uncertain time, and the decisions and planning that were occurring. This new communication method was a positive two-way communication channel. These sessions represented an efficient method of connecting with many staff at one time, in a relatively personal and engaging format.

Discussion
The first aim of this study was to understand the impacts of the VIDCASTS on staff. Staff indicated they valued the new communication platform and the ability to connect with the leadership team during the preparations for the pandemic. The leadership was accessible and visible, took the time to listen to

COVID-19
There'll be more beds available for our population per capita than all of these other areas that you're actually seeing in crises Every couple of hours of preparedness right now is worth hundreds of hours of benefit to us in the future PPE Both from a pragmatic and ethical point of view, you will not be expected to put yourself at risk to provide care On the PPE I think we've got a better handle on this than I believe any other health service in the country at the moment Infection control Look, we very much believe that the very basic principles that we have for infection control will see us through this, and very much back to even just hand hygiene and cleaning of surfaces and the social distancing ythe risk of spread in that context is within six feet of that person Workforce issues Which could be a growth of 300% capacity in our emergency departments, 200% in ICU, and we know, in addition to that, we have had to stand up our fever clinics [establishment of new COVID-19 testing services]. But the first thing we did with each of our respective workforce areas, we focused around allied health, medical services, nursing, digital, and admin workforce, is to say well, what would that look like, what would that growth take from us, and how would we best support that growth? We have launched a number of recruitment campaigns across nursing, allied health, our patients' support officers and our medical officers While a role might be able to be done from home, there's a whole lot of other facts to be considered and so each case would be being looked at by a line manager and then there will be business rules being applied in different facilities for how that will work for them Hospital business We have procured over 6600 items of equipment to dateybusily working away at procuring that equipment so the hospitals have the equipment that they need to respond to COVID-19 Reassurance and support Managing emotions ythe Clinical Senate facilitated a workshop last Friday which was looking at ethical decision making Certainly I feelyobviously I'm anxious that my parents may get unwell and diey[The presenter later provided reassurance to all:] What I want to get across is that things are under control at the moment, and we're lucky to live in the place that we live and we've got a great team looking after us Staff wellbeing We know that in order for you to do your best, and to really enjoy the environment that we're providing during this time, how important your wellbeing is for us to focus on at our HHS The other part of the resource that's important is staff and that's all of us. And really, we need to be in a good space, individually and as teams to deal with this. And if we do that then I think we'll do really well Building connectedness ythe first question is -if your child was admitted with COVID-19 would you be able to be with them, and I guess this is relevant for me, I've got two young kids I have every confidence that we're all going to be okay and if we pull together, we'll get through this Adapting to fast-changing situation  15 The HHS Executive was a textbook example of this strategy in action, proactively implementing a digital methodology to take the Executive out to staff. Staff feedback described the CE as approachable, transparent and reliable. The VIDCASTS helped build connection, which is important in times of uncertainty for building strong internal relationships within the organisation. 16 A robust digital communications platform is important to enable virtual leadership during the pandemic. 17,18 In addition to providing consistent and accurate information, the VIDCASTS provided the means for the staff voice to be heard and for 'more nuanced conversations' to be had. 19 Second, this study aimed to understand the key concerns of staff. This was important to ensure that the HHS was supporting its workforce, allaying concerns, building camaraderie and enabling the staff to focus upon the important tasks at hand. Not surprisingly, staff concerns at this HHS mirrored some of those of other recently published studies from around the world during the pandemic. [20][21][22][23][24] The dominant theme of the VIDCAST sessions was the dissemination of accurate information throughout the COVID-19 pandemic to questions that were front of mind for staff, including changes to PPE and infection control practices. A desire of staff to be kept up to date with accurate information throughout the pandemic was also a pervasive theme in a survey of hospital staff in Melbourne, Australia. 21 Studies from Wuhan 24 and Spain 22 reported staff concerns about levels of PPE and lack of experience in the required infection control practices. Interviews with 55 hospital staff at a facility in the US found the prominent theme of wanting information around risk assessment and planning. 20 The second theme from the VIDCAST transcripts was providing reassurance and support. Studies of hospital staff during the pandemic across Wuhan, 24 Spain, 22 the US 20 and Australia 21 all found a key concern of their staff was the health and safety of themselves and their families. Different organisational responses were reported; for example, the hospital in Wuhan established regular connection with family through social media channels and introduced wellbeing services, including a psychologist. 24 However, none of the studies reported having a direct two-way communication channel with their executive staff to allay fears, as was implemented in this HHS.
The final theme from the VIDCASTS was innovation and communication. Studies from hospitals in the US 20 and Spain 22 reported an increase in collaboration and communication between teams as they prepared for the surge. There was greater connectedness, a diminution of clinical hierarchies and recognition of the importance of interteam support and learning to cope with a more interdisciplinary way of working.
There was a key distinction between the methodology of the present study and the four previously mentioned studies. [20][21][22]24 This study was not at a single point in time, data were gathered over a 1-month period during pandemic preparations and the survey data immediately after that time. In addition, the VID-CASTS provided staff in the HHS with the opportunity to raise their concerns directly with the leadership. Therefore, the analysis was of participant-generated concerns, rather than staff being constrained by predetermined questions generated by the research team. The strength was the two-way conversation, with a mix of information from the Executive and staff queries, and authentic communication.
This study has several limitations. Despite positive feedback about the VIDCASTS from survey respondents, it is possible that respondents did not accurately represent the entire HHS staff. Only a small proportion of VIDCAST attendants responded to the survey, yet the number is larger than that from the other four published studies of hospital staff concerns at a similar epoch. Staff were advised that questions in the VIDCASTS and survey responses were anonymous, but there may have been reticence to interact due to a concern that they may be able to be linked back to individuals. Data were not gathered on how many questions were submitted before and during live VIDCASTS or the themes identified specifically in these questions. The focus of this study is the VIDCAST communications with staff, but it is not possible to cleanly separate the actions of the organisation in the pandemic response and the staff concerns raised in the VIDCASTS. Furthermore, this project reports on findings from one Australian HHS where the expected surge on COVID-19 cases did not eventuate. However, at the time when the VIDCASTS began, the expectations of the pandemic surge were reality.

Conclusion
The VIDCASTS were an effective vehicle to connect and support staff as the HHS prepared for an unprecedented demand for services. The combination of the digital innovations in the HHS with the leadership of the Executive enabled a large workforce to be supported and reassured to execute a successful response to the pandemic.

Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.