Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 116-123
Face to face with coronavirus disease 19: Maintaining motivation, psychological safety, and wellness

Department of Emergency Medicine, Singapore General Hospital; Adjunct Professor, Duke NUS Graduate Medical School; Adjunct Professor, Yong Loo Lin School of Medicine, National University of Singapore; Singhealth Duke NUS Institute of Medical Simulation, Singapore; Founding and Board Member, World Academic Council in Emergency Medicine

Click here for correspondence address and email

Date of Submission27-Feb-2020
Date of Decision31-Mar-2020
Date of Acceptance12-Mar-2020
Date of Web Publication10-Jun-2020


Emerging infectious diseases have the potential to spread across borders extremely quickly. This was seen during the severe acute respiratory syndrome (SARS) outbreak and now, coronavirus disease (COVID 19) (novel coronavirus) pandemic. For outbreaks and pandemics, there will be behavioral, affective, and cognitive changes and adaptation seen. This may be prominent in frontline workers and healthcare workers (HCWs), who work in high-risk areas, as well as people in general. What represents the psychology and mindset of people during a pandemic? What is needed to allay anxieties and instill calm? What will be needed to keep the motivation levels of people and HCW high so that they continue to function optimally? Which motivation theory can be used to explain this and how do employers and management utilize this in their approach/strategies in planning for an outbreak? Finally, the impact of culture, in the various contexts, cannot be overlooked in crisis and pandemic management. The author is a senior emergency physician in Singapore, who has been through SARS and now the COVID pandemic. She has been instrumental in sharing some of the changes and practices implemented in Singapore, since SARS 17 years ago, until now. Besides being a full-time practicing emergency physician, the author is also an elected Member of the Singapore Parliament for the last 14 years. She shares her views on an aspect often overlooked during a pandemic: psychological wellness and motivations of people, including for HCW at the frontline.

Keywords: Coronavirus disease 19, emerging infectious diseases, motivation, pandemic, psychological wellness

How to cite this article:
Lateef F. Face to face with coronavirus disease 19: Maintaining motivation, psychological safety, and wellness. J Emerg Trauma Shock 2020;13:116-23

How to cite this URL:
Lateef F. Face to face with coronavirus disease 19: Maintaining motivation, psychological safety, and wellness. J Emerg Trauma Shock [serial online] 2020 [cited 2022 Sep 26];13:116-23. Available from:

   Introduction Top

It is always an emotional experience dealing with infectious agents and infectious diseases. Outbreaks of infectious diseases can have a very powerful psychological effect, besides the physical/medical manifestations. In fact, infectious diseases have had their fair share of impact on human societies since time immemorial: from the great plaques of the past, the spread of tuberculosis, the period of the “First Germ Panic” (1900–1940s), the 1918–1919 Spanish influenza virus outbreak, the “Second Germ Panic” (also known as the “Viral Panic”), Severe Acute Respiratory Syndrome (SARS), Ebola, and now, the novel coronavirus disease (COVID 19) pandemic. The fear of the infection is real, and it calls for proper and adequate handling worldwide. Government involvement in the public health has evolved over the years. From the days when it was entirely managed by people in healthcare, it has now become a whole of government, whole of nation, and whole of humanity approach.[1],[2],[3]

Today, emerging infectious diseases cross borders extremely quickly with the connectivity of the world and ease of international transport, thus the need for travel restrictions and even lock down orders in some cities, as appropriate. Even the automatic subconscious responses when we hear of these infections and pandemics often spark off vision and imageries of death, disease, and suffering. In this day and age of the 21st century, with much scientific progress and developments, the fear may indeed seem unwarranted, yet it continues to exist. Predicting and preventing the natural events and actions that lead to the emergence and transmission of emerging infectious diseases are difficult and challenging. However, it is possible to be prepared, to plan within our capabilities such that we are able to react and respond quickly and decisively when such an even occurs. Healthcare workers (HCWs) must be briefed, orientated, and prepared to be nimble and adaptable to a more disruptive environment at both the national and global levels.

Human nature makes us all comfortable with the stable, the routine, and the status quo. Changes and upsurges can indeed cause unease, discomfort, and potential inability to adapt or cope. The preparedness training and planning as well as drills are necessary to inculcate actions and responses required. This will help people manage their mindset and expectations, while at the same time, plan the human response adequately. This allows people to anticipate what is expected of them and hopefully, manifestation of psychological distress will be much reduced. Surveillance, development of effective counter-measures, and creation of capacity to limit spread and care for the affected patients are all possible and important measures, individually or in combination.[3],[4]

The psychological distress and fear are seen not just in the public and laypersons but also among healthcare professionals. For the latter, the professional duty of care during pandemics and crises, in light of risks involved with emerging infectious diseases, represents one of the major concerns. Members of the global healthcare community and everyone must play their part to ensure effective containment of any outbreaks. It has become a health imperative we all cannot ignore.[3],[4],[5]

In the early December 2019, cases of persons with pneumonia of uncertain etiology began to be observed in Wuhan, Hubei Province, China. Many of them were linked to a seafood wholesale market, selling Hunan delicacies. This is a market popular with the sales of live animals, which is very commonly found in this part of China. Other sources of the potential links have also not been ruled out. A cohort of these patients developed severe acute respiratory distress, and some rapidly developed acute respiratory distress syndrome and respiratory failure. By the early January 2020, a novel coronavirus was identified by the Chinese Communicable Diseases Centre and this was then subsequently named the COVID 19 by the World Health Organization (WHO). By then, the numbers affected across many nations outside China began to increase. The numbers of death within China itself increased exponentially. The global community watched anxiously as reported numbers climbed and countries began to execute border checks, travel restrictions, temperature monitoring, screening questionnaire, and other restrictions protocols. By then, the spread had reached pandemic levels, globally. In healthcare institutions, concerns loomed as to whether the world would see another infectious disease epidemic similar to SARS. There began the heightened awareness and concerns due to interdependence in the world today… whether in transportation, travels, mass migration, and financial and even education sectors.[6],[7],[8],[9]

   The Mindset and Psychology in Outbreak Progression Top

In the early stages of an outbreak, people in general look to others and the majority as a source for their information and practice. This may not necessarily be the right thing to do, but human nature is thus described as the “herd mentality.” This can lead to large numbers of persons doing the same incorrect practices and making the wrong conclusions. This may take place until some persons, leaders, or body of authority come forth and provide the relevant information, to educate, share, instill order, and appropriate actions.

In the initial stages, there can be much emotional distress, especially with the high degree of uncertainty as the manifestation of the infection changes and continue to evolve. Information may be incomplete at this stage, and it would be common for an overestimation of the infection risk. This may be deduced by the cursory and personal observations of the statistics, swayed by media reports, or headlines. In today's context, social media too tends to play a major role in directing people's perceptions. Rationally, some may take a “wait-and-see” attitude and observe whether the situation turns into an epidemic or tapers down, wears off, or disappears. Threshold may be reached as more information becomes available, with global sharing by medical experts, infectious diseases specialists, and even governments. Bodies like the WHO making announcements pertaining to public health will also be very helpful in managing realistic expectations of people.[10],[11],[12],[13]

For psychological safety, frequent sharing of information and updates is necessary. These have to be timely. In the early stages of the pandemic, where there are many uncertainties and fear levels can be high, these may have to happen more frequently with adequate reinforcements. This early stage is also when most misperceptions happen and fake news can start to spread. Accurate data and information coming from leaders and familiar faces in the community are another way that can help. In some countries, hotlines are set up for public to contact for information and queries. Employers too play a crucial role during this period, and they should align with the nationally or internationally recognized guidelines and standards. Concern and care for ill staff and having those at high risk to stay home or work from home are some of the options. Keeping abreast of the latest developments is also important as during the emergence of a new infection; the situation remains very labile and new information may surface daily from experts. This also means that advisories may evolve and change.

Communications must be undertaken with caution and a great deal of importance during outbreaks and pandemics. Governments and public health departments must have a communications strategy, which can be customized and edited, uniquely for each outbreak. The delivery mechanism and timing of these communications too must be considered, as must the person who is to deliver the message. It must come across as effective, credible and can be a tool to inform, educate, and direct public behavior as the pandemic rolls out. For HCWs at the front line, some degree of transparency and accountability should be shared. In my view, any lack of essential communications while still at the prepandemic phase can result in confusion and can risk the lack of cooperation and collaborative efforts for stakeholders, especially as it progresses to a pandemic. Another point often overlooked is the partnership with the private sectors, whether in healthcare or other industries. These players too want to be engaged to play their role in society during crisis. The communication message must also be planned so that it is suited for the general population or be targeted to certain groups. It must help to allay anxiety and generate the intended outcomes from the public. In Singapore, a Multi-Ministry Committee and Taskforce was formed very quickly at the earliest stage of the outbreak and very frequent updates from their meetings were appreciated by the public. People in this position can also crush fake news that tends to spread-like wild fire during the early stages of the outbreak.

Keeping the motivation levels of HCWs high during a crisis is important. Here is where a combination of internal as well as external motivation comes into play. Currently, there is no one good universal theory that can reliably predict what will keep people (including HCWs) motivated.[3],[10],[11],[12],[13],[14],[15],[16]

The following are some motivation theories available to help explain and understand this interesting human value.

   The Protection Motivation Theory Top

The protection motivation theory (PMT) describes how individuals are motivated to react in a protective way toward a perceived threat. This is applicable to any threat for which there is an effective, recommended response to be carried out. The PMT works on the suggestion that people protect themselves based on four factors:[17],[18],[19]

  1. The perceived severity of the threat
  2. The perceived probability of the occurrence or their vulnerability
  3. The efficacy of the recommended preventive behavior
  4. The perceived self-efficacy.

As above, it can be seen that the PMT is linked to one's self efficacy. It proposes that if self-efficacy is stronger and more robust, it will:

  1. Lead to the individual taking up the protective action and behavior in an appropriate form
  2. Influence the degree of receptivity of the individual to the information and advisory provided
  3. Promote the likelihood of the individual taking effective remedial or corrective actions.

From this theory, a higher level of perceived risk of harm or threat will encourage the person to take action to reduce that risk. The root consideration is the individual's perception, which is known to be colored by one's life experiences, upbringing, character, personality, and other factors. With PMT, the individual will recognize the danger, assess that danger, and then counter with effective and efficacious mitigation options. This represents a very sophisticated and mature human response. The response will stem from an individual's threatappraisal (i.e. one will examine how serious the threat or the situation is) and one's copingappraisal (i.e. how one responds to the threat). This coping appraisal in turn is dependent on further two factors.[17],[20],[21]

  1. Efficacy (the individual's expectations that doing the recommended can help remove the threat)
  2. Self-efficacy (the belief in one's ability to be able to execute the recommended action).

The PMT does help explain the elements at play in keeping staff motivated and continuing to work even in crises mode. This is especially relevant with HCWs, who are at the front line in these pandemics and crises. It will be useful for the management and leadership to understand these in their quest to understand their staff and employee's performance and concerns as well as in planning their execution strategies.

[TAG:2]The Expectancy Theory[22][/TAG:2]

The expectancy theory (ET) is another theory that helps us understand motivation. The ET theory explains the cognitive variables involved in work motivation. It refers to the belief that people will be motivated when they perceive a task as surmountable and rewarding. It is believed that people will be motivated when they feel they are able to accomplish a task and will be rewarded and that reward will be worth their effort and time.[22] Like the PMT, there are also four assumptions:[22]

  1. People join an organization with expectations of their needs, motivations, and past experiences
  2. Individual behavior is a conscious choice that each individual makes
  3. People want and expect different things from the organization
  4. People will choose from alternatives so as to optimize outcomes for them personally.

There is a formula to link the suggested elements in this theory:

Motivation = Expectancy × Instrumentality × Valence.

Expectancy refers to an employee's expectation that their job-related effort will result in a certain level of performance. It is measured in the range 0–1. Employees in a healthcare institution for example will have different levels and types of expertise. Even their individual confidence and expectations levels will vary. Thus, employers and supervisors must also plan courses, training, and supervision so as to enhance their capabilities and, at the same time, manage their expectancy.[22],[23],[24]

Instrumentality refers to the perception of the employee or staff as to whether they will receive what they desire and get their expected reward. This is also measured on the range from 0 to 1.[22],[23],[24]

Valence is the emotional orientation the employee/staff holds with respect to rewards and outcomes. It can be a negative or positive measure and ranges from − 1 to + 1.

When all three scores are high, the level of motivation will be high as well. In fact, because the three factors have a multiplier effect (refer to the equation), the strength is multiplied many times over compared to just the sum of individual elements.[22],[23],[24] Again, individual perception and expectations are central in the considerations and mindset will affect these factors.

   Healthcare Workers in Pandemics Top

HCWs are professionals who play an integral role during the outbreaks and pandemics such as COVID 19. Their experience is an added benefit and their commitment paramount for the execution of governments' and public health strategies. Their motivations are not to be taken for granted. Already, in day-to-day practice, there are shortages of healthcare professionals in many countries and a variety of contexts. With pandemics, there will be many changes HCWs will have to go through, such as changes in timing of work and shifts. Many institutions will commence team-based shifts and longer commitment of each team, e.g. 12–15 h shift so as to reduce cross-interaction between teams. This would reduce likelihood of spread of infectious elements from team to team and also makes it easier for contact tracing. They will have to dorn personal protective gear during the work. These include masks (surgical masks, N95 masks), goggles, face shields, impervious gowns, and gloves and will have to perform regular hand washing and use alcohol hand rub, as appropriate.

HCWs are all exposed to a variety of risks, but the extent and load are not equally distributed. Those working in the critical areas such as the emergency departments (EDs), fever screening clinics, intensive care units, and respiratory medicine clinics are at higher risk during an infectious disease pandemic. Nurses, in general, have longer contact time with patients as they carry out nursing procedures and nursing care and may spend more time with patients. Nurses carrying out aerosol-generating procedures too are at higher risk and that is why, during infectious diseases outbreaks such as SARS and now COVID 19, nebulization is not done, but instead patients are given metered dose inhalation therapy with spacers. Even with the use of noninvasive ventilation, caution is advised in view of the positive pressure used, which means that the potential for droplet dispersal is present and can be of high risk. During SARS, one of the lessons learned was to restrict the number of staff attending to each patient and to allow the most senior and experienced doctor to manage the airway. This can help reduce the incidence and load of droplet spread, even with powered air-purifying respirator being utilized for intubations and airway procedures.[25],[26]

During times of pandemics such as COVID 19, the workload in elective surgery and nonessential specialist clinics is likely to see a reduction. In fact, some of the staff from such lower risk and lower demand areas during the pandemic may be seconded to other areas in need of HCWs. They have to be trained and be familiar with the workflow in these areas they are sent to work in. At times, they may have to be put through some training and testing first before they are allowed to work in the higher risk areas. Besides doctors and nurses, there are also personnel such as healthcare administrative and clerical staff, cleaning staff, and porters, whose welfare and health must also be addressed and handled.

In carrying out all their responsibilities, HCWs have certain moral obligations and duty to patients

  • Duty to themselves
  • Duty to their families
  • Duty to colleagues and the healthcare teams they work with
  • Duty to society.

These are all relevant and important. In the Good Medical Practice guidelines published by the UK General Medical Council, it is stated that “Doctors must not refuse to treat patients because their medical conditions may put the doctor at risk.” The balance between protecting individual doctors and their families from harm and ensuring patients are not put at any unnecessary risks is something with needs to be addressed and reflected upon by doctors.[27]

During these challenging times, the well-being of HCWs remains critical and must never be overlooked. Their commitment, altruistic spirit, and duty to care must not be taken for granted. They, like everyone else, feel fear, worry, fatigue, and emotional distress, over and above the stresses they face at work, dealing with life and death situations. During outbreaks, there is an additional layer to address, i.e. the need to wear personal protective equipment (PPE) during the work. Amid the discomfort of this equipment, it is necessary and can be lifesaving. There will of course be a heightened concern for their own safety and the risk of contracting the infectious agents themselves, spreading it to their loved ones at home and the fear of isolation. The situation and stresses can be deepened as during these outbreaks the public may shun HCWs, discriminate against them, and even make snipe remarks. They can feel the emotional distress tagged to their jobs and may even lose their own social support systems and networks. There will be a lot of uncertainties, especially in the early phases of the outbreak, and HCWs may start to reflect on their level of self-trust, organization trust, and confidence. Outbreaks are challenging times. HCWs face the risk of being stigmatized.[3],[28],[29],[30],[31],[32],[33],[34] They have to reassure their families and at times face the challenge of having to stay apart from spouses and children. There may be loss of intimacy. With their own multiple roles (e.g. as a wife, child, and parent), they may face conflicting thoughts. Therefore, the importance of managing HCWs through frequent reassurance from management and supervisors, commending them for their efforts and hard work, regular sharing and debriefing sessions, as well as mindfulness practices is important.

   Motivation and Morale Boosters at the Emergency Department Top

Frontline HCWs not only need courage and commitment but also need to have safe practices, be practical, and be vigilant at all times. Any lapses for them may make a difference between wellness and being ill or being infected by the offending agent. At the ED, the head and senior faculty are in-charge of looking out for the staff in their teams, as they work during the outbreak. Providing encouragement, sufficient rest time, balanced meals, and recognition of their good work can be very important. Every shift ends with a debrief so that everyone can share their issues, stresses, concerns, and feedback as these may serve as lessons for the others on the team. The welfare committee came up with a simple flyer with frequently asked questions pertaining to COVID 19 and e-mailed these to family members, so they can be assured their loved ones are being taken care of, at work.

Some of the other initiatives at the ED, Singapore General Hospital, include:

  1. Very regular and frequent communications and update to staff. Daily e-mails to update everyone started very early at the prepandemic stage. Further, the individual teams working in the ED have their own closed chat groups, where members can update and share information or workflow as necessary and when relevant, information becomes available, in a timely fashion
  2. Day-to-day workflow and changes to the case definition. Criteria for isolation to the ED's Fever Management Area or Isolation Bays are also updated regularly. New information is shared quickly as these evolve, especially in the early phases of the outbreak. Change becomes a constant. Communications and update channels must keep up as well. Besides being functional information for workflow purposes, these empower the staff and keep them in the loop. This also ensures they feel safe, secure, and confident in their work and are clear which PPE they need to use for different groups of people/patients and procedures
  3. There are daily meetings for the ED COVID Taskforce with representatives from both medical and nursing as well as administration. The discussions and decisions are very current and robust and are updated to the staff soonest after each day's session. Even for patients admitted by the respective teams, the development and outcomes are updated to them. This is a positive step as it keeps the staff abreast of the progress of the patients they saw
  4. The institution's Chief Executive Officer (CEO) and Chairman, Medical Board, send daily e-mail updates to all staff. Besides the factual updates, motivational messages are also shared. They also share openly with staff any feedback they receive
  5. The CEO does face-to-face dialog sessions and open to all staff, and they are able to ask questions openly and obtain frank responses directly from him
  6. Well-wishers sending cards, gifts, and messages, whether physically or through social media or e-mails, endorsing the work of the HCWs at the frontline are also important as morale boosters
  7. Institution-wide temperature recording and surveillance was instituted for all staff. They are to record their temperature twice a day and upload it onto an online surveillance system. This may seem like a simple step, but the repercussions can be very impactful in terms of showing how the HCWs well-being is important[35]
  8. Adequate supply of meals is also important. In view of the longer working hours and heavy patient load during this period, staff will spend more time in the ED and hospital. As such extra meals have to be catered. Lots of healthy drinks, fruits, and snacks for quick breaks were supplied. Some of these were donated from the public and organizations which wanted to show their support for frontline HCWs during this period
  9. We also found that having a planned scalable system in place to respond to surges is critical. As the staff are familiar with this and they have been briefed, they are less psychologically distressed with every change that takes place[35],[36]
  10. Being a multiracial and multireligious society, religious leaders and their congregation held prayers for the well-being of the nation, people, and the HCWs. This may seem a small gesture, but it shows the support level from a united front. The power of spiritual support as this cannot be underestimated
  11. Since 2003, after SARS, there have been many changes implemented in the ED, including environmental controls and infrastructure changes. These are all in place and help in the management of infectious disease cases. Environmental controls such as negative pressure areas and rooms are part of the normal day-to-day feature. Even the workflow and human factors element changes have been in place, and everyone is familiar and has been trained to be able to execute and be involved in these. All these interventions create peace of mind for the HCWs, and they feel comfortable, at ease and know that they are taken care of by the department and institution. They become confident working even in the highest risk environment
  12. Having sufficient PPE and not short-changing the staff is another very important point in ensuring their wellness and peace of mind during work. Stockpiles from institution and the country have to set aside adequately for frontline workers. In fact, our staff were also provided with disposable scrubs, additional showering facilities as well as resting spaces. All these may seem rather routine, but they can make a big difference to the perception of the HCWs
  13. With any crisis, welfare committees and volunteers help show support and uplift the emotions, mood, and feelings of HCWs. The institution's intranet series such as “Caring for Yourself” is uploaded for everyone's reference and use. The staff are frequently reminded of these from the department's Director of Quality or the person in-charge of staff welfare. Some of the topics covered include:

  • Self-compassion
  • Values and resilience
  • Mindfulness and self-care
  • Recognizing and managing stress
  • Sleep hygiene
  • Regulating strong emotions.

These topics are covered in a light-hearted but factual way with pictures and animation as well to make for quick reading for the busy HCWs. The message is that one should never be ashamed to seek help if one feels physically and psychologically overwhelmed. To do so is not a sign of weakness, but a demonstration of responsibility toward self, patients, and colleagues. Leadership and management do frequent visits to the front line to meet with the staff and thank them personally for their service and commitment. Regular observations of the psychological states of the staff are also something that is done by the more senior members of the team so as to be able to pick up signs early and make the onward referral for help and counseling. In the study by McAlonan et al.,[3] whereby high-risk frontline HCWs were reviewed and interviewed some 1 year after SARS, they showed increased levels of stress, depression, and anxiety. This may be cohort and community specific. Time from the exposure may also have an association on these observations.

While the focus has often been on HCWs, nonclinical and nonprofessional HCWs in healthcare institutions too must not be forgotten, as mentioned earlier. They would include staff such as porters, cleaners, administration staff, bed management unit staff, catering staff, and even information technology personnel. What do we expect from them. They have to continue to work, and the workload will increase as well. They are also exposed to the same risk as HCWs, and this is comparable to the areas they work in and are exposed to. They will need to have the same types of protection as well. The psychological burden for them is not any lesser.[37],[38],[39],[40]

   Quarantine and Its Impact Top

Just as there was much “SARS phobia” in 2003, we also observed “COVID 19 phobia.” This was more prominent in the early stages. In Singapore, since the time of SARS, we have instituted some categories of quarantine/isolation.

Quarantine refers to the restricted movements of an individual who has been exposed to contagion or infectious disease and who may/may not get ill. There are many levels and types of quarantine, and some may have restrictions on social gathering (social distancing), restriction on travel, and other day-to-day activities.

Isolation, on the other hand, refers to the restricted movements of persons known to be ill with an infectious disease.

Some of the categories of quarantine instituted locally include as follows.[41]

Quarantine order

This is whereby an individual is isolated with the aim of limiting the spread in the community. The quarantine order (QO) will be customized accordingly as some will need to be in hospital isolation facilities, while others may be quarantined at home or in designated government quarantine facilities. The QO is a directive with legal force, with specific penalties for noncompliance.

Leave of absence

This is instituted as a precautionary measure to reduce the possible transmission. Examples of these would include students returning from China after the Chinese New year period. They would have to stay at home, for 14 days, reduce contact with others, and monitor their health closely. They will be checked upon as necessary. They are allowed to leave their homes to handle urgent matters only, on a case-by-case basis, and this has to be informed to the officer in-charge.

Stay-home notice

This is a newly introduced category for Singapore residents and long-term pass holders returning from Mainland China (outside Hubei Province). This is also for 14 days currently and is stricter than the leave of absence (LOA). Those on stay-home notice (SHN) cannot leave the home at all. People who are in any of the above categories, including HCWs, are not just left on their own. There are regular checks and surveillance as well as follow-up assessments for them, planned at regular intervals.

During an outbreak such as COVID 19, there may be distress due to fear and anxiety. There may also be stigmatization of those affected. Other stressors may include concerns about family members, jobs, and other factors.

People, including HCWs who have to be quarantined, may face different emotions, such as fear, loneliness, boredom, anger, worry, and concern. They may go through these different emotions in phases. They may fear the resentment of others. Putting someone in quarantine requires trust-building.[31],[35],[36]

The important step is to explain clearly and rationalize with those who need to be quarantined. This is to be done in their best interest so as not to have them spread any infectious diseases to their loved ones and family members. They are usually given support, will be counseled, and will still be accessible through their communication devices, such as mobilephones and video conferencing or Skype. In some cases, food will be catered or sent to them daily and other needs and amenities will be made available. Television, radio, and newspapers will also be made available to them.

Public health measures such as QO, LOA, and SHN are embedded in a broader sociopolitical context and have to be handled in a sensitive way. Individual liberty has to be balanced with protection of the public and public health interest. This is also the “ethics of quarantine.”[31],[37]

   Culture Can Trump Strategy Top

Culture shapes attitudes and behavior. It helps to guide activities and tasks through shared assumptions and group norms. Healthcare organizations and institutions' leadership will provide the strategy and focus for their staff. The organization culture itself is about the behavior, nonverbal communications and cues, mindset, and social patterns of interaction within the organization. Leaders, especially during times of crisis, shape these through both conscious and subconscious actions and behavior. They have to articulate the aspirations and address concerns of their employees. The strength of the shared culture of the organization is reflected in the staff and employees, their behavior, values, and morale. It will be showcased through their thoughts, action and will thus, have direct impact on their performance and learning attitude. These cultural norms are essentially group and collective. These factors are important in determining how staff adapt and attitude happens over time and investment of effort by management and leadership is worthwhile to ensure that the employees are risk conscious and are taught to think things through carefully. Strong culture drives results, performance, and outcomes.

HCWs span across many disciplines. Some work at the frontline and higher risk areas. At the ED, Singapore General Hospital, the strategy is to inculcate and build the culture of camaraderie and trust during “peace times.” The regular preparedness and drills are useful to help us finetune our responses and practices. Regular meetings, updates, and both formal and informal sharing sessions by the head and senior faculty help develop the culture and strengthen it further, over a period of time. The importance of building this relationship cannot be underestimated. It may be the determining factor in the staff standing by each other and coming to work during upsurge and challenging times, such as the global COVID 19 pandemic. Each of the residents and medical officers in the ED is mentored by a senior faculty, whom they can turn to discuss any issues, whether academic or otherwise. This strengthens the bonds and sense of belonging. The just and open culture shared and demonstrated during mortality and morbidity rounds or departmental meetings too will give staff the perception of the culture of the department they work in. With these initiatives, we can breakdown hierarchies and have a more “horizontal practice” and flow of information. These values built up during good times will stay during crises. During the COVID 19 pandemic, the senior faculty continue to motivate their teams, be the role models, and “walk the talk.” They are the eyes and ears to help lookout for signs of fatigue, stress, and other emotional distress among their team members if any.

Staff's perception of a psychologically and mentally healthy workplace environment too is important. So too is their perception of their leadership and management's ability to recognize need for change and accept feedback, even negative ones. This is so critical that it is said to have ten times the impact of teamwork relative to all other organization climate factors, even more than remuneration. Thus, organization support, strength of relationships within the organization, having strong and positive role models, and being able to command clear action plans are all linked to strong organization culture and employees with good work outcomes and results.[30],[37],[42]

As Singapore is a multicultural society, coping strategies too can differ with the different cultures. Their ways of handling crises and stressors in their lives can also have some variations. For example, in the Chinese community, it is believed that taking a lot of fluids, “cooling foods,” and soups are very good during the periods of stress. Bird's nest and tonics are believed to be good for boosting mental strength. Professionals may tend to engage in preventive health measures such as exercises and yoga. Others may turn toward spiritual practices to help them keep their calm and balance. Some of these responses may be categorized as affective, cognitive, or behavioral. People, including HCWs, may also have their own community of support and networks to help them maintain their work–life balance.

   Conclusions Top

Preparedness is the resultant of the interplay between the state, governments, companies, institutions, nongovernmental organizations, families, and individuals. It represents a whole of society collaborative approach. There is no leaving anyone out. The threat of an emerging infectious disease remains real and highly possible. It is not just something seen in Hollywood movies or read in fiction novels anymore. The well-being of frontline HCWs cannot be a “by the way” consideration. All pandemic plans must include a psychological safety plan [Table 1]. Their physical and psychological wellness is paramount and must be mainstreamed into all preparedness plans and executed accordingly. As we move along, our strategies and interventions must continue to be planned, and re-planned as we must remain nimble and flexible in our approach, ready to adapt to the very quickly changing environment and infectious organisms. Living in an interconnected world today, with the emerging pathogens which do not respect boundaries, the global community must work together, share information, share best practices, and continue to enhance our global collaborative practice together[43],[44] [Table 1].
Table 1: The 10Cs: Framework for preparedness and handling emerging infectious diseases pandemics

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Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Fatimah Lateef
Department of Emergency Medicine, Singapore General Hospital

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_27_20

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