*3.4. Healthcare Organisation*

The whole sample gave 3.36 (±1.147) points for the response of healthcare centers' management to the COVID-19 pandemic. The professionals who worked in primary care gave a significantly better score (m = 3.61 ± 1.456) than those who worked in hospitals (m = 3.21 ± 1.169) and in nursing homes and other services (m = 2.97 ± 1.169) (H = 10.552; *p* = 0.005). Supervisors' concern for work teams' well-being was scored 3.74 (±1.316) points, and there were no significant differences for health services (H = 2.862; *p* = 0.239).

How work was organized obtained a mean score of 3.57 (±1.175) points and was significantly better assessed in primary care centers (m = 3.89 ± 1.125) than in hospitals (m = 3.53 ± 1.179) and nursing homes and other services (m = 3.26 ± 1.125) (H = 8.747; *p* = 0.013). No significant differences appeared in the assessments of either the healthcare protocols set up (m = 2.70 ± 1.281) (H = 1.853; *p* = 0.396) or the suitability of the circuits set up to attend to COVID-19 patients (m = 3.20 ± 1.091; *p* = 0.65).

No significant differences were found in the assessments of either training received (m = 2.71 ± 1.203) (H = 1.824; *p* = 0.402) or teamwork (m = 4.13 ± 1.115) (H = 3.418; *p* = 0.402) according to healthcare service. However, primary care professionals (m = 2.59 ± 1.425) assessed respect for their occupational rights as being significantly worse than those professionals from hospitals (m = 3.06 ± 1.336) and nursing homes and other services (m = 2.74 ± 1.483) (H = 6.661; *p* = 0.36); primary care professionals (m = 2.61 ± 1.402) assessed their working conditions as being significantly worse than those from nursing homes and other services (m = 2.9 ± 1.446) and hospitals (m = 3.04 ± 1.365) (H = 3.04 ± 1.365).

Finally, preparing health services to face a new COVID-19 outbreak obtained a score of 2.99 (±1.234) points, and significant differences were found depending on the service that the professionals worked for (H = 6.262; *p* = 0.027). Primary care professionals gave a lower score (m = 2.68 ± 1.23), followed by the professionals from hospitals (m = 3.02 ± 1.217), and finally nursing homes and other services (m = 3.32 ± 1.301). Table 4 shows the analysis done of these matters according to health department and professional category.



<sup>1</sup> Level of significance was set at *p* < 0.05.

#### **4. Discussion**

A well-organized and prepared health system should have the capacity to maintain reasonable access to high-quality health services during a healthcare emergency. This capacity depends on a coordinated response from health authorities, having contingency plans that allow for health services to be organized, clear protocols to attend to patients, and suitable human and material resources management [23]. Today the COVID-19 pandemic challenges the operation and sustainability of health systems worldwide, with differences among countries as far as measures taken and the obtained results [24]. Initially in Spain, a virus containment model was adopted and the national government centralized decisionmaking [13]. However, subsequent decisions seem to have been taken from a perspective of living with the virus and decision-making returned to the regional governments. It is convenient to remember that Spain is a decentralized country where health competences, among others, are transferred to regional governments. The measures adopted by the central government have an impact at the regional level and this can be observed in the interregional differences in the evolution of the pandemic [25], although the magnitude of this impact must be confirmed in future studies.

Nearly 50% of the healthcare professionals who participated in this study believed that healthcare quality worsened during the first COVID-19 wave. Doctors and registered nurses were the groups that assessed healthcare quality as worse during this period, probably because they were the professionals who worked in the first healthcare line of attention, and who endured a very heavy physical, psychological, and social load [26]. Indeed, more than 80% stated having been in contact with COVID-19 patients, although only 15.7% of the surveyed professionals had diagnostic tests. The prevalence of the healthcare professionals with COVID-19 in Spain was 20% but was 7.6% in this study. Nonetheless, the quantity of infected professionals varied from one region of Spain to another, and official data for provinces are not available to compare these results [27].

Workload was assessed as the factor that most impacted healthcare quality. In fact, a recent study indicates how the nursing workload was heavier when working with COVID-19 patients than with non-COVID-19 patients in an intensive care unit [28]. Nevertheless, it is striking that registered nurses were not the professional group that assessed human resources management, hiring staff, or respecting occupational rights as worse, according to the large body of evidence for occupational precariousness and shortage of registered nurses in Spain, with a nurse-patients ratio below the mean reported by the OECD [29]. Despite the current situation of the nursing workforce in Spain, which has been tremendously complicated by the pandemic, it is very possible that the humanistic values of the profession, its willingness to serve people who need it, and its capacity of resilience can explain these results, coinciding with other studies [20,30].

The differences encountered in health departments on the impact that workload had on healthcare quality, as well as other aspects on human and material resources management and organizing health care, can be explained by high healthcare pressure due to COVID-19 cases on HD2 and HD3 compared to HD1 [31]. Nevertheless, benchmarking techniques will help to detect the possible differences in the strategies adopted in the three health departments [32].

Moreover, those professionals who worked in primary care, nursing homes, and other services assessed human and material resources management worse. Spain's initial response came late and primary care strategies were not developed to contain SARS-CoV-2 from spreading, which coincided with the seasonal flu epidemic [33]. Moreover, the pandemic evidenced the precarious situation of nursing homes in Spain [34]. Therefore, all efforts had to center on supplying hospitals in order to attend to the increasing general number of cases and serious cases.

The healthcare organization assessment can be considered appropriate. Nonetheless, the primary care professionals better assessed their organization than that in hospitals, nursing homes, and other services. As previously mentioned, hospitals received most of the patients with this new disease caused by the virus that had recently appeared. Modes of viral transmission, its risk factors, clinical evolution, symptoms, or treatments for this disease are being investigated as the pandemic advances. These factors could have had an influence when setting up suitable circuits and clear protocols to attend to these patients, which could have made healthcare organization difficult. Another point to stress is the poor assessment that the professionals made of previous training in using PPE, disinfection, cleaning, and the new work organization. The WHO considers that training and supporting professionals are fundamental in this healthcare emergency [24].

The results of this work must be taken cautiously. On the one hand, this study was conducted only about the healthcare professionals working in one province in Spain and the impact of the first COVID-19 wave was variable. Professionals from other Spanish regions may have different views about healthcare management and quality. Even the opinion and perception of the same group of professionals may vary depending on their field of work. For example, there could be differences between the perception of registered nurses who work in hospitals, health centers, or nursing homes. However, our sample was limited and not randomized, which prevents some variables from being compared, e.g., if services were public or private. These types of analyses should be addressed in future studies, with representative and larger samples. In addition, there are not enough data available to determine the representativeness of the sample on the population studied according to the type of health system, department, center, or service. Another important aspect is related to the data collection instrument, since a survey was used instead of a validated questionnaire. This can affect the reliability of the results.

Other studies carried out in Spain, with online surveys and similar limitations, focused on studying the quality of life of healthcare professionals during the first COVID-19 wave [35] or the factors related to SARS-CoV-2 infection in healthcare professionals [36]. However, despite these limitations, our results are interesting because no previous studies about how Spanish healthcare professionals assess healthcare management and quality during an epidemic outbreak were found, possibly because Spain has not recently been affected by serious epidemic outbreaks. Knowing how healthcare professionals assess healthcare quality and management during the first COVID-19 wave is important. The outcomes of this study can help to detect aspects that can improve when preparing the health system for a new wave of COVID-19 or other infectious diseases. Specifically, it was observed how the emergency situation caused by the COVID-19 pandemic increased the needs of the workforce and material resources, in addition to requiring a new organization of patient care. Decision makers and managers of health services should seriously consider these factors when preparing contingency plans.
