. 2023 May 20;23:368. doi: 10.1186/s12884-023-05641-2

Table 2.

Supplementary Quotations

Reflective decision-making → Unique opportunities for service improvement	Pragmatic decision-making → Disruption of care	Reactive decision-making → Devaluation of care
“That is really bad that it took a pandemic to get the wellbeing staff, but now we have a psychologist that works alongside our staff and we have psychological support for the staff. If they have an adverse incident then there is a lot more support for them. We have to never lose that again. We have to always keep the wellbeing of staff at the forefront…” (Midwifery Clinical Manager) “Everyone handles their burdens differently, but on the whole I think people felt like they were able to go in and share and say, “How are things for you?” There was a really good support network colleague to colleague.” (Midwifery Frontline Clinician) “I felt that there was good support. I never felt alone and I never felt that there wasn’t anyone I could have asked and it felt like our department really came together…” (Research Midwife) “And I think it was actually good to go into hospital where you see people. In a way, working from home would have been, probably, more isolating. At least there was some kind of normality. But yes, there was definitely a group of people there who you did stick together and… Yes, very supportive so you felt very supported with your colleagues in the department, I would say…” (Nursing Frontline Clinician) “There’s lots of positive things, but turning things round and changing the way we do things has been quite tiring. It is like anything. Some people cope well with change, some people are very resistant and haven’t enjoyed it. Trying to cope with all your various staff reactions to everything is difficult.” (Obstetric Frontline Clinician) “I think in that sense it worked really well, and I felt much more part of a team than I had before, really.” (Research Midwife) “At the beginning I was really up for it. I felt, especially as a part-time worker, that I was doing my duty and I was helping out…” (Midwifery Clinical Manager) “We bumbled together. Despite the fact it was a very traumatic clinical time, it was one of the best times of my leadership career.” (Midwifery Strategic Leader) “I think actually for a long time what we did was focus on patients, patients, patients, patients and we completely forgot the needs of the staff and we weren’t paying attention to the fact that happy staff means that you are more likely to get happy patients and now we’ve reaped the consequences of leaving staff out of the picture and I think, I hope, that COVID has flipped that, and we now understand. And I think that was one of the good things is the level of wellbeing provision provided to the staff, but it wasn’t enough to fully mitigate the concerns that have been raised by staff since COVID, but it was never going to because we did too little too late.” (Obstetric Senior Clinician) “…we met every single week and we had real comradeship about, 'Look, this is what we are doing, and this is how we are doing it”. We really supported each other.' (Internal Medicine Senior Clinician) “I think that one of the things that we’ve learnt from this pandemic is that maintaining distance within healthcare environments has been really challenging, and the reason for that is that our healthcare environments are far too crowded” (Neonatology Senior Clinician) “I always have multiple projects going on and I don’t like hanging about, so for me it was actually exciting that we could decide, and we could implement it, so that was refreshing in that sense for me.” (Midwifery Strategic Leader)	“PPE creates a barrier because you are wearing a mask and a lot of communication is through that face to face. That made it very difficult, and I think that created barriers really to communicating and connecting with women. It was the trust really I think it affected; I would say.” (Midwifery Frontline Clinician) “We were trying to focus on so many different things and not necessarily getting any of them right. Now we maybe get a couple of things right and not many other things…” (Midwifery Clinical Manager) “ There’s a reason we do it the whole way through and the care that we give normally is the bare minimum of what we think is safe, so for us to cut back on that, like that’s why we do what we do, we try to run an efficient healthcare system, so knowing that you are then not seeing those women as often, you know that the care that you are giving is not the ideal… it’s not optimum care. So, there was definitely a real worry, one that things would get missed.” (Midwifery Frontline Clinician) “I think it was the way it was brought into us, being told that it was just going to happen straightaway, I think there was a little bit of a feeling of oh, well, is it not a worry for us being overheated and hot anymore?” (Midwifery Frontline Clinician) “…it felt that there was a real possibility that I would feel in a position where I wasn’t able to give what I felt was the kind of care I would want to because I’m not used to being in that area and there could be very little support because we are in the middle of this huge pandemic.” (Research Midwife) “Women are going through probably one of the most profound experiences of their life when they generally have some feelings of vulnerability however happy to be pregnant they are and all of a sudden a) they were living in this global pandemic and no one really knew what that meant for people who were pregnant, but also it meant that all of the things that it would normally be absolutely a given that you would share with someone and have support with, suddenly people were being asked to do on their own…” (Research Midwife) “…we have been quite innovative. First of all what needs to stay is the fact that things have been a lot quicker to get approved. If someone has a guideline it gets approved overnight whereas there was a lot of tape initially. That has been a positive: we know we can get things approved a lot faster. There has been a bit more initiative in adopting to become more virtual. We have set up education classes for our caesarean section pathway online now. Things like that…” (Obstetric Frontline Clinician) “It would just be that change in virtual, but we know how to do it because we did it last time. Going forward we have now got the skills. We know everyone needs a headset. We realised and we have started doing patient education online so if there is a second wave, one group has already done it so the other groups can copy and keep going. We will probably get a little more savvy if there is a second wave because we will be working to keep patients at home when possible. We will get more into patient virtual education a bit better. We didn’t have time last time.” (Obstetric Frontline Clinician) “It comes back down to seeing someone face to face, having a midwife appointment and being able to go, ‘I have this question that I want to ask you,’ which they might not ask if they weren’t seeing someone face to face or it was on the telephone. It is that human contact bit that would be important.” (Obstetric Frontline Clinician) “So, women are often seeing someone different every time, there’s no trust being built up, a lot of questions I can only imagine are going unanswered and you’d have thought, 'oh great', with online maybe there are going to be longer appointments. But is that happening? No, of course not. Then as soon as there’s internet issues or connection issues it’s automatically putting up more barriers between women and them feeling okay to ask questions and things.” (Midwifery Frontline Clinician) “I think it’s made me feel I’m more adaptable to change than I thought, having to adapt to all these different working systems and etc. I’d like to be able to give clinical care virtually again, I’ve enjoyed that, having more contact with the women.” (Research Midwife) “…what women are missing out on is tapping into a midwife’s brain. That corridor conversation when you are in a clinic of, ‘Oh yes, I was going to ask you…’” (Midwifery Clinical Manager) “I think from women’s perspective, I can imagine that it is very disjointed, because you don’t get to experience coming into the hospital, you don’t get to experience that with your partner.” (Midwifery Clinical Manager) “I think for me in a specialty or in a clinical situation where you need to be looking at body language and tone of voice and facial expression and the non-verbal cues, doing it by phone or non-verbal I think we are giving a substandard service….. I think that since we, to some degree, do need to deliver a virtual offering, it ought to be a good virtual offering, so face to face virtually rather than simply auditory contact and that means that our I.T. needs to be upgraded – that old chestnut again – to provide that level of service.” (Obstetric Senior Clinician) “…our other problem is that our GPs have, to some extent, gone AWOL and have taken themselves out of the picture so that women can’t get their drugs and they are coming to the hospital to do that when actually things like ongoing prescriptions should be provided within the community” (Obstetric Senior Clinician) “The biggest thing I am unhappy about – it is ongoing – is the change in the schedule of care and the lack of face-to-face contact.” (Midwifery Frontline Clinician) “I see the psychological impact on women is really traumatised, really upset, because it is more than the physical. It is not just the physical checking the baby is okay, and the placenta is in the right position. It is a really big emotional bonding moment, the start of a family if it is their first baby…” (Midwifery Frontline Clinician) “If we are cutting down the relationships and the time with women and we are not building relationships with us, they don’t know us, they don’t know who they can turn to, that risk is going up – the very real, big risk. COVID is a risk too.” (Midwifery Frontline Clinician) “I think it’s a fundamental human right for fathers to be there, particularly to see their babies, and for someone to make a blanket decision that you simply cannot come in, I think there will be a backlash. So those kind of approaches we need to think through and sometimes it’s a matter of saying what can we do which is safe and right rather than what is the easy thing for us to do.” (Obstetric Senior Clinician) “…actually, the virtual clinic, really I worry that it may not be as effective because you really need a very judicious administrative closure of the loop and I don’t think that happens very well, so it’s very difficult from that aspect…” (Obstetric Senior Clinician) “I think the clinical aspect, there should still be more face to face and interactive, particularly for maternity where you need to palpate the baby. I think this has been, to some extent, imposed on mothers without really understanding how they feel about it and I’m sure if you ask most mothers or even a mother with a baby, actually the interactions make a difference to them and it just seems so isolating for your team to be contacting you by phone or virtually.” (Obstetric Senior Clinician) “I feel it was a compromised offer [of care], but we did the best in the circumstance. But it wasn’t our optimal.” (Health Visiting Strategic Leader) “…virtual [care] is good. But virtual [care] is fine if you able to have the means and resources to do that, but for a large proportion of our population English is the second language, there’s digital poverty.” (Health Visiting Strategic Leader) “…the idea of false compliance, because we were unable to go into their house to do home assessments and see whether there is maybe a health and safety issue or whatever thing that we need to discuss with them, or even if for example, those ones who are going through DV, maybe the perpetrator is still in the house or some other things. But before when we go in, we have to do that. But on the video, you don’t know.” (Health Visiting Clinical Manager) “…there’s certain camaraderie that happens when you just think… you know, you have to sort of surrender to it, but the thing is it’s that fine line between surrendering and just thinking, oh well, we can only do what we can do and then suddenly you are in complacency and there’s an incident and you think, oh my god, I took my eye off the ball for a minute there…” (Health Visiting Clinical Manager) “The FFP thing… we were quite lucky because we didn’t have to wear full FFP3, which was a real godsend. I got given one of the really big masks and you can’t understand what people are saying through them. It is all about communication. It is about eye contact, the real subtle things. That has been a detriment. Family photos. We take nice photos when the women have their babies. People wearing face masks – that has had an effect. Most patients understand and it is not a big deal, but there are subtleties lost with the PPE.” (Anaesthetic Frontline Clinician)	“I guess it would be really helpful if the messages were always the same, I think that’s the hardest thing. You’d hear something from the Government one day, then we’d hear something new at work, and it felt like we were guided by what the Government was saying. I just find that really frustrating at times, because I feel like we’ve got some real experts here that are worried about people’s health, not financial stuff. And if you have a universal message.” (Midwifery Frontline Clinician) “I’ve dropped my hours again because I don’t feel that the service is keeping me safe.” (Midwifery Frontline Clinician) “I can’t imagine anyone ever saying that they thought it would be okay that people wouldn’t be able to have someone with them throughout their labour and in the postnatal period and that was kind of suddenly just accepted that that was okay and I’m not sure still now that that is okay because actually one person who is well staying with that person, would that have really increased the risk of virus transmission hugely and would not having that impact massively on people’s long-term mental health?” (Research Midwife) “…the morale of a lot of people will change if we can’t ensure that the work/life balance is better.” (Obstetric Frontline Clinician) “I think we functioned similarly to pre-COVID, it was just a different staffing, a different work pattern. We held up all the services we provide. Nothing stopped. It was just the way it was delivered was a little different.” (Obstetric Frontline Clinician) “I was expecting at least at work to be my bubble and that we would be able to get on better looking out for each other more, but unfortunately I found the opposite and quite a stark difference to how it was before. As I mentioned, working in the office sometimes I found difficult because whether it is personality or the dynamics that were going on, that became much more obvious during the pandemic. It really has destroyed the team dynamics almost completely…” (Imaging Sciences Frontline Clinician) “It has been stressful trying to keep up with all the changes that were taking place in the trust or nationally and the concern that I wasn’t being protected with PPE as well as I could have been. At the beginning there were much stronger protective measures that were put in place, then as time went on it became less and less, but the virus is still the same, so you wonder: how effective is this that I am doing? I have always felt like I have had to do more than what was put out in the trust.” (Imaging Sciences Frontline Clinician) “It works much better if they are in clinic face to face and you can do LanguageLine because it makes you slightly worry about: are you missing anything?” (Obstetric Frontline Clinician) “I felt a responsibility to give them [friends] correct information, but I also didn’t really have a lot of information and it kept changing, so I just felt frustrated by that.” (Midwifery Frontline Clinician) “…so much of being a midwife and looking after a woman is about that rapport and being able to see each other’s faces and communication and non-verbal communication and so much of it is taken away when you have that physical barrier in front of your mouth, so it’s much harder to communicate and to get across empathy. So I think from the woman’s point of view, there must be a lot of stuff that is lost in translation and there’s a lot of empathy and compassion giving that’s probably not received because it can’t be given as well as it would usually.” (Midwifery Frontline Clinician) “…a lot of my colleagues were quite visibly so, so on already a fast-paced, high-risk environment where labouring women can go from 0 to 100 in two seconds, it just added more [of the same], I suppose, and colleagues were, I guess, a bit more pre-occupied with other things as well and life and home and the news.” (Midwifery Frontline Clinician) “…the first six weeks were extremely stressful, trying to manage the new reality. And then the way I split it in my head is the first six weeks were very stressful, the next six weeks were very boring [laughs]. Because once the stress had passed the variety of the clinics disappeared. Not seeing people face-to-face was boring.” (Internal Medicine Frontline Clinician) “Some women have preferred the fact that they don’t have to come in. I think for those women who don’t look after themselves as well as they should it has sometimes been an excuse for not looking after themselves even more, whereas perhaps we would have brought them in on a weekly basis…” (Internal Medicine Frontline Clinician) “…we coped with for a while because we all felt like we were doing the right thing. And then it got tiring and then we started to get burnt out. I started to get burnt out. I tapped into the psychological support, the e-mails that we got were lovely, and then it started to wear thin. And it still is wearing thin.” (Midwifery Clinical Manager) “For women who are more vulnerable, who would shy away, who don’t want to face it alone, then it’s probably not a very good service. And then they just turn up and have a baby. It’s lonely, ultimately. I think it’s a lonely service.” (Midwifery Clinical Manager) “…they can’t see your face; you can’t see their face and in women who have drug and alcohol situations or mental health situations that’s unsatisfactory. I also have lots of women with eating disorders. If you don’t see them, you can’t make a true assessment. Often, you’d call them, and they wouldn’t answer and they wouldn’t call back if they didn’t answer and you left a message, so it’s pointless, therefore the follow-up processes were also sub-optimal.” (Obstetric Senior Clinician) “…we’ve given less good care because we haven’t seen the women, we’ve missed things like growth restrictions… with the opportunity to miss things like growth restriction, pre-eclampsia sometimes and things like that.” (Obstetric Senior Clinician) “[on telephone clinics] It is less time-consuming. That is the only advantage I can think of, but I don’t really see it as an advantage.” (Midwifery Frontline Clinician) “We are not putting women at the centre of our care in this. Maybe that is the right decision. I am just a little midwife, I am not a person who is looking at the bigger picture, but I came into midwifery because I am a feminist and I believe in supporting women. In my training I learned that you put a woman at the centre of your care and everything else goes around that. I don’t see that is what is happening, but maybe in the bigger picture we are because we are trying to safeguard the whole population and women are part of that. I do see that there is more than one side of this.” (Midwifery Frontline Clinician) “I think that clearly there’s lack of acceptance that there may be a digital divide, so for some women I think it may actually cause harm and we’ll know later…” (Obstetric Senior Clinician) “…and I think that dictum that keep COVID patients away from the NHS to save the NHS, certainly in pregnancy, didn’t help!” (Obstetric Senior Clinician) “I found it mentally and physically exhausting to balance everything from a distance whilst shielding. And even in the early days. Yes. I was running on empty at times…” (Health Visiting Strategic Leader) “We didn’t have enough PPE at that time, and for me and my staff, the way I see it, maybe during that time when I was running around to make sure that they were safe and they had enough PPE, maybe that was when I contracted this virus myself.” (Health Visiting Clinical Manager) “…it’s been a challenge. I mean, for me, personally, I think I really struggled with trusting that the team are doing what they should be doing whilst they are not in the office, but then there’s no reason to suspect, and I think that’s often related to when I’m feeling a bit out of control, like I haven’t got tabs on things and I don’t know who is doing what and then I will have a call from a nurse who is in tears because she’s like, 'I can’t sit in my bed and do a case conference about horrendous things and then just log off and I’m sitting on my bed that I sleep in, it’s not working'. So that aspect of not having a boundary has been really tough emotionally for them.” (Health Visiting Clinical Manager) “[on banning partner visiting] It was a little draconian and a bit cruel on women.” (Anaesthetic Frontline Clinician) “There were a lot of women’s lives that were put at risk because we were having to do probably unnecessary PPE and resuscitation guidelines. Women’s lives were put at risk from limitations as opposed to my life being put at risk.” (Anaesthetic Frontline Clinician) “[on mixed messages for pregnant women] There are only so many times a woman would hear a maternity message in the day or a hospital message saying, ‘Please come to hospital if you are unwell,’ as opposed to the number of times they would hear a disaster message, death and destruction and everything, the NHS can’t cope – that ‘Leave the NHS alone’ message. They were fighting a losing battle ultimately.” (Anaesthetic Frontline Clinician) “It is the apathy and the frustration. We have done it before, and we didn’t like doing it before.” (Anaesthetic Frontline Clinician) “For the proportion of women that needed those assessments, probably the standard of their care went down because they weren’t being seen face to face for the Anaesthetic antenatal assessments. It is harder to pick up on cues about what exactly a woman is worried about, where exactly a woman might be reassured by things you might say to her.” (Anaesthetic Frontline Clinician) “The things I haven’t enjoyed about it, the things I found quite personally challenging, have been in the midst of it the relentlessness of it. […] Alongside that, the lack of any tangible holiday or break has been very hard because everything was cancelled in Covid. There was no annual leave, there didn’t seem any point in taking annual leave because you couldn’t travel. […]Even if you did, that all-pervasive Covid headlines are hugely draining in any healthcare professional because you are wondering what is coming next and when it is all going to change again, when is the sand going to shift, when are you going to be asked to do more or change again? 'How can I prepare, how can I get everything ready?' There is this baseline of tension.” (Anaesthetic Frontline Clinician) “…you realise is staff have got incredibly complex social circumstances themselves, and therefore that resilience within your workforce is not there at the same levels, so if something like this happens then I think that’s when you realise how fragile your workforce is.” (Midwifery Strategic Leader) “The balance between we have got to get on with it, to this is the best way of doing it, to this is just good enough, is really hard for some of our clinicians. Our clinicians are used to – generally, by and large – being able to provide really high-quality care. That was a real hit to them, but not something we could control…” (Obstetric Strategic Leader) “What I found the most difficult thing to navigate was the conflicting advice from… Say for instance the Institute of Health Visiting versus the NHS England guidance versus the PHE [Public Health England] guidance versus the [local] guidance, so trying to assimilate all the various guidance and protocols and service delivery mechanisms, trying to make sense of it and then distilling it into a standard operating procedure for each service where they could understand what was expected of them, when, how and where, doing what……… It was the all-consuming part of my role at that time” (Health Visiting Strategic Leader)

Reflective decision-making → Unique opportunities for service improvement

Pragmatic decision-making → Disruption of care

Reactive decision-making → Devaluation of care

“That is really bad that it took a pandemic to get the wellbeing staff, but now we have a psychologist that works alongside our staff and we have psychological support for the staff. If they have an adverse incident then there is a lot more support for them. We have to never lose that again. We have to always keep the wellbeing of staff at the forefront…” (Midwifery Clinical Manager)

“Everyone handles their burdens differently, but on the whole I think people felt like they were able to go in and share and say, “How are things for you?” There was a really good support network colleague to colleague.” (Midwifery Frontline Clinician)

“I felt that there was good support. I never felt alone and I never felt that there wasn’t anyone I could have asked and it felt like our department really came together…” (Research Midwife)

“And I think it was actually good to go into hospital where you see people. In a way, working from home would have been, probably, more isolating. At least there was some kind of normality. But yes, there was definitely a group of people there who you did stick together and… Yes, very supportive so you felt very supported with your colleagues in the department, I would say…” (Nursing Frontline Clinician)

“There’s lots of positive things, but turning things round and changing the way we do things has been quite tiring. It is like anything. Some people cope well with change, some people are very resistant and haven’t enjoyed it. Trying to cope with all your various staff reactions to everything is difficult.” (Obstetric Frontline Clinician)

“I think in that sense it worked really well, and I felt much more part of a team than I had before, really.” (Research Midwife)

“At the beginning I was really up for it. I felt, especially as a part-time worker, that I was doing my duty and I was helping out…” (Midwifery Clinical Manager)

“We bumbled together. Despite the fact it was a very traumatic clinical time, it was one of the best times of my leadership career.” (Midwifery Strategic Leader)

“I think actually for a long time what we did was focus on patients, patients, patients, patients and we completely forgot the needs of the staff and we weren’t paying attention to the fact that happy staff means that you are more likely to get happy patients and now we’ve reaped the consequences of leaving staff out of the picture and I think, I hope, that COVID has flipped that, and we now understand. And I think that was one of the good things is the level of wellbeing provision provided to the staff, but it wasn’t enough to fully mitigate the concerns that have been raised by staff since COVID, but it was never going to because we did too little too late.” (Obstetric Senior Clinician)

“…we met every single week and we had real comradeship about, 'Look, this is what we are doing, and this is how we are doing it”. We really supported each other.' (Internal Medicine Senior Clinician)

“I think that one of the things that we’ve learnt from this pandemic is that maintaining distance within healthcare environments has been really challenging, and the reason for that is that our healthcare environments are far too crowded” (Neonatology Senior Clinician)

“I always have multiple projects going on and I don’t like hanging about, so for me it was actually exciting that we could decide, and we could implement it, so that was refreshing in that sense for me.” (Midwifery Strategic Leader)

“PPE creates a barrier because you are wearing a mask and a lot of communication is through that face to face. That made it very difficult, and I think that created barriers really to communicating and connecting with women. It was the trust really I think it affected; I would say.” (Midwifery Frontline Clinician)

“We were trying to focus on so many different things and not necessarily getting any of them right. Now we maybe get a couple of things right and not many other things…” (Midwifery Clinical Manager)

“ There’s a reason we do it the whole way through and the care that we give normally is the bare minimum of what we think is safe, so for us to cut back on that, like that’s why we do what we do, we try to run an efficient healthcare system, so knowing that you are then not seeing those women as often, you know that the care that you are giving is not the ideal… it’s not optimum care. So, there was definitely a real worry, one that things would get missed.” (Midwifery Frontline Clinician)

“I think it was the way it was brought into us, being told that it was just going to happen straightaway, I think there was a little bit of a feeling of oh, well, is it not a worry for us being overheated and hot anymore?” (Midwifery Frontline Clinician)

“…it felt that there was a real possibility that I would feel in a position where I wasn’t able to give what I felt was the kind of care I would want to because I’m not used to being in that area and there could be very little support because we are in the middle of this huge pandemic.” (Research Midwife)

“Women are going through probably one of the most profound experiences of their life when they generally have some feelings of vulnerability however happy to be pregnant they are and all of a sudden a) they were living in this global pandemic and no one really knew what that meant for people who were pregnant, but also it meant that all of the things that it would normally be absolutely a given that you would share with someone and have support with, suddenly people were being asked to do on their own…” (Research Midwife)

“…we have been quite innovative. First of all what needs to stay is the fact that things have been a lot quicker to get approved. If someone has a guideline it gets approved overnight whereas there was a lot of tape initially. That has been a positive: we know we can get things approved a lot faster. There has been a bit more initiative in adopting to become more virtual. We have set up education classes for our caesarean section pathway online now. Things like that…” (Obstetric Frontline Clinician)

“It would just be that change in virtual, but we know how to do it because we did it last time. Going forward we have now got the skills. We know everyone needs a headset. We realised and we have started doing patient education online so if there is a second wave, one group has already done it so the other groups can copy and keep going. We will probably get a little more savvy if there is a second wave because we will be working to keep patients at home when possible. We will get more into patient virtual education a bit better. We didn’t have time last time.” (Obstetric Frontline Clinician)

“It comes back down to seeing someone face to face, having a midwife appointment and being able to go, ‘I have this question that I want to ask you,’ which they might not ask if they weren’t seeing someone face to face or it was on the telephone. It is that human contact bit that would be important.” (Obstetric Frontline Clinician)

“So, women are often seeing someone different every time, there’s no trust being built up, a lot of questions I can only imagine are going unanswered and you’d have thought, 'oh great', with online maybe there are going to be longer appointments. But is that happening? No, of course not. Then as soon as there’s internet issues or connection issues it’s automatically putting up more barriers between women and them feeling okay to ask questions and things.” (Midwifery Frontline Clinician)

“I think it’s made me feel I’m more adaptable to change than I thought, having to adapt to all these different working systems and etc. I’d like to be able to give clinical care virtually again, I’ve enjoyed that, having more contact with the women.” (Research Midwife)

“…what women are missing out on is tapping into a midwife’s brain. That corridor conversation when you are in a clinic of, ‘Oh yes, I was going to ask you…’” (Midwifery Clinical Manager)

“I think from women’s perspective, I can imagine that it is very disjointed, because you don’t get to experience coming into the hospital, you don’t get to experience that with your partner.” (Midwifery Clinical Manager)

“I think for me in a specialty or in a clinical situation where you need to be looking at body language and tone of voice and facial expression and the non-verbal cues, doing it by phone or non-verbal I think we are giving a substandard service….. I think that since we, to some degree, do need to deliver a virtual offering, it ought to be a good virtual offering, so face to face virtually rather than simply auditory contact and that means that our I.T. needs to be upgraded – that old chestnut again – to provide that level of service.” (Obstetric Senior Clinician)

“…our other problem is that our GPs have, to some extent, gone AWOL and have taken themselves out of the picture so that women can’t get their drugs and they are coming to the hospital to do that when actually things like ongoing prescriptions should be provided within the community” (Obstetric Senior Clinician)

“The biggest thing I am unhappy about – it is ongoing – is the change in the schedule of care and the lack of face-to-face contact.” (Midwifery Frontline Clinician)

“I see the psychological impact on women is really traumatised, really upset, because it is more than the physical. It is not just the physical checking the baby is okay, and the placenta is in the right position. It is a really big emotional bonding moment, the start of a family if it is their first baby…” (Midwifery Frontline Clinician)

“If we are cutting down the relationships and the time with women and we are not building relationships with us, they don’t know us, they don’t know who they can turn to, that risk is going up – the very real, big risk. COVID is a risk too.” (Midwifery Frontline Clinician)

“I think it’s a fundamental human right for fathers to be there, particularly to see their babies, and for someone to make a blanket decision that you simply cannot come in, I think there will be a backlash. So those kind of approaches we need to think through and sometimes it’s a matter of saying what can we do which is safe and right rather than what is the easy thing for us to do.” (Obstetric Senior Clinician)

“…actually, the virtual clinic, really I worry that it may not be as effective because you really need a very judicious administrative closure of the loop and I don’t think that happens very well, so it’s very difficult from that aspect…” (Obstetric Senior Clinician)

“I think the clinical aspect, there should still be more face to face and interactive, particularly for maternity where you need to palpate the baby. I think this has been, to some extent, imposed on mothers without really understanding how they feel about it and I’m sure if you ask most mothers or even a mother with a baby, actually the interactions make a difference to them and it just seems so isolating for your team to be contacting you by phone or virtually.” (Obstetric Senior Clinician)

“I feel it was a compromised offer [of care], but we did the best in the circumstance. But it wasn’t our optimal.” (Health Visiting Strategic Leader)

“…virtual [care] is good. But virtual [care] is fine if you able to have the means and resources to do that, but for a large proportion of our population English is the second language, there’s digital poverty.” (Health Visiting Strategic Leader)

“…the idea of false compliance, because we were unable to go into their house to do home assessments and see whether there is maybe a health and safety issue or whatever thing that we need to discuss with them, or even if for example, those ones who are going through DV, maybe the perpetrator is still in the house or some other things. But before when we go in, we have to do that. But on the video, you don’t know.” (Health Visiting Clinical Manager)

“…there’s certain camaraderie that happens when you just think… you know, you have to sort of surrender to it, but the thing is it’s that fine line between surrendering and just thinking, oh well, we can only do what we can do and then suddenly you are in complacency and there’s an incident and you think, oh my god, I took my eye off the ball for a minute there…” (Health Visiting Clinical Manager)

“The FFP thing… we were quite lucky because we didn’t have to wear full FFP3, which was a real godsend. I got given one of the really big masks and you can’t understand what people are saying through them. It is all about communication. It is about eye contact, the real subtle things. That has been a detriment. Family photos. We take nice photos when the women have their babies. People wearing face masks – that has had an effect. Most patients understand and it is not a big deal, but there are subtleties lost with the PPE.” (Anaesthetic Frontline Clinician)

“I guess it would be really helpful if the messages were always the same, I think that’s the hardest thing. You’d hear something from the Government one day, then we’d hear something new at work, and it felt like we were guided by what the Government was saying. I just find that really frustrating at times, because I feel like we’ve got some real experts here that are worried about people’s health, not financial stuff. And if you have a universal message.” (Midwifery Frontline Clinician)

“I’ve dropped my hours again because I don’t feel that the service is keeping me safe.” (Midwifery Frontline Clinician)

“I can’t imagine anyone ever saying that they thought it would be okay that people wouldn’t be able to have someone with them throughout their labour and in the postnatal period and that was kind of suddenly just accepted that that was okay and I’m not sure still now that that is okay because actually one person who is well staying with that person, would that have really increased the risk of virus transmission hugely and would not having that impact massively on people’s long-term mental health?” (Research Midwife)

“…the morale of a lot of people will change if we can’t ensure that the work/life balance is better.” (Obstetric Frontline Clinician)

“I think we functioned similarly to pre-COVID, it was just a different staffing, a different work pattern. We held up all the services we provide. Nothing stopped. It was just the way it was delivered was a little different.” (Obstetric Frontline Clinician)

“I was expecting at least at work to be my bubble and that we would be able to get on better looking out for each other more, but unfortunately I found the opposite and quite a stark difference to how it was before. As I mentioned, working in the office sometimes I found difficult because whether it is personality or the dynamics that were going on, that became much more obvious during the pandemic. It really has destroyed the team dynamics almost completely…” (Imaging Sciences Frontline Clinician)

“It has been stressful trying to keep up with all the changes that were taking place in the trust or nationally and the concern that I wasn’t being protected with PPE as well as I could have been. At the beginning there were much stronger protective measures that were put in place, then as time went on it became less and less, but the virus is still the same, so you wonder: how effective is this that I am doing? I have always felt like I have had to do more than what was put out in the trust.” (Imaging Sciences Frontline Clinician)

“It works much better if they are in clinic face to face and you can do LanguageLine because it makes you slightly worry about: are you missing anything?” (Obstetric Frontline Clinician)

“I felt a responsibility to give them [friends] correct information, but I also didn’t really have a lot of information and it kept changing, so I just felt frustrated by that.” (Midwifery Frontline Clinician)

“…so much of being a midwife and looking after a woman is about that rapport and being able to see each other’s faces and communication and non-verbal communication and so much of it is taken away when you have that physical barrier in front of your mouth, so it’s much harder to communicate and to get across empathy. So I think from the woman’s point of view, there must be a lot of stuff that is lost in translation and there’s a lot of empathy and compassion giving that’s probably not received because it can’t be given as well as it would usually.” (Midwifery Frontline Clinician)

“…a lot of my colleagues were quite visibly so, so on already a fast-paced, high-risk environment where labouring women can go from 0 to 100 in two seconds, it just added more [of the same], I suppose, and colleagues were, I guess, a bit more pre-occupied with other things as well and life and home and the news.” (Midwifery Frontline Clinician)

“…the first six weeks were extremely stressful, trying to manage the new reality. And then the way I split it in my head is the first six weeks were very stressful, the next six weeks were very boring [laughs]. Because once the stress had passed the variety of the clinics disappeared. Not seeing people face-to-face was boring.” (Internal Medicine Frontline Clinician)

“Some women have preferred the fact that they don’t have to come in. I think for those women who don’t look after themselves as well as they should it has sometimes been an excuse for not looking after themselves even more, whereas perhaps we would have brought them in on a weekly basis…” (Internal Medicine Frontline Clinician)

“…we coped with for a while because we all felt like we were doing the right thing. And then it got tiring and then we started to get burnt out. I started to get burnt out. I tapped into the psychological support, the e-mails that we got were lovely, and then it started to wear thin. And it still is wearing thin.” (Midwifery Clinical Manager)

“For women who are more vulnerable, who would shy away, who don’t want to face it alone, then it’s probably not a very good service. And then they just turn up and have a baby. It’s lonely, ultimately. I think it’s a lonely service.” (Midwifery Clinical Manager)

“…they can’t see your face; you can’t see their face and in women who have drug and alcohol situations or mental health situations that’s unsatisfactory. I also have lots of women with eating disorders. If you don’t see them, you can’t make a true assessment. Often, you’d call them, and they wouldn’t answer and they wouldn’t call back if they didn’t answer and you left a message, so it’s pointless, therefore the follow-up processes were also sub-optimal.” (Obstetric Senior Clinician)

“…we’ve given less good care because we haven’t seen the women, we’ve missed things like growth restrictions… with the opportunity to miss things like growth restriction, pre-eclampsia sometimes and things like that.” (Obstetric Senior Clinician)

“[on telephone clinics] It is less time-consuming. That is the only advantage I can think of, but I don’t really see it as an advantage.” (Midwifery Frontline Clinician)

“We are not putting women at the centre of our care in this. Maybe that is the right decision. I am just a little midwife, I am not a person who is looking at the bigger picture, but I came into midwifery because I am a feminist and I believe in supporting women. In my training I learned that you put a woman at the centre of your care and everything else goes around that. I don’t see that is what is happening, but maybe in the bigger picture we are because we are trying to safeguard the whole population and women are part of that. I do see that there is more than one side of this.” (Midwifery Frontline Clinician)

“I think that clearly there’s lack of acceptance that there may be a digital divide, so for some women I think it may actually cause harm and we’ll know later…” (Obstetric Senior Clinician)

“…and I think that dictum that keep COVID patients away from the NHS to save the NHS, certainly in pregnancy, didn’t help!” (Obstetric Senior Clinician)

“I found it mentally and physically exhausting to balance everything from a distance whilst shielding. And even in the early days. Yes. I was running on empty at times…” (Health Visiting Strategic Leader)

“We didn’t have enough PPE at that time, and for me and my staff, the way I see it, maybe during that time when I was running around to make sure that they were safe and they had enough PPE, maybe that was when I contracted this virus myself.” (Health Visiting Clinical Manager)

“…it’s been a challenge. I mean, for me, personally, I think I really struggled with trusting that the team are doing what they should be doing whilst they are not in the office, but then there’s no reason to suspect, and I think that’s often related to when I’m feeling a bit out of control, like I haven’t got tabs on things and I don’t know who is doing what and then I will have a call from a nurse who is in tears because she’s like, 'I can’t sit in my bed and do a case conference about horrendous things and then just log off and I’m sitting on my bed that I sleep in, it’s not working'. So that aspect of not having a boundary has been really tough emotionally for them.” (Health Visiting Clinical Manager)

“[on banning partner visiting] It was a little draconian and a bit cruel on women.” (Anaesthetic Frontline Clinician)

“There were a lot of women’s lives that were put at risk because we were having to do probably unnecessary PPE and resuscitation guidelines. Women’s lives were put at risk from limitations as opposed to my life being put at risk.” (Anaesthetic Frontline Clinician)

“[on mixed messages for pregnant women] There are only so many times a woman would hear a maternity message in the day or a hospital message saying, ‘Please come to hospital if you are unwell,’ as opposed to the number of times they would hear a disaster message, death and destruction and everything, the NHS can’t cope – that ‘Leave the NHS alone’ message. They were fighting a losing battle ultimately.” (Anaesthetic Frontline Clinician)

“It is the apathy and the frustration. We have done it before, and we didn’t like doing it before.” (Anaesthetic Frontline Clinician)

“For the proportion of women that needed those assessments, probably the standard of their care went down because they weren’t being seen face to face for the Anaesthetic antenatal assessments. It is harder to pick up on cues about what exactly a woman is worried about, where exactly a woman might be reassured by things you might say to her.” (Anaesthetic Frontline Clinician)

“The things I haven’t enjoyed about it, the things I found quite personally challenging, have been in the midst of it the relentlessness of it. […] Alongside that, the lack of any tangible holiday or break has been very hard because everything was cancelled in Covid. There was no annual leave, there didn’t seem any point in taking annual leave because you couldn’t travel. […]Even if you did, that all-pervasive Covid headlines are hugely draining in any healthcare professional because you are wondering what is coming next and when it is all going to change again, when is the sand going to shift, when are you going to be asked to do more or change again? 'How can I prepare, how can I get everything ready?' There is this baseline of tension.” (Anaesthetic Frontline Clinician)

“…you realise is staff have got incredibly complex social circumstances themselves, and therefore that resilience within your workforce is not there at the same levels, so if something like this happens then I think that’s when you realise how fragile your workforce is.” (Midwifery Strategic Leader)

“The balance between we have got to get on with it, to this is the best way of doing it, to this is just good enough, is really hard for some of our clinicians. Our clinicians are used to – generally, by and large – being able to provide really high-quality care. That was a real hit to them, but not something we could control…” (Obstetric Strategic Leader)

“What I found the most difficult thing to navigate was the conflicting advice from… Say for instance the Institute of Health Visiting versus the NHS England guidance versus the PHE [Public Health England] guidance versus the [local] guidance, so trying to assimilate all the various guidance and protocols and service delivery mechanisms, trying to make sense of it and then distilling it into a standard operating procedure for each service where they could understand what was expected of them, when, how and where, doing what……… It was the all-consuming part of my role at that time” (Health Visiting Strategic Leader)