The role of personal agency

The physiotherapists reported that their desire and efforts in joining the COVID-19 teams was driven by their own personal motivations rather than any external motivation from the health system or the government.

…it was personal motivation; government did not motivate me in anyway… (P8).

These included the physiotherapists’ innate ability to derive joy in improving patients’ lives, wanting to ‘do unto others as you would have them do unto you’, and the love for adventure and challenges, serving mankind and making impact.

…he [patient] still tells me “thank you for saving my life…’ (P4).

I see it as a ministry…not just an occupation. It’s something you do to touch lives (P5).

Personally, I love challenges… (P7).

…I’d always looked for opportunities to serve…(P3).

…I’m offering something to the community (P6).

The physiotherapists’ initial fear regarding the virus became replaced with a sense of purpose as they gained experience and confidence in their roles.

Previous experience managing highly infectious diseases or being a cardiopulmonary physiotherapist

The confidence and desire to be involved in managing patients with COVID-19 appeared to be influenced at least in part by previous experience managing highly infectious and potentially fatal diseases.

…being in neuromedicine… I’ve had to attend to patients with HIV…tuberculosis…hepatitis… So…I just brought forward those …knowledge and precautions… (P1).

The cardiopulmonary physiotherapist also appeared to be highly motivated in becoming and remaining part of the COVID-19 team. This appeared to be due to his perception of his expertise in this field into which the pandemic predominantly falls in. He did not appear to be influenced by lack of remuneration or suboptimal provision of other resources. He regarded many COVID-19 related complications as routine in his day-to-day physiotherapy services.

……because my area of specialisation is cardio-respiratory… it’s like, a calling to me… I decided … whether they pay me or not, I will go and manage patients that have COVIDCOVID-19… (P6).

One of the physiotherapists desired to support patients with COVID-19 in their periods of pain, difficulties, and hopelessness because of her previous first-hand experience of having life-threatening illnesses.

…I’ve had series of health conditions myself that got me thinking, will I ever be fine again? So, I’ve had a first-hand experience of what it feels like to not have hope again. Just stay there and be thinking like…let death just come already… (P5).

Sense of professionalism

All the interviewed physiotherapists stated not being initially invited to be part of the COVID-19 teams.

‘…initially we were not invited… it is actually the physiotherapist that will have to go and be telling them…like an advocacy…Even the presidential taskforce, does not even have physiotherapy…’(P1).

They were motivated by the desire to publicise the important role of physiotherapy in the successful management of COVID-19 as well as the competence and skills of physiotherapists.

to my knowledge, I was the only physiotherapist in the frontline in the country as at that time. …they saw the consequences of my action…they are now more well informed than they used to be…when the coordinator of the isolation centre is talking…he usually makes reference to…physio, there was no time he’s giving a progress report that he doesn’t make reference to physiotherapy (P2).

The efforts yielded some positive outcomes with reports of increasing people within the health system having information about the role of physiotherapy in COVID-19 management.

…the national vice president had written to the NCDC, WHO…because I remember there was a circular from the ministry of health requesting for the training of health professionals, and they requested for physiotherapists…In this way, I think they are getting to know. The national body has also submitted our own guidelines… (P1).

Half of the front-line physiotherapists appeared unfazed by their initial lack of recognition by other members of the COVID-19 teams, and believed that other health professionals, particularly medical doctors and nurses, would acknowledge the importance of physiotherapy when they observed the positive clinical effects of their actions on patients with COVID-19. These physiotherapists expressed confidence in the uniqueness of their knowledge and clinical expertise.

…I just usually do not feel bad because I know what I know and I know nobody that is not a physiotherapist knows what I know and cannot do what I do. It was going to be a matter of them appraising their actions before me coming… I acted, I acted, and they saw the result of my actions. They saw the result of my actions, it gave me that feeling of satisfaction, that feeling of “yes, I’m the boss”, this field I know it better… I was going to represent not just myself but the profession. I was going in to make a statement, but for me how best to make a statement than your action and the result of your action? I never felt threatened (P2).

The breaking point: finally exiting the team

All the interviewed physiotherapists were disappointed that despite their increased advocacy about physiotherapy, and perceived competence in discharging their clinical duties, their recognition and respect within COVID-19 teams in Nigeria remained very poor. They believed that this was associated with the teams being clinically and administratively led by medical doctors.

…We made our clinical presentation about patient management and how we are supposed to be an integral part of the team. We made some recommendations. Then, we met the head of the infectious unit team outside, he told us point-blank that there is no provision for us… (P7).

…So many things happened…that suggest we were not recognised. They [doctors] did not see us as important. Why? Because it was the doctors that were coordinating everything. When they were demanding for the names of those that should be paid, they requested forty names from the hospital. The coordinator who is a consultant [physician] decided to put the names of all the doctors and left out other health workers including physiotherapists, not even one of them… (P8).

This led to three of the interviewed physiotherapists not wanting to remain part of the COVID-19 team after the first COVID-19 wave in Nigeria. They refused to rejoin the teams when the second wave started in Nigeria.

…I was so discouraged that I did not want to be part of the team again. So, when the second wave started…I said I was not going back…(P7).

Lack of teamwork in the ICU and COVID-19 wards of government hospitals

Multidisciplinary teamwork was reported as suboptimal in the government owned COVID-19 treatment and isolation centres and the government hospitals. All the interviewed front-line physiotherapists viewed the nurses as complementary and supportive of physiotherapy roles, although this appeared to be sometimes hampered by poor infrastructure such as irregular electricity supply that impacted on the use of suctioning machines.

…Times when I needed to turn the patient and the patient was bigger than me, if I don’t get the porter, I could get the ICU nurse to help me out… (P5).

…most of the time suctioning is done by nurses in the wards…we may need the patient to be suctioned during treatment. They do that for us. The only problem will be if there is no light and there is no manual suctioning machine…(P1).

In contrast, the physiotherapists reported that most of the front-line doctors viewed other health professionals including physiotherapists as inferior, disregarding them as team members.

…so the nurse was like…what you did today, I was in awe… The doctor that was on duty was like “don’t do that, don’t do that, he will asphyxiate… (P3).

Consequently, they believed that this led to doctors taking over the role of some multidisciplinary team members in the government hospitals.

…it is the house officers [medical interns] that do the nurse’s job… (P8).

…the nurses doubled as record officers. I did not actually see them work in the ward…(P7).

In contrast, multidisciplinary teamwork was perceived as adequate by front-line physiotherapists in the private COVID-19 treatment and isolation centres.

…we had a very strong teamwork and team spirit, so it was really easy…’ (P5).

Discrimination of physiotherapists within COVID-19 teams

The six physiotherapists working in the government-owned COVID-19 health facilities felt that they were treated and regarded less favourably than other health professionals in the COVID-19 teams by the medical team leads.

They perceived that this manifested as lack of remuneration, protective equipment and accommodation.

…the doctors are paid, and the physiotherapists are not being paid… (P6).

…Doctors are provided accommodation, we are not…(P7).

Three front-line physiotherapists reported not being informed, tested for COVID-19, or supported in any way when they were exposed to the virus in contrast to their medical colleagues. They believed that their discriminatory experiences were due to interprofessional rivalry.

…interprofessional rivalry in our clime here…there is nothing the medical doctor will do without having a nurse … They look at others as competing with them… (P1).

Three front-line physiotherapists working primarily in the ICU (Intensive Care Unit) and COVID-19 wards of government hospitals and one front-line physiotherapist working in a private COVID-19 isolation/treatment centre reported attempts to either completely remove physiotherapists from the COVID-19 teams by the government COVID-19 taskforce led by medical doctors, or to side-line physiotherapists by assigning their roles to other health professionals by the hospital medical team leads. Three physiotherapists reported feeling ‘alone’ and being the lone physiotherapist within their teams in contrast to other professionals. They described relying on their knowledge of medical presentations and clinical expertise to feel comfortable relating with the other health professionals.

…I felt like a loner because I was the only physiotherapist. Nobody could really relate with me. I couldn’t relate with most people. But because of the vast knowledge of my training, in my pre-clinicals we did everything that medical doctors would do…did. So, I could relate with the medical presentations better… (P3).

Over half of the physiotherapists reported no longer seeking validation from the medical teams after learning to be contented with patients’ appreciation of their positive clinical impact.

…so I wasn’t really seeking…the validation from them [medical team leads]… (P4).

…I am not here to impress anybody but to make my patient better… (P6).

Better acceptance of physiotherapists in private non-governmental or state-owned non-hospital centres

In contrast to the experience of front-line physiotherapists engaged in government hospitals, the two physiotherapists in the private COVID-19 centres felt accepted and recognised by the other team members. This was particularly by the medical team leads, after they had understood physiotherapy roles in COVID-19 management. The physiotherapists greatly appreciated this, and this seemed to encourage and motivate them.

…the medical colleagues … they are a wonderful set of people… they were just treating me like a King… that acceptance from them…gave me the psychological balance to focus on what I wanted to do… (P3).

They regarded their acceptance by the medical team leads as more important than the provision of physiotherapy equipment which was often lacking. These two physiotherapists also reported no discrimination in terms of remuneration, provision of accommodation and other services provided to other members of the COVID-19 team.

…we were paid well…and they foot all the bills (P3).

…they provided accommodation to us and the other team members… (P5).

Stigmatisation that is wide ranging

All the physiotherapists reported being stigmatised by either physiotherapy colleagues who were not involved in the front-line management of patients with COVID-19, other health professional colleagues, extended family members, friends, acquaintances, or the general public for fear of contracting the virus from them.

Some people find it offensive when I try to say hi to them from a distance because I am involved with treating patients with COVID-19 …(P7).

I had been hearing about stigma… I didn’t really know the impact in the lives of people until I was a front liner you know (sighs). I didn’t tell anybody at home, I only told 2 of my siblings, and one of them is a step sibling and he went ahead to mention it errr…in a very demeaning way that err…I should not be allowed to do certain things that I actually wanted to do errrr… I can’t go into the details of that because they are my personal life…the stigmatization really got to me for some days and I was like, is it a crime to actually be a health professional that is working to actually salvage his generation…? I think they just took advantage of the information I actually put at his door step and used it against me so I got to know that yes stigma could be a very difficult thing for patients with COVID-19 themselves to deal with, so that made me actually know that if somebody is actually positive if he doesn’t want to communicate about it I can really relate with him because it is quite difficult what people can do with stigmatisation… (P3).

Two of the physiotherapists who were stigmatised by extended family members, found succour with some of their physiotherapy colleagues and friends.

…my colleague spoke with me; my friends just encouraged me…she really helped me… I should not put my mind there… I’m doing something very honourable and venerable so I should not allow anybody to get to my head… (P3).

Friends were the source of stigmatisation for two of the physiotherapists.

I mentioned it to my friend, since then my friend ran away from me because I was working in the isolation centre… (P8).

All the physiotherapists were stigmatised by the public.

…But another challenge we had to deal with was the thought of coming out of the centre, because the centre was located on the island. Even after you finished the work for the day and you clean up… once you step out of the centre, people see that you are coming out of the centre…everybody wants to avoid you… (P5).

Stigmatisation was reported as the greatest challenge by one of the physiotherapists, and she desired external support. For another physiotherapist, stigmatisation by the general public was through social media (Twitter and Facebook). He had gone public about his infection with the virus in a bid to make Nigerians understand the reality of COVID-19 and reduce the conspiracy theories regarding COVID-19 in Nigeria. He was rather treated with suspicion by the Nigerian public who thought that he was being used by the government. The physiotherapist was consequently concerned about the possible impact of this on his family members.

…people said that the government paid me money…Then I worried about my parents…my siblings… (P4).

He, therefore, avoided informing his family about his involvement and had to rely on the acceptance and support from professional colleagues and religious associates. Consequently, most of the front-line physiotherapists avoided informing family members and friends about their involvement in the front line. Three of the physiotherapists reported relying on their immediate nuclear family as their only source of support. Physiotherapy colleagues were the source of stigmatisation for two of the front-line physiotherapists, which they found difficult, as they were also dealing with discrimination within COVID-19 multidisciplinary teams.

…they did not provide us accommodation like the doctors and others…so when we get to the department, we were being treated like foreigners, because everybody started avoiding us… (P7).

Fear, anger and having ‘off days’

All the physiotherapists gained confidence with a clearer understanding of their roles in COVID-19 management. Their initial fear about the uncertainty surrounding COVID-19 was no longer present.

… Now, the fear, has been replaced with a sense of purpose… (P7).

All the interviewed front-line physiotherapists were afraid of getting infected with COVID-19 or dying from it in the front line.

…I mean I got COVIDCOVID-19 so… I was a bit scared…like…what’s going to happen, am I gonna die? (P4).

One of the physiotherapists was not afraid of death as he assessed his risk as very low, although he also sought spiritual sustenance.

…I prayed about it and then, I allowed God to take control… (P6).

Two of the physiotherapists had their fear reinforced through communication with or infection of other COVID-19 team members. They attempted to reduce this fear by taking steps to minimise the severity of a potential disease or by convincing themselves that the benefits of their involvement were worth the risk. For two of the physiotherapists, the fear of getting infected was paralysing, and they described having ‘off days’ in relation to this, when they felt like being alone, and not being involved in activities they usually enjoyed.

…I was feeling scared, …really really scary, and I was really really down… (P2).

They described critically analysing their risk of exposure and infection during such ‘off days’. Recovery from this debilitating fear was facilitated by convincing themselves that they were unlikely to have been exposed and infected or feeling that they were unlikely to experience a severe disease even when infected or remembering their patients with COVID-19 who were relying on them for survival.

…those that died … are those having comorbidities, … I didn’t think I fit into that category… (P2).

…the thought of the patients looking up to me made me want to get up… (P3).

One of the physiotherapists reported becoming angry at getting infected with the virus while working in the front line. He blamed himself and regretted exposing himself and his family members to the virus in a health system that did not even acknowledge or appreciate his role as a physiotherapist.

I was angry because I got it because I volunteered. In the western world, when volunteers go to an active environment, they are well protected. Coming into an environment where you are not even acknowledged… (P7).

All the physiotherapists felt that exposure to the virus and infection of some of their colleagues was due to inadequate provision of personal protective equipment (PPE), and lack of support from both the health system and the government.

The fear of infecting beloved family members had severe impact on physiotherapists’ personal lives and mental health. Family interaction and relationship became adversely affected as they stopped or minimised contact with their close family members in an attempt to protect them.

…I would just get home and lock myself in the room… because of the fear… (P5).

…my wife, …was pregnant, so we had to keep distance… (P8).

All the front-line physiotherapists were also dreading the possibility of losing their patients to complications of COVID-19.

…Scary in terms of those in the ICU, on oxygen, with an SPO2 of below 80, nobody wants a patient to die in his hands… (P2).

…as I am treating the patient, I will be like arrrh, this patient might not do well…(P6).

Feelings of severe loss

All the front-line physiotherapists expressed feelings of severe loss in terms of prolonged use of uncomfortable and restrictive clothing; little or no physical contact or support from family and friends; diminished social circle from reduced religious and other social activities; reduced physical activity; adverse economic outcomes from loss of income from private practice; increased transportation costs; and their patients dying of COVID-19 complications.

…having to wear a facemask every day, …the back of my ears… are beginning to hurt (P4).

…We have to protect ourselves with all these uncomfortable stuffs… (P8).

…limited my movement… Visiting friends has drastically reduced… churches were even locked up… (P1).

I had to avoid everybody, I had to avoid my wife, I had to avoid my kids, I had to be locked up… (P7).

…we were accommodated …so I had to change my environment totally, I changed my friends, I changed everything… (P3).

…affected my work… I’m a private practitioner and patients were not coming (P3).

…but when the pandemic came …the cash flow was going down. There was financial strain… The financial impact affected me personally (P7).

…before, I could easily use a public transport…now I have to use Uber so it’s even more costly… (P5).

Physiotherapists’ roles in COVID-19 management are not fully harnessed in Nigeria

All the interviewed physiotherapists reported not being optimally involved in the therapeutic stages of COVID-19 management. They also did not view themselves as adequately involved in preventive efforts and in the rehabilitation and long-term management of the complications from the disease.

they have…post infection symptoms, a lot of them require physiotherapy…but we don’t see them (P1).

‘On your own’: lack of material and psychological support

All but two front-line physiotherapists felt unsupported by the health system and the government. They interpreted the lack of provision of PPE, lack of sanitation facilities, lack of remuneration and allowances, and lack of health and life insurance in the case of infection, severe disease, and death, as very discouraging.

…… we don’t feel confident that if you get infected that you are not on your own… (P1).

…we don’t have equipment, we don’t have good funding, remuneration is zero… (P2).

The PPEs were not the best quality, … I had no help; I had no support…I was not even paid… (P7).

Physiotherapists’ reliance on self-support and support of one another

All six front-line physiotherapists in the government facilities reported learning to manage their expectations and depend only on themselves and fellow front-line physiotherapists. More senior physiotherapists were supporting and guiding the younger ones.

…and you call them [junior physiotherapists] before they start their work. …how was your night? Ask about their health. … And then try to explain to them what happened the previous day. If they have some cases that they think they [junior physiotherapists] need special information about, we [senior physiotherapists] try to do that for them…’ (P1).