Introduction
Disruption in health care is considered when a change upsets the current system to a point where the existing operating system fails to adapt to the change. The current systemic health disruption caused by the COVID-19 pandemic outbreak is not the first and only existing disruption witnessed in healthcare systems. Health systems globally had previously been confronted by an immense change and disruption even before the outbreak of the COVID pandemic (Shaw & Chisholm, 2020). There have been existing disruptions in healthcare which include; finding new techniques of diagnosing, preventing, treating, and forms of organization and delivery of quality health care before the coronavirus pandemic. However, a severe acute respiratory syndrome caused by the Coronavirus pandemic has surpassed these earlier changes and disruptions in healthcare, leading to a global public health crisis. But what exactly does ‘disruption’ mean to the health care systems, and do the existing health care systems able to cope well with the disruptions. The existing health care systems globally are seen to struggle to cope with disruptive changes, especially during the current pandemic period, despite being a common problem to the healthcare systems over decades (Morris et al., 2011; Chaudoir et al., 2013). Healthcare systems, including healthcare nurses and patients visiting these centres, experience liminal time and space disruptions due to the change in their environment brought about by uncertainties and unpredictability of their situations.
Define What Is Meant by Liminal Time and Space
Liminal is derived from the Latin word limens, which means to limit or threshold. It is an unstructured or invisible period of transition where something is being initiated into a different state (Gibbons et al., 2014). According to theologian Richard Rohr, liminal time is a period when “ you have left, or are about to leave, the tried and true, but have not yet been able to replace it with anything else. It is when you are between your old comfort zone and any possible new answer. If you are not trained in how to hold anxiety, how to live with ambiguity, how to entrust and wait, you will run… anything to flee this terrible cloud of unknowing” (Stoner, 2020). Liminal space, however, is a transition space when crossing a threshold where you have left something behind; hence you are not entirely into something else. It can be physical, psychological, or conceptual, where an individual can manage disruption and ambiguity when the social environment is subjected to change. An anthropologist, Arnold van Gennep first developed the concept of liminal space through his seminal work Rites of Passage, published in 1908. It is a time between what is considered to have existed and what will be in the future. For instance, the liminal space based on COVID was normal then, while now we are in a physical space. The past traditional routines we considered normal are suspended while we remain uncertain of the future.
Why Is Healthcare Experiencing Liminal Time and Space Disruption?
Over recent times, disruption in healthcare continues to exist with disruption taking hold of the major players in healthcare, including the pharmaceuticals, technological advancement in healthcare provision, and the healthcare personnel in dire need to transform healthcare delivery to reduce costs and improve access better care. Advancement of innovation during this technological era has disrupted healthcare leading to radical changes that disrupt the usual way of doing things relied on in the past, thus causing a ripple effect throughout the healthcare industry. For instance, the service model innovations in healthcare facilities are disrupting shifts. In the past decades, healthcare facilities management focused on rationalization and prioritization efforts. The latter challenges healthcare personnel to be more patient-centred in service delivery (Rasche, Margaria & Floyd, 2017). Healthcare facilities must cope with financial, political, medical, legal, technological, and societal shifts that expose them to uncomfortable risk positions, especially client-focused hospitals during the current digital age. Healthcare workers now operate through shifts that disturb the sleep patterns of healthcare professionals, thus experience a reduction in quality of sleep which increases their fatigue, psychological and cardiovascular symptoms.
In addition, healthcare professionals are experiencing liminal time and space disruption due to the global COVID-19 pandemic. During this pandemic period, the healthcare system can only function when the healthcare workers have adequate protective gears to protect them against infection from the coronavirus. According to the Center for Disease Control and Prevention (CDC), the COVID-19 has killed over 375 healthcare workers in the U.S. as of 2020. More than 450,000 have been infected over the same period globally (Kambhampati, 2020). Strict protocols have since been established in healthcare centres that require strict adherence to ensure healthcare workers remain healthy to take care of the existing chronic diseases. Hence, during the current pandemic, healthcare workers are experiencing liminal time and space disruption. They are limited and burdened in providing adequate healthcare due to the backlog of surgical and non-surgical procedures and other chronic diseases (Hartley & Perencevich, 2020). Exhaustion from caring for critically ill patients during the pandemic has led healthcare personnel to limit their capacity to care for other patients suffering from chronic illness and take other huge backlogs in existence. Healthcare necessities and resources have been diverted to address and combat the pandemic resulting in the suspension of delivery of care to other illnesses such as cancer screening.
Moreover, the progression of healthcare facilities from the previous pavilion layout of a single block layout to more recent facilities with transient corridor space has afforded healthcare professionals a more convenient and ‘ad hoc’ environment to engage in conversations and knowledge exchange. Healthcare professionals experience feelings of powerlessness and vulnerability when in the presence of patients and family members. Hence, hospital corridors provide the liminal space sometimes required by healthcare professionals. Its liminal status offers transitory space for conversation by these healthcare professionals without the need for conventional conventions (Shortt, 2015). Incorporation of corridors and waiting rooms in the current healthcare facilities designs provide liminal space that creates opportunities that enhance experiences that aid well-being.
Where Is Healthcare Experiencing Liminal Time and Space Disruption (Be Specific)
Healthcare facilities are indeed ultimate destinations of liminal time and space experienced for decades. Liminal space is experienced in in-patient wards during delegation and supervision of newly qualified nurses who have just joined the healthcare institutions. Where newly qualified nurses are required to learn through delegation and supervision of duties, tasks, and responsibilities from their healthcare assistants, the process occurs through a liminal time and space (Allan et al., 2014). The new nurse finds themself in a liminal space to try and conceptualize learning by shifting from being a student to a newly qualified nurse, especially during this pandemic period whereby newly graduated nurses are constricted in terms of the limited amount they had to try as much as possible to learn and grasp as much from the healthcare assistant to be able to deliver care individually. The pandemic witnessed an increased number of patients who needed medical attention; hence, with fewer medical professionals dying from COVI-19, newly graduated nurses in all healthcare facilities found themselves experiencing liminal space and time to learn quickly and to balance between whom to admit to the hospitals due to the limited space available in the health facilities during the pandemic period.
Also, liminal time and space are frequently experienced in intensive care units (ICU) in healthcare institutions. Healthcare professionals in the ICU experience liminal space and time from the time they are initially introduced into the hospital to their daily routine imposed upon them. The spaces in the hospital cause upheavals among the medical personnel, including nurses, since they a limited in providing care to the patient’s ensuring patients in the ICU with decreased awareness require immediate attention and assistance in terms of movement and provision of care while at the same time providing care to other patients especially during the pandemic period when healthcare facilities were experiencing influx traffic of patient’s. Furthermore, liminal space in ICU is experienced during a code Blue scenario when a patient is dying. During this event, healthcare professionals and nurses are in a liminal space since the patient is considered neither here nor there, and the nurses are forced to implement a ritualize set of protocols that entail cardiopulmonary resuscitation (CPR) and the call overhead to prevent the patient from staying dead (De Villers & Devon, 2012). Similarly, nurses experience a liminal time where they are constantly faced with uncertainties on which patient to care for, how unstable and sick the patient they provide care for, or how and when the patient will suddenly be stable. Also, the separation of nurses from their families and patients tends to push the nurses in healthcare facilities into liminal spaces.
What Is/will be the Impact of The Liminal Time and Space Disruption in Healthcare.
The impact of liminal time and space in healthcare facilities has been negative, especially during the coronavirus pandemic. An increased admission of patients affected by COVID-19 in urgent need of respirators and ventilators led to a deficit and accessibility of this equipment by other patients in urgent need of the equipment s either those with advanced chronic illness and other COVID-19 patients. Hence, due to the limited space and availability of these equipment’s, medical professionals were cornered to determine which patient’s to save due to the liminal space caused by limited equipment’s to cater to the increasing number of patients diagnosed with COVID and other chronic illnesses (Sengupta et al., 2021). Similarly, the lack of enough protective equipment’s for the healthcare professionals when providing care to the patients in healthcare facilities contributed to the loss of their lives. Healthcare professionals experienced liminal spaces to provide healthcare to patients even when they lacked adequate protective equipment to protect them.
Also, there is a significant problem in public health departments leading to disruption in healthcare among nurses and public health professionals who focus on caregiving for the elderly with dementia, children with chronic illness, cancer patients, and veterans from the armed forces. Whereas family caregivers who choose to care for their loved ones at home have a symbiotic attachment while providing care are often in a state of liminal time since they are not sure the indeterminate and prolonged period they would require to continue providing care for their loved ones (Gibbons et al., 2014). Similarly, healthcare facilities are experiencing disruption in the liminality of time and space where increased patients in healthcare facilities are in dire need of formal care by nurses. An increased number of elderly patients and children with chronic illnesses and disabilities often require frequent caregiving and attention, thus limiting the limited number of nurses to provide care for other patients. These public health nurses are confronted with an alternative life course characterized by ambivalence and uncertainty. Most health caregivers focus on providing care from an increased number of patients requiring formal care in the hospitals.
In addition, health care is experiencing disruption in liminal space, especially during this pandemic period where perinatal hospital social workers need to ensure their safety and maintain social distance when managing the needs of vulnerable patients (Barach, 2020). The COVID pandemic has contributed to the increased complexity of service delivery by healthcare workers and patients while seeking medical services in healthcare departments. Considering the case of a pregnant social worker in a hospital and is conscious of the possible risk of getting COVID to her unborn child and her family at home, she is mindful of personal safety in the liminal space while at the hospital. The notion of liminal space indicates that we realize that since the pandemic, time tends to have a new meaning since what was once normal does not seem to exist anymore, and we are only waiting to reach a new normal (Wilson, 2019). The concept of time during the COVID pandemic has almost become meaningless since COVID-19 has disrupted the normal day-to-day healthcare policies and practices as healthcare workers remain unclear of when or if the restrictions imposed globally by nations to curb the spread of COVID are going to be lifted any time soon or completely (Wilson Jackson & Shannon, 2021). Social workers in healthcare facilities find time more defined and prescriptive, which was previously determined by the strictures of their healthcare protocol and risk management (Laurie, 2017).
Conclusion
The above research has examined healthcare disruption in a liminal time and space in healthcare facilities and healthcare professionals when providing care. Advancement in technology in the healthcare facilities and the global COVID-19 pandemic creates liminal time and space full of uncertainties experienced by healthcare professionals. Also, hospital facilities contain many liminal spaces, including the Intensive Care Unit (ICU) and in-patient wards newly graduate nurses experience liminal space in re-contextualizing knowledge to ensure adequate safety care is provided. Furthermore, the experiences of liminal space by the healthcare professionals have impacted the lives of healthcare professionals and patient’s where healthcare professionals are unable to provide care to all patients due to limited space and equipment’s and where healthcare professionals put their lives in danger to provide care where protective equipment needed to protect themselves while providing care are insufficient.
Bibliography
Allan, H. T., Magnusson, C., Horton, K., Evans, K., Ball, E., Curtis, K., & Johnson, M. (2015). People, liminal spaces and experience: understanding recontextualization of knowledge for newly qualified nurses. Nurse education today, 35(2), e78–e83. https://doi.org/10.1016/j.nedt.2014.10.018
Barach, P., Fisher, S. D., Adams, M. J., Burstein, G. R., Brophy, P. D., Kuo, D. Z., & Lipshultz, S. E. (2020). Disruption of healthcare: Will the COVID pandemic worsens non-COVID outcomes and disease outbreaks?. Progress in pediatric cardiology, 59, 101254. https://doi.org/10.1016/j.ppedcard.2020.101254
Chaudoir, S. R., Dugan, A. G., Barr, C. H. I. (2013). Measuring factors affecting the implementation of healthcare innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implementation Sci. 8, 22–42. DOI: 10.1186/1748-5908-8-22
De Villers, M., & DeVon. (2012). Moral distress and avoidance behaviour in nurses working in critical care and non-critical care units. Nursing Ethics, 20(5), 589—603.
Gibbons, S. W., Ross, A., & Bevans, M. (2014). Liminality as a conceptual framework for understanding the family caregiving rite of passage: an integrative review. Research in nursing & health, 37(5), 423–436. https://doi.org/10.1002/nur.21622
Hartley DM, Perencevich EN. (2020). Public health interventions for COIVD-19: emerging evidence and implications for an evolving public health crisis. JAMA 323(19) 2020:1908–1909. doi:10.1001/jama.2020.5910.
Kambhampati, A. K. (2020). COVID-19–Associated Hospitalizations Among Health Care Personnel—COVID-NET, 13 States, March 1–May 31, 2020. MMWR. Morbidity and Mortality Weekly Report, 69. https://doi.org/10.15585/mmwr.mm6943e3
Laurie G. (2017). Liminality and the Limits of Law in Health Research Regulation: What are we Missing in the Spaces in-Between?. Medical law review, 25(1), 47–72. https://doi.org/10.1093/medlaw/fww029
Morris, Z. S., Wooding, S., Grant, J. (2011). The answer is 17 years; what is the question: understanding time lags in translational research. J. R. Soc. Med. 104 (12), 510–520. DOI: 10.1258/jrsm.2011.110180
Rasche, C., Magaria, T, & Floys, B.D. (2017). Service Model Innovation in Hospitals Beyond Expert Organizations. Service Business Model Innovation in Healthcare and Hospital Management, Springer International PublishingDOI 10.1007/978-3-319-46412-1_1
Shortt, H. (2015). “Liminality, Space and the importance of ‘transitory dwelling places’ at work.” Human Relations, Vol. 68 (4) 633-658. sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0018726714536938
Sengupta, M., Roy, A., Ganguly, A., Baishya, K., Chakrabarti, S., & Mukhopadhyay, I. (2021). Challenges Encountered by Healthcare Providers in COVID-19 Times: An Exploratory Study. Journal of Health Management, 23(2), 339–356. https://doi.org/10.1177/09720634211011695
Shaw, B., & Chisholm, O. (2020). Creeping Through the Backdoor: Disruption in Medicine and Health. Frontiers in Pharmacology, 0. https://doi.org/10.3389/fphar.2020.00818
Stoner, S. (2020, March 20). Liminal Time. Living Compass. https://www.livingcompass.org/wwow/liminal-time
Wilson, E., Jackson, K., & Shannon, A. (2021). Perinatal social work during the Covid-19 pandemic: Reflecting on concepts of time and liminality. Qualitative social work: QSW: research and practice, 20(1-2), 443–448. https://doi.org/10.1177/1473325020973306
Wilson E (2019) Social work, cancer survivorship, and liminality: Meeting the needs of young women diagnosed with early-stage breast cancer. Journal of Social Work Practice 34(1): 95–111.
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