Dialectics and dilemmas arising from Covid-19 immunity testing: presenting a workforce management paradox

Purpose – Covid-19 has caused many businesses to rethink their short- and potentially long-term workforce operations. The use of lateral flow serology can provide a clinically convenient approach for the assessment of prior infection with Covid-19. However, its widespread adoption in organisations seeking to use it to test for workforce immunity is controversial and confusing. This paper aims to explore the paradoxical dilemmas and dialectics immunity workforce testing creates. Design/methodology/approach – Thisstudyinvolvedcapturingtheethnographicalparticipationofachief executiveofficer(CEO)dealingwiththeexperienceofmanagingtheoutcomesofCovid-19workforceimmunitytesting.TheaimwastotakeasnapshotintimeoftheCEO ’ s empirical world, capturing their lived experiences to explore how management actions resulting from Covid-19 immunity testing can played out. Findings – Providing staff with immunity tests at first glance appears sensible, decent and a caring action to take. Nevertheless, once such knowledge is personalised by employees, they can, through dialectic dialogue, feel disadvantaged and harbour feelings of unfairness. Subsequently, this paper suggests that immunity testingmayonlyservetoraiseawarenessanddeepentheoriginalmanagementdilemmaofwhethertestingisa worthwhile activity. Originality/value – This paper aims to be amongst the first works to empirically explore the workforce management challenges that arise within small businesses within the service sector following the completion of Covid-19immunitytestingoftheirstaff.ItseekstoachievethisviautilisingtherobusttheoreticalframeworkoftheparadoxtheorytoexamineCovid-19 ’ simpactuponsmallbusinessworkforcemanagementthinkingandpractice. Staff were very keen to see if they had antibodies for Covid, even those who ’ s results were negative were keen to explore how this could affect their working practices.


Introduction
The Covid-19 pandemic has seen the disruption of clinical services across the UK, including the National Health Service (NHS) outpatient activity, and has also had a major impact on the delivery of aesthetic medicine. The UK government has mandated the closure of aesthetic clinics during the peak of the outbreak and has been slow in allowing the re-opening of services.
Despite services now re-opening, uncertainty persists around further restrictions associated with a second wave and also what the impact of the pandemic will be on patients. Studies reveal that patients have postponed urgent treatment during the Covid-19 pandemic as a consequence of fear of contracting the illness (Cairns, 2020). Similarly, a fear of contracting illness is cited as a reason for not attending other related activity in the beauty and hospitality sectors (op cit). The potential re-opening of clinics has also been fraught with controversy where aesthetic medicine has been bracketed with beauty salons rather than as a clinical service that are delivered by health-care professionals.
The recent and ongoing Covid-19 pandemic has prompted a proliferation of publications on its impact upon commerce: a Google Scholar search of the term "Covid" returned over unpacking and tackling seemingly insoluble problems (Smith and Lewis, 2011;Smith and Tracey, 2016). For instance, Ozanne et al. (2016) use PT to explore the issues that surround the pursuit of the competing goals of the "Triple Bottom Line" resolve the inherent problems of social enterprise hybridity, and Lewis et al. (2014) equalise leader's simultaneous and competing demands. Further reflecting the pragmatic dimension of PT, Bednarek et al. (2017), Calabretta et al. (2017), Jansson (2014), Lewis et al. (2014) utilise case study approaches to "encourage leaders to. . .work through competing demands simultaneously" (Lewis et al., 2014, p. 73).
Paradoxes consist of "contradictory, yet interrelated elements-elements that seem logical in isolation, but absurd and irrational when appearing simultaneously" (Lewis, 2000, p. 760) that exist within businesses and society (Lewis, 2000;Stevenson, 2010). The term paradox is usually used in regard to a conundrum that is considered insoluble (Stevenson, 2010) because the available options are on-off, yes-no or black-white. These situations result in indecision and immobility within organisations (Stevenson, 2010), yet humans are destined to, and capable of, living with seemingly incompatible propositions (Clegg et al., 2002).
PT may enable the resolution of these issues through temporal and spatial separation (Smith et al., 2013), the "exploration" (of new opportunities) and "exploitation" (of existing opportunities) (Papachroni et al., 2015), cycles of "splitting" and "synthesising" (Ozanne et al., 2016) or "assimilation" and "adjustment" (Hargrave and Van den Ven, 2017;Poole and Van De Ven, 1989). Smith and Lewis (2011) provide a valuable addition to PT by differentiating between tensions that may be classed as either dilemmas or dialectics. A dilemma is "a tension such that each competing alternative poses clear advantages and disadvantages" (p. 382). Presuming that either option is available (i.e. they are economically and practically feasible), addressing a dilemma is, therefore, a decision-making problem (Dubetz et al., 1997;Kotarba et al., 2013). This decision-making process need not be binary (either/or) in nature, but may be analogue (more/less) and even include decisions that require some form of organisational ambidexterity (Ozanne et al., 2016;Papachroni et al., 2015;Shepherd et al., 2019;Zimmerman et al., 2018). A dialectic is "an ongoing process of resolving tensions through integration" (Smith and Lewis, 2011, p. 386). It is a search for "truth" that is achieved through dialogue and compromise (Calton and Payne, 2003;Hargrave and Van den Ven, 2017;Raisch et al., 2018).

Research context
Background to the business The "You Can Clinic" is a business consisting of 20 staff who deliver cosmetic and aesthetic medical training, as well as pharmacy services. Now in its second decade of delivery, the company has an annual turnover of roughly £4m. The outbreak of the Covid-19 pandemic and the imposition of lockdown posed an existential threat to the company. Prior to lockdown, the company was delivering weekly training courses across a range of aesthetic products, including botulinum toxins, fillers, as well as other complementary aesthetic services. These courses rely on face-to-face interactions between trainer (doctor or nurse), trainees (a variety of health-care professionals) and models. Prior to lockdown the weekly courses were popular and were fully booked three months in advance. This business was suspended following lockdown in early 2020 and remained suspended until the end of August 2020. Also, as all aesthetic services were suspended, the You Can Clinic did not receive any prescriptions to fulfil for pharmaceutical products. The only service that remained available to the company was the fulfilment of online orders for private prescriptions for non-aesthetic medicines.
Covid-19 immunity testing As a consequence of the lockdown, the majority of staff were placed on furlough, and only essential staff were retained for the completion of online non-aesthetic orders. As the lockdown eased and the aesthetic services were allowed to re-open, so the company needed to develop a strategy for re-opening clinical aesthetic services and training. Government guidance on personal protective equipment (PPE) for the safe delivery of aesthetic services is clear (BACN, 2020), but anxiety still persisted amongst health-care staff and the public regarding the risk of transmission of Covid-19 in health-care settings. Whilst the evidence suggests that prior infection with Covid-19 does offer some protection, it appears still too early to determine whether it confers complete immunity. However, of the current 23 million documented cases of Covid-19 infection in the world literature, there is only one clear report of re-infection following previous exposure (Armstrong, 2020). This data must suggest that prior Covid-19 infection confers some immunity, a conclusion supported by the study in macaque monkeys who were infected with Covid-19 and then subsequently re-exposed to the virus (Deng et al., 2020). None of the animals was re-infected, leading the authors to conclude that prior infection offers protection against re-infection.
For the business to support the safe and productive return of staff to the workplace, it embarked on testing staff with lateral flow serology, which assesses the presence of antibodies derived from prior Covid-19 infection. The objectives were that as a small healthcare business, the You Can Clinic would pay for the testing of staff doing its utmost to support physical and mental well-being while also seeking the best and safest deployment of staff activity. Therefore, 20 staff were subsequently tested prior to their return to work.
All subjects volunteered to have the test, and all participants received pre-and post-test medical advice concerning the specifics of the test and the test results. It should be noted that the entire workforce felt that this was a positive move on behalf of the company. This too is in line with data revealing that 90% of employees want their employer to offer antibody testing (Day One Strategy, 2020). The 20 staff from the You Can Clinic in Cardiff who were involved in a variety of departments, including clinical, administration, reception, finance and training, were invited to have antibody testing using lateral flow serology for Covid-19 throughout June 2020. Of the 20 staff, four tested positive for Covid-19 IgG antibodies (20%), which indicates recovery from past infection. None of the staff had IgM antibodies that would suggest ongoing or acute infection. This is a high prevalence in comparison to other research, where UK studies have thus far suggested antibody positivity of around 5-10% (Imperial, 2020). However, this high prevalence may be explained by the fact that the staff would be defined as health-care workers, with rates of around 25% described in this group (Shields et al., 2020). Three of the four had mild symptoms, including cough, mild fever and loss of sense of smell. The fourth had moderate symptoms consisting of cough, fever and shortness of breath, but did not require hospitalisation but had been tested positive on swab reverse transcription polymerase chain reaction (rt-PCR) testing.

Methodology
This study adopts an interpretivist perspective, based upon data generated from the present CEO of the You Can Clinic. Thus, the fieldwork consisted of an ethnographical account of the CEO's lived experiences of managing the outcomes from Covid-19 immunity workforce testing. Ethnography for this study took its lead from Bray (2008) who suggests that this approach to data collection attempts to understand behaviour from within its naturalistic habitat, helping to interpret how people give meaning to lived experiences. This study involved capturing the ethnographical participation of a CEO dealing with the experience of managing the outcomes of Covid-19 workforce immunity testing. The aim was to take a snapshot in time of the CEO's empirical world, capturing his managerial and organisational situations, views, motives, interactions, interpretations and actions to explore how the actions of Covid-19 immunity testing have informed and altered the organisation (Blaikie, 2000). While Bray (2008) suggests that ethnographic participation helps researchers really understand what is going on, Charmaz (2006) reminds us of the constraints ethnographical research can have. This study was no exception, with major constraint of access (due to the pandemic) recognised from the outset. Thus, the availability to conduct "elite interviews" (Dexter, 2006) with the CEO of the You Can Clinic who witnessed and managed the outcomes of actioning a workforce Covid-19 immunity testing scheme appeared the only safe and legal way forward for suitable data collection. Such interviews, with individuals who are in important positions, provide unique insight into both policy and practice (Aberbach and Rockman, 2002).
Semi-structured interviews were chosen to explore the managerial implications of immunity testing a workforce. The interview questions were operationalised according to Smith and Lewis' (2011) work on PT and differentiated the acquired data between dilemmas and dialectics. The fieldwork consisted of two semi-structured interviews over a period of three days (4.27 h of interviewing time). These interviews were conducted to explore the detailed background of the outcomes following the outcomes of a workforce Covid-19 immunity testing process. By embedding the research process within an organisational context, rich, contextualised data and insight into the subject were garnered (Fetterman, 2010;Rabinow and Sullivan, 1988). The final interview (2.11 h) was conducted two weeks later than the original interview to further probe rapidly emerging lines of enquiry (given the fluidity of the Covid-19 pandemic) while also helping validate the preliminary interpretations of the data (Sandelowski, 1993).
Data analysis was performed using cyclic thematic indexing (Guest et al., 2012;Braun and Clarke, 2006). Interview transcripts were color-coded to indicate discussions and issues that pertained to Smith and Lewis' (2011) interpretation of dilemmas and dialectics.

Findings
This section aims to capture the dilemmas and dialectics that have emerged as a result of an organisation conducting Covid-19 immunity testing programmes for its workforce. Two, temporally distinguished, groups of dilemmas are identified that comprise the immediate and the longer-term impacts of the pandemic upon the operations of the You Can Clinic. The use of serology testing has sparked an ongoing dialectic around the utilisation of the results to determine how staff are deployed in customer-facing roles.

Dilemmas
The first group comprises the immediate issues that the organisation faced in the sourcing and provision of PPE. In response to government advice, the provision of suitable PPE was the first line of defence in controlling the spread of Covid-19 among staff and clients: We have also employed adequate and mandatory PPE as currently advised. This also supports relations with employees.
However, as many other organisations discovered and was widely reported in the press (BBC, 2020a), the rapid demand for appropriate equipment quickly outstripped supply. Sourcing of PPE, therefore, became an immediate dilemma, not only because of supply shortages, but also because, similar to many organisations (White et al., 2016), "sourcing and procurement" was not previously a key skill within the organisation: I really wasn't sure of the value of PPI both in terms of how it can help protect the workforce or how it could be used to increase confidence in all our stakeholders. In the end a decision was made to source and use PPI in certain situation, particularly those who are client facing.
In attempting to source PPE, the organisation suddenly became embroiled in a competitive arrangement with other organisations that were not competitors in terms of the product or service that they offered. The dilemma of identifying potential providers of PPE, and choosing with whom to place orders, thereby became further complicated by the exogenous commercial factors that manifested during the pandemic: How to get hold of PPE become a real challenge, and once we had some supplies how to use was also another managerial headache. What staff to priorities and in what roles was a real dilemma for me.
In tandem with the national efforts to manufacture and acquire PPE, the government emphasised the importance of antibody testing (BBC, 2020b). There had been much discussion over the efficacy of antibody testing (Armstrong, 2020) and the advice from government was unclear: We were trying to gauge what the mood music of the government was regarding the utility of antibody testing.
The organisation's staff were "keen to know their serology", which is perhaps to be expected of an organisation that comprises health-care professionals. As a consequence, and utilising the organisation's expert knowledge of contemporary medical developments, they opted to utilise "lateral flow serology" to test their staff. This was an important decision because it: . . .provided us with a competitive advantage.
The organisation was thereby able to undertake objective analyses of the current Covid-19 infections among its staff. This enabled the intelligent deployment of staff according to their serology results. Rather than arbitrarily committing its entire workforce to working from home, staff could be deployed according to their infection-risk profile. Not only did the testing "reassure a number of the employees", but it also acted as an "assurance" for clients: Clients were expected to trust statements made by the organisation indicating the value and security of those who had immunity test: As a tool to improve employee-employer relations it has been effective as the workforce has been appreciative that we have been behaving responsibly and offering a service that no other provides.
The organisation is currently considering the practical challenges of extending lateral flow serology testing to its clients: However, this would be a costly exercise and again may not necessarily offer the desired confidence in the current environment.
A second group of dilemmas comprises those that are concerned with long-term decisionmaking. In the midst of the shifting landscape of infection rates and government advice, businesses have had to develop strategies that can offer some security: It is very difficult in the current environment to be able to develop any clear strategy as government policy continues to shift regarding delivery of clinical services, local, regional and potentially national lockdowns.
Long term planning therefore is difficult.

Dialectics
The speculation of both the value and use of Covid-19 antibody testing formed the basis of an entanglement of contradicting discourses between employees, employees and management, management and customers and finally customers and staff. Indeed, at the time of offering testing, there was much speculation on the use of testing as a means of allaying anxiety amongst employees regarding return to work and in what capacity: Staff were very keen to see if they had antibodies for Covid, even those who's results were negative were keen to explore how this could affect their working practices.
While for management, questions around its validity to inform job realignment to offer reassurance to customers were also raised. For those employees whose serology test proved positive for Covid-19 antibodies, it did appear to offer them with greater confidence to interact with their peers and perhaps more pertinently with the general public (customers). Indeed, the early signals following this testing appear to support the idea that the testing can offer some level of reassurance to customers and clients that they are dealing with a responsible organisation whose staff they can trust to deliver what is essentially a very personal service with limited risk to their health: The signs are that our clients feel that as a clinical organisation we have taken a responsible approach to testing and can offer immune positive employees a customer facing role.
It was additionally recognised that facilitating management, staff and clients' confidence to engage with the organisation following a positive Covid-19 serology test were discussion in the media and by governments of "immunity privilege" and "immunity passports" (The Guardian, 2020). This is argued to have help drive confidence in immunity, particularly in the case of the organisation's customer-centric clinical services where other regulations such as 2 m social distancing is impossible.
This provides an interesting dialectic that is yet to be fully resolved, given no organisation or clinical trial has yet to come out and state that immunity is offered by prior infection, despite the likelihood of re-infection at present being understood as very low: It's interesting to note that immunity to Covid-19 is still yet to be proven, yet I have seen a higher level of confidence in staff who have recovered from the virus and developed antibodies, than those who haven't.
However, the flipside of serology testing cannot be discounted. While 20% of the workforce may have this newfound confidence, they clearly are unable or unqualified to do 100% of the organisation's customer facing activities. This presents further dialectical issues faced by the 80% whose serology test has returned negative. At a meso level, staff and management will inevitably be faced with shifting job demarcation and possible fractious employee and management congruence as a result of changing operational practices. More pertinently, at a macro level, client and staff well-being related to an anxiety of possibility of contracting Covid-19 will also need to be considered: As an example, we had by a visitor at reception who had talked socially to a member of staff. This person rang two days later to explain that they had had a fever and was going to be tested for Covid-19 infection. Testing was negative but in the interim, the employee who had spoken to that individual was particularly anxious and did not come into work.
The findings thus reveal the potential for a number of further competing contradictions between not only the workforce, management and clients but also between the 20% of the workforce whose serology tests have returned positive and the 80% of those who have not.

Discussions and conclusion
Unquestionably, Covid-19 has caused many businesses to rethink their short-and potentially long-term operations. The use of lateral flow serology provides a clinically convenient approach for the assessment of prior infection with Covid-19. However, its widespread adoption in organisations seeking to use it is both controversial based on uncertainty of what the test result means and the dilemmas and dialectics it creates for management and staff seeking to respond and deal with the information it generates.
The complexities of resource planning and the mitigation of risk in the workplace are exacerbated by social distancing measures and regulations enforced to ensure the safety of employees. Many organisations, such as the You Can Clinic, will require their employees to come into close contact with customers and clients on a daily basis, as many staff have specialist skills to carry out key procedures. To plan effectively, managers in some settings would need to know how many staff were available at one time who could provide services to their clients. Therefore, to facilitate such planning, they would need to know which of their staff could work safely in close contact adhering to Covid rules in a Covid-safe environment. Assuming that the presence of antibodies equips the individuals who possess them with a level of immunity, the test results would appear, prima facie, to provide an answer to the management dilemma of basic human resource allocation. However, being in possession of the results garnered through the testing of their staff, the You Can Clinic have not only created a further dilemma, i.e. What do we do with this information, but also an ongoing dialectic that could prove harmful to morale and could lead to a legacy of poor motivation that hitherto did not exist.
The results of a Covid-19 antibody tests, once fed back to employees, serve to raise a level of awareness and prompt dialectic dialogue and peer discussion amongst staff. The element of the workforce having perceived immunity following the tests could initially feel a sense of newfound confidence and freedom. However, this has to be managed carefully, and the 20% of workers identified cannot be viewed by the clinic simply as an available resource to call upon to carry out the front-facing duties that are needed. The implications of reallocating tasks to the 20% of workers who demonstrate some immunity may begin to influence behaviours and attitudes linked to the psychological contract between management and its workers. Although not a written contract, the psychological contract, according to Mullins and McClean (2019), relates to a range of expectations workers may have of their employer such as safety, equity, fairness and respect. Blanchard (2011) also highlighted how workers expected a level of equity and fairness as well as good positive working relationships with colleagues. Equity and fairness in the workplace often translate, in modern times, according to Colquitt et al. (2001), to organisational justice whereby a final decision is not judged in terms of fairness as much as the process gone through by managers to arrive at the final decision. A sense of unfairness in decision-making can breach expectations and can influence workers' behaviours and cause them to question their employer's commitment to what Ghoshal et al. (2000) referred to as a moral contract. Safety, both physical and psychological, is sought after and cherished by workers; should perceived safety levels fall below what the employee considers acceptable, then motivation and engagement levels can be compromised (Alderfer, 1972;Nohria et al., 2008).
The knowledge, skills and ability of front-facing staff will potentially differ and may be specialist in nature. Workers from the group with immunity may lack the skills and knowledge required to carry out these roles, thus creating knowledge and skills gaps amongst the workforce, and this would need addressing as a priority. Having skills gaps in a workforce can cause issues in supply of service, health and safety, some legal requirements to practice, but also for the productivity and engagement of staff. Skills gaps have implications for service delivery, but as Herzberg et al. (1959) highlighted, insufficient training can also impact the motivation and productivity of workers restricting their ability to perform well. Providing opportunities to upskill, develop and self-actualise can, under conducive circumstances, allow workers to work towards their higher level growth and development needs, leading to positive behaviour towards their work through increases in motivation, which can be associated with an expectation to succeed. The offer of training and opportunities for personal growth may be perceived by employees as being a recognition of their worth and value to the business. It could also be perceived to have emanated from a manager demonstrating authenticity and a democratic approach to the workforce, aimed at gaining the rewards associated with employee empowerment and engagement, with a view to harnessing innovation and goodwill. However, because this training would need to be completed as a necessary requirement of the workers with immunity to fulfil the roles of those without, they may form a different or negative perspective, and it could be argued the offer of such training could instigate conflict between staff. The outcome of the serology test carried out by the You Can Clinic and the legitimacy of sharing the results must be questioned. The impact on motivation and employee engagement levels must be anticipated, as too must the potential conflict it may prompt and its legacy and lasting effects.
Once the results of the tests are made available to the workers, they will need to process this information and make sense of it in relation to their work and personal lives. It is at this point that the dilemma faced by You Can Clinic may become augmented, and questions may be asked as to the validity, legitimacy and value of collecting and attempting to use such data in the first instance. When the tests results are made available to employees, the managers may need to manage potential conflict carefully to avoid a dysfunctional outcome that could have a harmful legacy affecting levels of trust and group cohesion. According to Robbins and Judge (2017, p. 257), a conflict process has five stages. Stage 1 is where conditions are such that conflict and conflicting views may flourish. This "Potential Opposition" stage relates to conditions influenced by people's emotions, values and differences. If the employees at You Can Clinic become aware of their test result, and that it differs to other co-workers, then the "Potential Opposition" stage of the process will be satisfied and the issue may or may not move to the next stage, Stage 2 "Cognition and Personalisation". Once workers realise that by testing positive or negative, it could have an impact on their job role for example, they may start to personalise the consequences and the impact on them and their families. This could push the conflict to Stage 3. Stage 3 of the conflict process is actualised as individuals establish their intentions and choose their behaviours accordingly. Part of this intention to act may push the conflict process to its next stage, Stage 4, whereby the workers choose how to react. Workers' reactions at this stage may show themselves as minor disagreements or as aggressive and destructive physical acts. Behaviours chosen at this stage will move to bring about one of two outcomes. Stage 5 of the process sees the outcome of the conflict process. The outcome can be functional where an agreement is reached and the conflict experienced is constructive where opinions of all are heard and higher-order goals may be met. Dysfunctional outcomes, however, occur when the conflict process has been uncontrolled and the conflict instead breeds discontent, affecting group cohesiveness and trust. Dysfunctional outcomes move the conflict process back to Stage 1 once again where conditions are set once more for future conflict.
Once all staff within an organisation are aware of the results of the serology tests, they will internalise this personal information and assess its relevance to them and those closest to them. If this leads to taking on frontline roles or other extra jobs for those with different results, this could lead to disharmony that could affect working relationships and team cohesiveness within a previously cordial work group.
Whether motivated by altruistic concern for workers or by the need to resource plan the argument in relation to carrying out these tests at the You Can Clinic is thought provoking. While using PT to frame an analysis, the validity of testing employees in this way must be questioned. It may be suggested that it would not be worth risking conflict when the outcome can be awareness raising at best, and at worst, the cause of disharmony and bad feeling lasting for some time, affecting teamwork and morale. Testing staff for potential immunity for Covid-19 does present obvious benefits to some businesses. Providing staff with free tests that provide valuable information regarding their well-being is at first glance a sensible, decent and caring action to take. However, once such knowledge is personalised by employees, they may well, through dialectic dialogue, feel disadvantaged and exploited harbouring feelings of unfairness. However well-intended, the dilemma of whether to test staff for coronavirus antibodies may be fraught with unintended consequences. In discussing their results, the employees may only serve to raise awareness and deepen the original dilemma further with little compromise.
While this study proffers valuable insight into the managerial consequences of dealing with Covid-19 via immunity testing, the results are necessarily limited by the nature of the methods employed and the prevailing conditions that surround the pandemic. Access to data sources, particularly those that would support rich interpretive analysis, is severely restricted at this time. As the pandemic diminishes, so access to such sources will improve, and future research should aim to capitalise upon further sources of first-hand experiences.