key: cord-0889148-1ds0vtcv
authors: Gordon, Lisi; Scanlan, Gillian M.; Tooman, Tricia R.; Walker, Kim A.; Cairns, Patrick; Ferguson, Julie; Aitken, Gillian; Cecil, Joanne; Cunningham, Kathryn B.; Smith, Kathrine Gibson; Johnston, Peter W.; Laidlaw, Anita; Pope, Lindsey M.; Wakeling, Judy
title: Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID‐19
date: 2021-12-09
journal: Med Educ
DOI: 10.1111/medu.14698
sha: 6cff2c9c83ec25ef1b84f1a038784f6fe4ccc372
doc_id: 889148
cord_uid: 1ds0vtcv

INTRODUCTION: Supporting doctors' wellbeing is crucial for medical education to help minimise negative long‐term impacts on medical workforce retention and ultimately patient care. There is limited study of how doctors' transitions experiences impact wellbeing, particularly socially and culturally. Multiple Multidimensional Transitions (MMT) theory views transitions as dynamic, incorporating multiple contexts and multiple domains. Using MMT as our lens, we report a qualitative analysis of how transitions experienced by doctors during the pandemic impacted on social and cultural aspects of wellbeing. METHODS: Longitudinal narrative inquiry was employed, using interviews and audio‐diaries. Data were collected over 6 months in three phases: (i) interviews with doctors from across the career spectrum (n = 98); (ii) longitudinal audio‐diaries for 2–4 months (n = 71); (iii) second interviews (n = 83). Data were analysed abductively, narrowing focus to factors important to social and cultural wellbeing. RESULTS: Doctors described experiencing multiple interacting transitions triggered by the pandemic in multiple contexts (workplace, role, homelife and education). Patterns identifiable across the dataset allowed us to explore social and cultural wellbeing crosscutting beyond individual experience. Three critical factors contributed to social and cultural wellbeing both positively and negatively: being heard (e.g., by colleagues asking how they are); being valued (e.g., removal of rest spaces by organisations showing lack of value); and being supported (e.g., through regular briefing by education bodies). CONCLUSIONS: This study is the first to longitudinally explore the multiple‐multidimensional transitions experienced by doctors during the COVID‐19 pandemic. Our data analysis helped us move beyond existing perceptions around wellbeing and articulate multiple factors that contribute to social and cultural wellbeing. It is vital that medical educators consider the learning from these experiences to help pinpoint what aspects of support might be beneficial to trainee doctors and their trainers. This study forms the basis for developing evidenced‐based interventions that ensure doctors are heard, valued and supported.

Transitions are an inevitable part of any medical career. [1] [2] [3] Transitions are defined Jindal-Snape as 'ongoing processes of psychological, social and educational adaptation over time due to changes in context, interpersonal relationships and identities' which can be both positive and negative experiences. 4,5 p1007 The increased risk of burnout and potential for challenges to wellbeing during times of intense transitions (such as the move from university to clinical practice or the move from trainee doctor to trained doctor) is well documented in the medical education literature. [1] [2] [3] [4] [5] The global response to the COVID-19 pandemic created unprecedented transitions in the provision of healthcare and healthcare education, as well as transitions beyond the work context in everyday living, to which doctors have had to adapt personally, professionally and educationally. 6 Consequently, the pandemic has focused concern to the effect of these changes on doctors' wellbeing (across the career spectrum). 7 Whilst the definition of 'wellbeing' remains unsettled, a growing body of empirical literature has studied physical and psychological wellbeing of doctors and other healthcare professionals. [8] [9] [10] [11] This research has highlighted that healthcare professionals are at increased risk of physical and mental exhaustion, stress and burnout, which can affect patient safety and workforce retention. [8] [9] [10] [11] Supporting the wellbeing of doctors across the career spectrum, both as learners and educators, is crucial for medical education to minimise negative long-term impact on medical workforce retention, access to medical education, and ultimately patient care. 7 Psychological and physical wellbeing are known vital components for the medical workforce; however, the wellbeing literature is limited by a tendency to focus on the individual, and ways in which mental and physical wellbeing can be supported through building individual resilience. 9, 10, 12 In medical education there are calls for broader definitions of wellbeing that move beyond the individual and solving individual problems. 13 We support this view and suggest that conceptualisations of wellbeing should consider the deeper, more complex, social and cultural aspects that stretch beyond the individual, and place the responsibility for wellbeing onto groups, organisations, educational institutions and society. 13, 14 In order to access and understand better these multiple facets of wellbeing, this paper reports a qualitative analysis of the transitions experienced by doctors across the career spectrum during the pandemic and how these transitions impacted on doctors' wellbeing, with particular focus on social and cultural aspects. In the following section, we articulate in detail the conceptual framing of this study.

Multiple Multidimensional Transitions (MMT) is a theoretical framework used in medical education for articulating doctors' transitions beyond the individual, taking a more complex view that transitions are dynamic, incorporating multiple contexts (role, workplace, home and education) and multiple domains (physical, psychological, social and cultural). 1, 4 Previous research using MMT has unearthed the complexity of doctors' educational transitions (e.g., from trainee doctor to trained specialist), allowing for consideration of how transitions in one area of an individual's life (e.g., new job role) will impact on other areas (e.g., a resulting home move) and an individual's significant others (e.g., new work colleagues or a child moving schools). 1, 4 Transitions researchers have also argued that during periods of significant transitions, it is important that opportunities for learning and development are maximised whilst the potential for negative impacts on wellbeing are minimised. 2, [15] [16] [17] We chose to use MMT for this study to provide a conceptual framework during data collection that explored the complexity of doctors' experiences in multiple contexts (e.g., role, workplace, homelife and educational) and how these experiences might be affecting doctors in social and cultural domains. 17 

In this section, we define current thinking about social and cultural wellbeing. Later in the paper when describing our data analysis, we will articulate how our analysis had led us to re-explore the literature on wellbeing and refine definitions to include aspects related to social and cultural wellbeing (as presented here).

The World Health Organisation describes wellbeing as a 'resource for healthy living' and a 'positive state of health' that is 'more than the absence of an illness' such that we are able to thrive physically, emotionally and socially. 18,p1 As previously stated, physical and psychological wellbeing are well researched and not the focus of this paper. [19] [20] [21] [22] [23] [24] [25] [26] [27] However, at this point, we acknowledge the interconnections and relationships between social and cultural wellbeing and good physical and psychological health.

Social wellbeing has been defined as the perception of support from others and a sense of belonging, inclusivity and social stability. 28, 29 Culture and cultural wellbeing is dependent upon the context in which an individual identifies or the context under study. [30] [31] [32] For example, culture can be related to an individual's ethnicity but equally can be related to a profession to which an individual belongs (e.g., the medical profession or a specialty such as surgery). Therefore, one way in which social and cultural wellbeing may be felt is if an individual or group of individuals feel connected to the community (or organisation) to which they identify and share the same values, thus creating a sense of belonging. [30] [31] [32] Conversely, unresolved conflict in social and cultural expectations can lead to an individual or group questioning their own notions of belonging and values, which in turn can have a detrimental impact on the wellbeing of a community or organisation. [30] [31] [32] Whilst the focus of this paper is social and cultural wellbeing, we acknowledge that the multiple facets of wellbeing are integrated and often hard to separate. For example, a lack of provision of support for physical wellbeing (such as adequate hydration) could be perceived as an indication of a lack of concern on the part of the organisation for the employee, potentially affecting their psychological and social wellbeing and furthermore establishing cultural markers about how an organisation prioritises staff wellbeing.

By exploring doctors' experiences in a time of profound and sustained transitions (triggered by the pandemic), this study aimed to inform and build on knowledge about social and cultural aspects of wellbeing in the medical workforce across the career continuum (i.e., both learners and their educators). We asked how doctors' experiences of transitions during the pandemic impacted on social and cultural wellbeing and what was perceived to be important to sustain support for social and cultural wellbeing?

In Scotland, the location of this study, the pandemic triggered wideranging changes to the way healthcare and healthcare education was, and continues to be, delivered. 33 For example, the reorganisation of hospitals into COVID and non-COVID spaces, virtual patient care, a pause or delay in routine procedures and appointments, shifts to home working, virtual learning and redeployment to COVID wards were commonplace as the health service responded to the potential for significant and ongoing increases in COVID-19 in-patients during the first (March to May 2020) and second (December 2020 to April 2021) waves. 33 This paper reports on the empirical data collection workstream of a wider project that aimed to develop evidence-based interventions to support doctors' wellbeing and promote resilience during and beyond COVID-19. 7, 12, 34, 35 Longitudinal narrative inquiry was employed to explore the experiences of doctors' transitions during the pandemic. 36, 37 This approach, through multiple interviews and longitudinal audio-diaries (LADs), enables participants to describe and make sense of their experiences in-the-moment and over time. 5, 37 The research team, part of the Scottish Medical Education acknowledge that our analysis would have been affected by our own backgrounds and experiences. Indeed, we were all experiencing changes because of the pandemic during this study. To encourage team reflexivity, the whole team met on a weekly basis to discuss data collection, analysis and our own experiences and understandings. In addition to full team meetings, those undertaking data collection met at least weekly (sometimes twice weekly) throughout the study. 

Due to COVID-19 restrictions, interactions with participants were undertaken virtually, using Microsoft Teams, email and telephone. The data collection team consisted of six of the authors (LG, GS, TT, KW, PC and JF). What participants were asked at each data collection point was influenced by our conceptual framework (MMT). During the entrance interview, doctors were asked to share their experiences of the multiple transitions they had experienced during the COVID-19 pandemic including changes at work, to their role, at home and in their educational context. Additionally, they were asked about the support they received or accessed for these transitions and what they anticipated the next few months were going to be like (at this point Scotland was exiting the first wave of the pandemic, but it was yet unclear whether a second wave would occur). All of those participating in this initial interview were invited to take part in the LAD phase for 2-4 months.

In the LAD phase, participants were asked to record stories, incidents and thoughts pertaining to their transitions experiences during the pandemic and were encouraged to share experiences that occurred in multiple contexts (i.e., workplace, individual role, home or educational contexts). Participants that found audio-recording difficult were given the option to submit written diaries. Participants used their smart phones to record their diary entries and these were then emailed to their designated researcher (LG, GS, TT, KW, PC or JF). Participants were provided with a prompt sheet and were emailed regular reminders to submit a diary. The prompt sheets asked participants to describe their experiences, discuss how this affected their overall experiences of transitions during COVID-19, how they had been supported and whether their wellbeing had been affected. The entry interviews sensitised the participants to the types of experiences they might wish to share. Participants were emailed the transcripts of their diaries for their own records. Furthermore, researchers responded to the content of each diary entry in the reminder emails, which helped maintain the researcher and participant relationship as well as sensitising the researchers to doctors' ongoing experiences. 5 All participants who undertook the entrance interview were invited to undertake a second interview in September/October 2020 (just as the second wave of the pandemic was taking hold in Scotland).

In this interview, the focus was on the longitudinal story of their transition experiences over the last months. Where possible, diary and interview transcripts were used to prompt the discussion. Participants were asked to reflect on their experiences over the prior 6 months as well as consider how they felt about the approaching 6 months. Participants were also asked about support for the transitions they had and were experiencing, as well as how these experiences were affecting their health and wellbeing long-term. All interviews were audiorecorded, and along with the diaries, were transcribed by an experienced, approved and confidential transcription service.

Our approach to data analysis was abductive which promotes moving between data and the literature including our conceptual framework (i.e., MMT). 38 First, the research team sensitised themselves to the data set by reading through excerpts of data, and regular team discussion.

Through these discussions and our conceptual framing, we developed an initial coding framework based on the MMT domains. 17 This framework was then utilised to code a sub-section of data (by JF, PC and GS) using NVivo 12 qualitative data analysis software. Coding was then verified with the lead author in a coding session where coding meanings and data examples of these codes were discussed. Following this initial coding exercise, all entrance and second interviews and a subsection of LADs (from 44 participants) were reviewed and coded using this framework (by JF, PC and GS). To code this large data set, we began by coding a diverse range of participants' transcripts (this diversity included gender, career stage, ethnicity, specialty and geographic location). The team's deep familiarity with the whole data set allowed us to determine that coding of transcripts was sufficient in terms of research rigour and that relevant data excerpts could be located in uncoded data if required.

Finally, through repeated (weekly) discussion within the data collection team (LG, GS, TT, KW, PC and JF) we undertook more indepth analysis of the coded dataset to focus on the impact of these transitions to doctors' wellbeing. Through this analysis, we identified the importance of social and cultural aspects which led us to return to the wellbeing literature and to develop our understanding of social and cultural wellbeing definitions as described above. Table 1 shows details of the participants. Doctors were from all 14 territorial boards in Scotland and were diverse in terms of gender, ethnicity, career stage, specialty and geography (e.g., urban, remote or rural). Whilst we recognise and acknowledge that all perceptions of experiences are unique, patterns were identifiable across this large dataset allowing us to make broader conclusions about social and cultural wellbeing that crosscut the dataset beyond individual experience. Through analysis of the data we were able to prioritise three critical factors that contribute to social and cultural wellbeing: being heard; being valued; and being supported. Before we present this detailed analysis, we will present what transitions doctors perceived Community (e.g., psychiatry, public health)

Other specialties (e.g., anaesthesia and lab-based specialties) 12 12.3

Not answered 13 13.3 to have been triggered by the pandemic. Then we will consider each of the three factors, being heard, being valued, and being supported, and how they impacted doctors' social and cultural wellbeing.

Throughout, to illustrate our findings, we have used selected quotes that have been chosen because they are compelling yet pithy examples of our findings and are typical of the data. 39 Perhaps unsurprisingly, all doctors described considerable transitions triggered by the pandemic and our questioning using MMT as our framing allowed participants to depict transitions in multiple contexts (including role, workplace, home and education). In the workplace, doctors described operational and structural changes within their organisation, the cancellation of routine procedures and reallocation of staff. In secondary care (hospital-based), many doctors were redeployed across specialties and departments. These workplace changes led to multiple transitions in doctors' individual roles and responsibilities as illustrated in the quote below.

We had a relatively short period of time in which to be able to cancel routine activity. As somebody whose work is almost entirely outpatient-based, that was big … everything stopped. 

In this section, we present how social and cultural wellbeing was be impacted by the three factors: being heard; being valued; and being supported. We explore these three factors in terms of the positive impact on participants' wellbeing of the presence of each dimension and the negative impact in the absence of each dimension. (GP, Second Interview).

In contrast to being heard, participants' perceptions of being valued and lack of being valued centred on how they were treated by organisations (both healthcare and educational). A key example, which was repeatedly discussed across the data set, was the provision of access to water and nutritious food in new rest and relaxation (R&R) spaces which were created in the early days of the first wave for hospital-based staff. In addition to physical sustenance, these spaces offered the option for healthcare professionals to regroup and debrief after a challenging shift.

This, in turn, helped minimise feelings of psychological and social isolation. As a result, the R&R spaces provided a safe place for doctors to tend to their wellbeing needs as well as a means for interpersonal support in the workplace. Furthermore, doctors explained that the R&R spaces signalled that the organisation valued their staff's wellbeing. Some doctors reported that many were removed between the first and second waves which led to a feeling that they were not being 'prioritised'.

… I'm sad to say they are taking them away now they were gone yesterday, they were taking all the bean bags out … and we were told that R&R rooms were no longer necessary. We're going back to you know, we are not being prioritised. (Foundation doctor, First Interview).

Participants expressed concern around the longevity of support mechanisms that had been put in place by organisations.

There was a concern that the consideration of doctors' wellbeing was 'just for COVID' and that long term this support would evaporate.

There's a lot being said at the moment and sent out in emails about emotional wellbeing and support … it's very visible that there's an effort towards looking after mental wellbeing in employees, and it's a good start.

But I think that a lot of people are thinking, 'Well, this is just what's fashionable to do whilst we're in this pandemic'. (GP, First Interview). This is a striking example of the perception of the temporary nature of wellbeing interventions that manifested in a sense of lack of value and priority given to healthcare staff and their wellbeing long term.

The third and final dimension of social and cultural wellbeing reflects both being heard by colleagues and being valued by their organisations and centres around the ways in which doctors perceived that they were being supported. Educationally, the pandemic had specific implications for trainee doctors at pivotal stages in their careers. Whilst they understood the reasons, there was concern about the long-term impact of reduced support for routine learning opportunities. Some identified that there was a lack of recognition of learning experiences obtained during the pandemic. For some, this meant no longer being eligible to apply for a preferred specialty due to lack of exposure resulting in negative implications for career progression. Doctors with long term conditions at higher risk from COVID (as with others in the United Kingdom with high risk conditions) were asked to self-isolate for an extended period (termed shielding Finally, support for doctors was mixed; some experiencing positive support mechanisms (often from individuals and groups nearby) and others left feeling unsupported (by organisations). Whilst support measures in place were appreciated, there was concern (possibly through lack of organisational trust) about the longevity and sincerity of the support offered by the organisation. 22 Thus, people become disconnected and question their unity and connection with that organisation. [30] [31] [32] Our data revealed signs of such disconnect and a lack of clear communication from organisations. This is an important contribution to the literature, which has been previously criticised for expecting the responsibility for wellbeing to lie only with the individual. 1 We found the types of support doctors accessed differed, suggesting a one-size-fits all approach to supporting trainees and their educators might not be effective moving forward. This aligns with ongoing arguments in medical education for a move away from the focus on single solutions to consider multiple influences and aspects. 13 

Our study has many methodological strengths. First, our substantial longitudinal qualitative data set from a large and diverse sample (in terms of gender, age, career stage, ethnicity and geography) means our data brings a uniquely broad and rich perspective and thus a high likelihood of strongly resonating with other doctors and indeed the wider health workforce. 42 Second, the longitudinal nature of our study meant that we could explore doctors' unique experiences over the course of the first year of the global pandemic, allowing us to return to these experiences in second interviews to explore in more depth. 5, 36, 37 Furthermore, collecting diaries meant that thoughts and feelings about experiences were collected in the moment rather than filtered through memory. 5 Indeed, arguably the diaries themselves acted as 'safe spaces' for participants to reflect. 43 Third, our teambased approach to data analysis added rigour and reflexivity to our analysis. 44 Indeed the large research teams' diversity in terms of gender and background (e.g., psychology, management and clinicians) brought diversity of perspectives to our analysis and resulting interpretations of the data. 45 As with all research, our study is not without limitations which should be accounted for when drawing conclusions. Whilst our sample is diverse, we acknowledge that most participants (80.6%) self-identified as white. This does reflect the workforce within the country that the data were collected; nevertheless, this may affect transferability of our findings to those of ethnicities other than white. This is particularly pertinent in the context of COVID-19 as a disease which is known to have a disproportionate effect on certain ethnic groups. 46 As previously articulated, we also acknowledge that analysis would have been iinfluenced by our own backgrounds and experiences, including our own ongoing experiences of the pandemic. Despite these limitations, our findings have implications for educational practice and future research discussed below.

Unique to our data set was the exploration of the experiences of both trainee doctors and their educators. The potential long-term impact of these experiences on the whole medical workforce should not be underestimated. As medical educators it is vital that we are cognisant of how these experiences will affect medical education moving forward beyond the pandemic. Potential harm from doctor burnout, challenges to workforce retention and ultimately patient safety are ever present. [8] [9] [10] [11] As with other studies into doctors' transitions, it is important for educators to be cognisant of the complex interplay of the multiple contexts and domains that can be affected. 1, 5 Lessons need to be learned from this study as to where the onus for wellbeing is placed and how the multiple facets of wellbeing interact. 1, 5, 17 Our findings suggest that social and cultural wellbeing should be considered, moving beyond individual responsibilities, and interconnected with organisations, communities, and social relationships.

The study highlights the need for an organisational push to show value of staff across the organisation, including health professional students. This could be achieved through, for example, regular listening exercises that cross-cut all staff and students within an organisation, such as a feedback app. 34 Accordingly, medical educators can develop learners' abilities to articulate their needs and openly discuss the multiple aspects of wellbeing (physical, psychological, social and cultural).

Finally, the 'stigma' identified around accessing support should be prioritised by medical educators as we move beyond the pandemic. Measures to reduce and ultimately eliminate the 'perceived concerns' associated with help seeking is critical moving forward.

Indeed, the doctors in our study emphasised the beneficial nature of taking the time out to share and talk about their experiences with colleagues and peers. We advocate making time in the working day to discuss experiences with peers, and to ask each other 'how was your day'. 34 This could improve acceptability and accessibility of accessing support. 34 Perhaps the 'gift of time' within medical education to undertake supportive activities is key to creating a culture that encourages help seeking and provides supportive networks for this to take place. This could go a long way in encouraging wellbeing and foregrounding workforce value within organisations.

In the first instance, given the size of this data set, this analysis pro- wellbeing long-term is crucial.

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Heard, valued, supported? Doctors' wellbeing during transitions triggered by COVID-19

The authors would like to thank all study participants who invested significant time and energy into participating in this study in exceptional circumstances. The authors would also like to thank study funders: Chief Scientist Office (Scotland) and Scottish Medical Education Research Consortium (SMERC).

None.

This study was approved by the University of Aberdeen Human Research Ethics Committee.

All authors contributed to the conception and design of the study and secured funding. LG, GS, TT, KW, PC and JF undertook all data collection. All authors contributed to data analysis. LG, GS and TT wrote the first draft of the paper and LG and TT redrafted multiple iterations. All other authors edited multiple iterations of the paper. All authors approved the final manuscript prior to submission.