key: cord-0951237-vbwup3cc authors: Selvaskandan, Haresh; Nimmo, Ailish; Savino, Manuela; Afuwape, Sarah; Brand, Sarah; Graham-Brown, Matthew; Medcalf, James; Cockwell, Paul; Beckwith, Hannah title: Burnout and long COVID among the UK nephrology workforce: results from a national survey investigating the impact of COVID-19 on working lives date: 2021-12-13 journal: Clin Kidney J DOI: 10.1093/ckj/sfab264 sha: 0a9f2fd007e6f346363f972f85012e3dc1cf234a doc_id: 951237 cord_uid: vbwup3cc BACKGROUND: The COVID-19 pandemic is placing a significant strain on healthcare. We conducted a national survey of the UK nephrology workforce to understand its impacts on their working lives. METHODS: An online questionnaire incorporating the Maslach Burnout Inventory Score was distributed between 31(st) March and 1(st) May 2021, with a focus on COVID-19 and long COVID incidence, vaccine uptake, burnout, and working patterns. Data were analysed qualitatively and quantitatively; multivariable logistic regression was used to identify associations. RESULTS: 423 responses were received. 29% had contracted COVID-19, more common among doctors and nurses (OR 2.18, 95%CI 1.13–4.22), and those under the age of 55 (OR 2.60, 95%CI 1.38–4.90). 36% of those who contracted COVID-19 had symptoms of long COVID, more common among ethnicities other than White British (OR 2.57, 95% CI 1.09–6.05). 57% had evidence of burnout, more common amongst younger respondents (OR 1.92, 95% CI 1.10–3.35) and those with long COVID (OR 10.31, 95% CI 1.32–80.70). 59% with reconfigured job plans continue to work more hours. More of those working full-time wished to retire early. 59% experienced remote working, with a majority preference to continue this in the future. 95% had received one dose of a COVID-19 vaccine; 86% had received two doses by May 2021. CONCLUSIONS: Burnout and long COVID is prevalent with impacts on working lives. Some groups more at risk. Vaccination uptake is high, and remote and flexible working were well received. Institutional interventions are needed to prevent workforce attrition. The impact of these pandemic driven reconfigurations on nephrology HCPs has not been well described. To address this, we surveyed the UK nephrology workforce in July 2020, following the first surge of UK COVID-19. We reported fatigue, burnout, and compromises to work-life balance and training (1). We did not investigate the proportion that suffered with COVID-19, nor its impacts on their lives. It is also uncertain if our early findings are sustained in the second year of the pandemic. The aim of this study was to identify the impact of the pandemic on the nephrology workforce, twelve months on, with regards to; (i) the incidence of COVID-19 and long COVID, and its impacts on working lives (ii) the An online questionnaire was developed by the UK Kidney Association (UKKA). The UKKA represents nephrology affiliated HCPs including doctors, nurses, technicians, pharmacists, psychologists, and social workers (2) . The questionnaire was distributed via two emails sent three weeks apart to all members of professional nephrology groups, through social media, and was cascaded regionally by HCPs. Responses were accepted between 31st March and 1st May 2021. Questions were grouped into; 1) demographics, 2) COVID-19, exposures, and vaccinations, 3) burnout 4) working patterns 5) remote working 6) training 7) perceived future impacts and 8) overall experience. Free-text answers were analysed qualitatively to identify key themes using the following steps; 1) comments were categorised as positive/negative; 2) inductive codes were derived and applied to relevant comments using "key-words in context" and "repetition of words" techniques; 3) codes sharing similar meaning were amalgamated into subthemes and frequencies were measured; 4) descriptive analyses were applied to describe free-texts respondents' demographics in accordance with reported best practice techniques (7, 8) . Themes and codes were analysed independently by MS and HB and discrepancies resolved by discussion to enhance the reliability of results. 423 responses were received. The majority were female (74%), of White ethnicity (80%), and were nurses (36%) or doctors (34%) predominantly caring for adults (90%). Consultants (attending clinicians) were the most frequent respondents among doctors (64%), and dialysis nurses the most among nurses (29%) ( Table 1, detailed breakdown in Supplementary Table 1 ). By (Table 2) . Self-isolation episodes were reported by 59% (242/411) due to confirmed or suspected COVID-19, or a possible exposure. 517 episodes were reported; 44% (106/242) of respondents isolated once, while 29% (69/242) isolated at least three times. On adjusted analyses, being a doctor or a nurse (OR 1.83, 95% CI 1.10-3.04), or under the age of 55 (OR 2.37, 95% CI 1.37-4.08) associated with needing to self-isolate (Table 2) . Of those who had COVID-19, 36% (43/120) had persistent symptoms consistent with long COVID. Fatigue was most common (70%, 30/43), followed by mood changes (19%) and ageusia/anosmia (14% Table 3) . Patterns of work changed in 65% (233/360) between March and August 2020. 43% reported changes after August 2020. Changes were most commonly due to departmental restructuring due to the pandemic (79%), with personal health vulnerabilities, carer responsibilities and personal choice comprising the remainder. More of the nephrology workforce worked in intensive care units (12% vs. 4%), remote settings (11% vs. 3%), and in acute internal medicine (20% vs. 10%) during the pandemic. Fewer were involved in academic work (3% vs. 9% pre-pandemic). 75% of those who underwent role reconfigurations felt they received adequate preparation, despite the same proportion receiving less than two weeks' notice of working pattern or role changes. 60% of all respondents reported working more hours, and 67% worked more frequently out of hours. By May 2021, 61% (140/228) had returned to their pre-pandemic work role and pattern. Return to normal working patterns occurred before August 2020 in 26% (33/125), between August and December 2020 in 27% (32/125), and between January and May 2021 in 48% (60/125). Of those still in adapted roles at the time of the survey, 59% reported continuing to work more hours overall and more frequently out of hours. Fatigue increased after the first wave (March-May 2020 peak in UK COVID-19 cases (10)) and second wave (November 2020-April 2021 peak in UK COVID-19 cases (10)) in 54% and 59% of respondents respectively. 22% (n=88) of respondents noted increased aggression displayed by patients towards staff at work. Fewer educational opportunities were reported by 66% after the first wave, and by 46% by the end of the second wave. Difficulties in accessing development opportunities compared to pre-pandemic levels was reported by 61% after the first wave and 46% after the second wave. 79% of the workforce felt supported overall, and a stronger sense of team was reported by 70% after both waves. There was no difference in perceived education and development opportunities reported by those working remotely, but they had a diminished sense of team compared to those working on site (59% vs. 24%, Chi-square p=0.01). Of the 35 respondents in a training (fellows) programme (24 female, 11 male), nearly one third (n=11) reported extension to training, or being unable to complete training when planned. Over 20% (n=8) reported that time worked during the pandemic would not count towards training; mainly by those who returned to clinical work from research or who were working from home. 51% (167/327) moved to partial remote working, 8% (27/327) moved to complete remote working. Remote working was adopted to minimise staff contact/enable social distancing in the workplace (47%), to provide remote clinic services for patients (26%), and for medical/personal reasons. Whilst 75% felt they were adequately resourced, there were concerns regarding internet/computer software reliability and inadequate phlebotomy services to facilitate telephone clinics. 84% experienced job satisfaction and felt their work was valued and 80% wanted to preserve an element of remote working in the future. These findings mirrored feedback from fellows following a national fellows virtual seminar (Renal SpR Club, March 2021), in which only 24% (19/78) expressed a preference to continue with exclusive face to face events . The pandemic affected career plans for 22% (72/321) of respondents. Over 50% more participants want to retire early (Fisher's exact test, p<0.001), but numbers considering leaving nephrology did not change (Table 4 ). Full-time workers, those closer to retirement, doctors and nurses, and those with long COVID were more likely to want to retire early (Table 5) . Free-text questions were completed by 64% (Supplementary Table 3 ). Thematic analysis identified four themes: support, working relationships, workload and impacts on care provision, and changes in working conditions (Table 6 ). Support at a departmental level was considered positive, but perception of support from higher level management was negative. Trainees highlighted a the lack of support for professional development. Managers were perceived to have high expectations, with little empathy for strain on personal lives. Camaraderie reported early in the pandemic reduced over time, due to persistently tiring working conditions. Fatigue is a persistent theme; staff shortages were seen as a leading cause tension amongst staff. Workload and impacts on care provision Understaffing due to isolation and sick leave lead to increased workloads for those on front-line duty. Reducing outpatient clinical activity was also considered a risk to the adequacy of patient care. While remote working was considered positive for flexibility and in some cases patient care, there is a growing urge to return to face-to-face interactions where needed. Hybrid forms of work were proposed. While initial concerns regarding personal protective equipment was lack of provisions, concerns were now the physical barriers they present to interacting with patients. We report the impact of the COVID-19 pandemic on the UK nephrology workforce. We found persisting burnout, a presence of long COVID -particularly amongst non-White HCPs -and a higher proportion of staff intending to retire early. Reassuringly, we also report high vaccine uptake and describe positive experiences with remote and flexible working. Following the UK's first COVID-19 wave, 54% of the nephrology workforce had evidence of burnout (1). This issue persists a year later as measured by the MBI score (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) Burnout in the context of this pandemic is multifactorial. Burnout associates with fatigue and workload, particularly when working longer and out of hours (11, 37) . Nearly twelve months on from our initial work, working pattern alterations remain common; 59% of those in adapted roles continue to work longer shifts with more out of hours shifts compared to pre-pandemic, with associated fatigue. We also report 517 episodes of staff self-isolation among 411 respondents, which may have contributed to increased workloads. As Sever et al. explore in their review of burnout among nephrology personnel during mass disasters, HCPs had to manage multiple roles during this pandemic, beyond that of their professions. This ranged from being parents and carers themselves, to being patients affected or recovering from COVID-19 (38) . Indeed, we found a high prevalence of long COVID in our workforce. Long COVID refers to a constellation of symptoms that persist following the resolution of acute COVID-19 (39, 40) . Of our respondents, 29% contracted COVID-19, with 36% describing persistent symptoms consistent with long COVID. This proportion is higher than that reported in the general population (41) (42) (43) . Free text comments highlighted the negative impacts of long COVID on personal and professional lives, which are similar to those reported by HCPs in other settings (44) . Crucially, those with long COVID were ten times more likely to experience burnout. Although pathways for managing long COVID are beginning to emerge (44) , institutional support for HCPs with long COVID are needed to prevent workforce attrition. Distinct groups within the workforce are more at risk of contracting COVID-19 and developing long COVID. We found those under the age of 55, doctors and nurses, and males were all at least twice as likely to have had COVID-19, while respondents of non-White ethnicity were more than twice as likely to have had long COVID. An association between ethnicity and long COVID among HCPs has not been previously reported, and we note this finding is at odds with larger studies of the general population (40, 45, 46) . Recognising the limited number of participants in our study, these findings need to be further investigated. Despite these stark findings, we found a series of promising results. We also found that a shift to remote working was well received. Remote working offers flexibility affording an improved work life balance (45, 46) . Staff worked remotely felt their work was valued and experienced job satisfaction. 80% wanted to preserve an element of remote working. Although there is unlikely to be a 'one size fits all' answer for managing burnout (13), remote working may prove an efficient method solution in part, if feasible. Other solutions may include flexible working patterns, autonomy regarding job structure, protected time for personal and professional development, and normalising individualised burnout management plans (11, (47) (48) (49) ) Support for those with long COVID is also critical and should complement interventions to promote wellbeing. Measures such as these will be imperative to preventing workforce attrition. Our findings also highlight the need to ensure sufficient measures are in place during times of prosperity, to prevent burnout among staff during times of unprecedent disruption. This includes preparing staff to manage stress and workloads effectively, as well as organisational relief plans which could be implemented during periods of disruption. Such plans could involve periodically rotating staff from high stress roles to low stress roles, to distribute the burden of excessive working during crises, and implementing supervisors with the specific role of monitoring staff for exhaustion and excessive workloads (38) . Our work has limitations. Data were self-reported and non-identifiable to preserve anonymity. This aimed to facilitate honest responses but meant confirmatory cross checks against national databases were not possible. It was also not possible to identify an appropriate denominator to calculate a response rate given the open methods by which the survey was distributed, which included social media platforms and regional distribution Impact of the COVID-19 Pandemic on Training, Morale and Well-Being Among the UK Renal Workforce UK Kidney Association The Maslach Burnout Inventory Manual. In: Evaluating Stress: A Book of Resources Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning. The Psychologist Techniques to Identify Themes. Field methods Office for national statistics: An analysis of published data on the waves and lags of coronavirus (COVID-19) from the Coronavirus (COVID-19) Infection Survey, the Scientific Advisory Group for Emergencies (SAGE) and Public Health England (PHE) Physician burnout: contributors, consequences and solutions Maslach Burnout Inventory: Third edition. In: Evaluating stress: A book of resources Burnout in internal medicine physicians: Differences between residents and specialists Burnout and satisfaction with work-life balance among US physicians relative to the general US population Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev Estimating the Attributable Cost of Physician Burnout in the United States An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada The Associations Between Long Working Hours, Physical Inactivity, and Burnout Mass Disasters and Burnout in Nephrology Personnel: From Earthquakes and Hurricanes to COVID-19 Pandemic Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms. Front Microbiol The Conundrum of 'Long-COVID-19ʹ: A Narrative Review Persistent symptoms following SARS-CoV-2 infection in a random community sample of 508,707 people . Pre-print Covid-19: Third of people infected have long term symptoms Attributes and predictors of long COVID Developing services for long COVID: lessons from a study of wounded healers Assessing the growth of remote working and its consequences for effort, well-being and work-life balance. New Technology, Work and Employment An Exploration of Work-Life Wellness and Remote Work During and Beyond COVID-19. Canadian journal of career development Interventions to reduce the consequences of stress in physicians: a review and meta-analysis Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis Psychological 'burnout' in healthcare professionals: Updating our understanding, and not making it worse The authors would like to thank all survey respondents. The authors would like to thank all survey respondents. All authors contributed to the design of the survey. Survey analysis was performed by HS, AN, MS and HB. All authors contributed to manuscript preparation.