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Abstract
Objective The COVID-19 pandemic has transformed healthcare delivery in the USA, but there has been little empirical work describing the impact of these changes on clinicians. We conducted a study to address the following question: how has the pandemic impacted US clinicians’ professional roles and relationships?
Design Inductive thematic analysis of semi-structured interviews.
Setting Clinical settings across the USA in April and May of 2020.
Participants Clinicians with leadership and/or clinical roles during the COVID-19 pandemic.
Measures Emergent themes related to professional roles and relationships.
Results Sixty-one clinicians participated in semi-structured interviews. Study participants were practising in 15 states across the USA, and the majority were White physicians from large academic centres. Three overlapping and inter-related themes emerged from qualitative analysis of interview transcripts: (1) disruption: boundaries between work and home life became blurred and professional identity and usual clinical roles were upended; (2) constructive adaptation: some clinicians were able to find new meaning in their work and described a spirit of collaboration, shared goals, open communication and mutual respect among colleagues; and (3) discord and estrangement: other clinicians felt alienated from their clinical roles and experienced demoralising work environments marked by division, value conflicts and mistrust.
Conclusions Clinicians encountered marked disruption of their professional roles, identities and relationships during the pandemic to which they and their colleagues responded in a range of different ways. Some described a spirit of collaboration and camaraderie, while others felt alienated by their new roles and experienced work environments marked by division, value conflicts and mistrust. Our findings highlight the importance of effective teamwork and efforts to support clinician well-being during the COVID-19 pandemic.
- COVID-19
- organisation of health services
- health services administration & management
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Strengths and limitations of this study
This study represents the perspectives of US clinicians working during the COVID-19 pandemic and suggests opportunities to better support clinicians and clinical teams as the pandemic continues.
The main limitation of this study is that our results may not capture the perspectives of clinicians practising in other parts of the world or regions of the USA not included in our study or clinicians from demographic groups and clinical backgrounds not well represented in our study.
The dynamic nature of the pandemic means that challenges faced by clinicians early in the pandemic might differ from those that they are currently facing.
Introduction
The COVID-19 pandemic has challenged healthcare systems around the world in unprecedented ways, requiring large-scale and rapid alterations to healthcare delivery and exposing vulnerabilities, deficiencies and rigidities in existing healthcare systems, policies and practices.1–3 Some US healthcare institutions have reported being able to successfully adapt their health delivery systems, care processes and clinical teams to meet the myriad challenges of the pandemic.4–9 Nonetheless, personal narratives in the popular press and medical literature10–12 and the results of surveys and qualitative studies13–16 suggest a high degree of strain and burnout among healthcare workers.
Existing guidelines for institutional emergency responses offer a theoretical framework for how to adapt healthcare delivery during a pandemic.17 18 However, there has been little empirical work to understand the real-world impact of the pandemic on clinicians and care processes.14–16 19 As the COVID-19 pandemic continues and many healthcare institutions are stretched to capacity,20 a detailed understanding of how the pandemic has shaped clinicians’ professional experience may be helpful in identifying unmet needs and opportunities to support clinicians and institutions going forward. We performed a qualitative study to learn about clinicians’ professional roles and relationships during the pandemic.
Methods
Participants
We conducted a qualitative study among US clinicians who had cared for patients and/or occupied healthcare leadership roles during the COVID-19 pandemic with the goal of eliciting their perspectives and experiences pertaining to clinical care, leadership and resource limitation. Herein, we describe emergent themes pertaining to clinicians’ roles and relationships. Themes related to resource limitation are described elsewhere.19
We used purposive snowball sampling to select a group of clinicians with diverse work experiences. We began by recruiting clinicians practising in Seattle, Washington, then expanded recruitment to include clinicians practising at other locations around the USA. We intentionally recruited clinicians with a range of different clinical roles (eg, physicians, trainees, nurses and care coordinators), formal or informal leadership responsibilities--including participation in institutional pandemic response planning--and clinical backgrounds (eg, intensive care, nephrology and palliative care). Participants were invited to provide contact information for colleagues with relevant experience working during the pandemic.
Data collection
Interviews were conducted between 9 April and 26 May 2020. Clinicians completed one audio-recorded interview of 30–60 min with CRB (a senior nephrology fellow trained in qualitative methodology). All but one interview (for which two participants asked to be interviewed together) were conducted one-on-one. Two interviews were completed over two sittings to accommodate the participants’ schedules. A semi-structured interview guide (online supplemental table 1) was developed by CRB, AMO, and SPYW (the latter two being academic nephrologists with experience in qualitative methodology) and included open-ended questions to elicit clinicians’ perspectives and experiences pertaining to clinical care, professional interactions, institutional policies and resource limitation during the pandemic. The interview guide was iteratively refined throughout data collection and analysis by CRB with input from AMO and SPYW to allow for elaboration of emerging themes. Because of uncertainty about the course of the pandemic, we initially prioritised recruitment over analysis and ultimately interviewed more participants than needed to achieve thematic saturation. Interviews were recorded and transcribed verbatim. To protect confidentiality, participants were offered the opportunity to review their written transcripts for accuracy and to identify passages that they did not wish to have published. Participants were also asked to complete an online survey with questions about their demographic characteristics and clinical practice. At the beginning of the interview, clinicians were asked to list their clinical, administrative and/or leadership roles. Those with positions that included the terms director, chief, head, leader and/or manager were considered to have a formal leadership role. Information on the size of the primary hospital with which participants were affiliated or for which they volunteered during the pandemic was obtained from institutional websites.
Supplemental material
Qualitative analysis
Two investigators (CRB and AMO) independently reviewed and openly coded interview transcripts line-by-line until reaching thematic saturation (ie, the point at which no new concepts were identified).21–23 This occurred after reviewing 30 transcripts intentionally sampled to support saturation including a range of interview dates, participant locations and participant backgrounds. One of these coauthors (CRB) coded all of the remaining transcripts to ensure congruence with emerging themes and to identify additional exemplar quotations. Throughout the analysis, the two investigators reviewed codes across transcripts, collapsing codes into groups with related meanings and relationships, developing broader thematic categories and returning frequently to the transcripts to ensure that emergent themes were well grounded in the data.22–24 All coauthors (including EKV, a palliative care physician and bioethicist, and CSN, a paediatrician with expertise in healthcare teams and leadership) reviewed draft tables containing exemplar quotations and themes and all authors worked together to refine the final thematic schema. We used Atlas.ti V.8 (Scientific Software Development GmbH) to organise and store text and codes.
We report details of our methods using the Consolidated Criteria for Reporting Qualitative Research reporting guideline (online supplemental table 2).25
Supplemental material
Results
We approached a total of 97 clinicians by email, of whom 75 (77%) agreed to participate. Of these, we purposively sampled 61 clinicians representing a range of perspectives and experiences to participate in semi-structured interviews. All except one participant completed the online survey. Participants’ mean age was 46 (±11) years and most were White (39, 65%), were attending physicians (45, 75%) and were primarily practising at large academic centres (table 1). Participants were located in 15 different US states, with the majority practising in areas most heavily impacted by COVID-19 at the time of the study (eg, Seattle, New York City).
Participant characteristics
Three overlapping and inter-related themes pertaining to professional roles and relationships emerged from thematic analysis of clinician interviews: (1) disruption, (2) constructive adaptation, and (3) discord and estrangement. Exemplar quotations (from 39 different participants) are referenced in parentheses in the text and listed in tables 2–4.
Theme 1: disruption
Theme 2: constructive adaptation
Theme 3: discord and estrangement
Theme 1: disruption
Clinicians experienced marked disruption in their personal and professional lives, and their usual clinical roles and practices were upended.
Blurred boundaries between work and home life
Clinical concerns—including providing medical care and minimising risk of infection—spilled over into clinicians’ personal lives (1) and conversations with friends and family (2) such that home and social life no longer offered respite from work (3). Some clinicians voiced scepticism, cynicism or frustration with perceived inconsistencies between approaches to infection control across settings (4, 5). They also worried about the risk of exposing their families to the virus (6) and/or subjecting them to stigmatisation in their communities (7). For some, the profound impact of the pandemic on personal and family life (eg, child care obligations and concerns for family safety) could distract from or overshadow challenges at work (8).
Challenges to professional environment, roles and identity
Work environments (9, 10) and usual clinical practices (11, 12) were transformed during the pandemic. Several of the physicians with whom we spoke likened the high level of uncertainty and steep learning curve of practising during the pandemic to internship training (13).
Caring for young and otherwise healthy patients with severe complications of COVID-19 and seeing their colleagues become sick could make clinicians feel personally vulnerable. This sense of vulnerability prompted them to consider for the first time the risks involved in their work (14), and whether and how their own health issues should shape their professional roles and identity (15, 16).
The boundaries between the roles of patient and clinician also became blurred, as for example, when clinicians experienced first-hand what it was like to be seriously ill (17). The content of clinical encounters also tended to expand beyond strictly medical matters to include considerations of patients’ general well-being (18). Visitation restrictions could mean that clinicians sometimes did their best to subsitute for family members at the bedside of seriously ill patients (19).
Demands on leaders
Leadership roles could be especially challenging during the pandemic. One clinician leader compared her experience to running ‘an ultra (marathon) without a finish line’ (20). In addition to the increased volume of work (21), clinician leaders could feel a substantial weight of responsibility for staff well-being while also being constrained in their ability to prioritise staff interests in the face of other organisational needs and priorities (22, 23).
Some of those in leadership roles felt compelled to present a united front and consistent message to staff even if they did not always agree with institutional policies (24). Many were also mindful of how their decisions and actions might be perceived by others (25, 26) and described needing to choose their words carefully (27) and to project more confidence and competence than they might be feeling (28, 29).
Theme 2: constructive adaptation
Some clinicians were able to find new meaning in their work during the pandemic and described a spirit of collaboration, shared goals, open communication and mutual respect among colleagues.
Meaning-making
Many clinicians valued the opportunity to participate in direct patient care during the pandemic more than at other times in their careers and being able to make a tangible difference in patients’ lives (30, 31). For some, work during the pandemic served as a reminder of why they had originally chosen a career in healthcare (32). Some clinicians, especially intensivists, appreciated the chance to put their specialised training to good use (33), while others embraced and found meaning in filling gaps in care even if this meant taking on tasks outside their specialised skill set (34).
Collaboration
Many clinicians described a spirit of collaboration among colleagues that they would not have thought possible before the pandemic (35, 36). Some made conscious efforts to be more responsive to colleagues’ requests for help (37-39) and more accepting of their clinical decisions (40). A similar dynamic could occur at the organisational level, with competing institutions setting aside differences and working together toward a common goal (41).
Many clinicians voiced appreciation for more collaborative leadership styles and expressed admiration for leaders who led by doing (42) and were responsive to the concerns of practising clinicians (43). This sentiment was mirrored by comments from some leaders emphasising the importance of incorporating the first-hand experience of frontline clinicians in institutional planning and policy-making (44, 45).
Building mutual respect and empathy
Clinicians described a shared sense of uncertainty and vulnerability, which could help build camaraderie and mutual respect among colleagues with diverse backgrounds and skill sets (46). Expressions of concern for personal well-being (47) and face-to-face interactions (48) could help to strengthen collegial relationships. Clinician–patient relationships could also be enriched by shared challenges (49, 50) and expressions of concern for one another’s well-being (51).
Theme 3: discord and estrangement
Some clinicians felt alienated from their clinical roles and described demoralising work environments marked by division, value conflicts and mistrust.
Alienation from clinical role
Some clinicians described feeling alienated from new clinical practices and roles that did not align with their professional values (52, 53) and questioned the value and purpose of their work during the pandemic (54). Many experienced feelings of defeat and powerlessness when faced with the enormous loss of life among seriously ill patients with COVID-19 (55). Others less directly involved in caring for patients with the infection described feeling ineffectual and guilty about not doing more to help (56, 57).
Interprofessional power differentials
For some clinicians, more centralised institutional decision-making processes during the pandemic could feel unfamiliar or restrictive (58, 59). Several clinicians offered concrete examples of how inflexible, top-down policies had adversely impacted patient care (60).
The pandemic could create, expose and/or widen power differentials between staff with differing clinical roles. Intensivists sometimes assumed greater decision-making authority, which might leave other specialists feeling sidelined (61, 62). Nurses generally had less power than physicians to control their work environment and to limit exposure to the virus (63, 64) and were often expected to fill a wide range of different gaps in care (65).
Exposing value conflicts
The pandemic also exposed divergent values and beliefs about professional obligations among clinicians (66). Differences in how individual clinicians prioritised and operationalised competing concerns could be a source of conflict, especially when institutional guidelines were unclear or evolving. Heterogeneity in the relative value placed on obligations such as preserving limited healthcare resources, protecting oneself, limiting viral spread and directly examining patients with COVID-19 could provoke moral judgements (67-69). Some clinicians who were seeing patients in person felt unsupported and even ostracised by colleagues (70) and could percieve these colleagues to be prioritising their own safety over the needs of patients and other clinicians (71, 72). Physicians could also be critical of colleagues who they felt were insufficiently protective or unsupportive of nurses (73, 74).
Mistrust of leadership
Clinicians did not always trust that institutional leadership had their best interests at heart (75). Legacy concerns about the trustworthiness of those in leadership roles could be magnified during the pandemic (76), particularly when communication was poor (77) or when there was a lack of transparency or apparent inconsistencies in new policies (78, 79). Several clinicians described being more trusting of leaders with active clinical roles as opposed to ‘administrators’ without clinical backgrounds, who were seen to be out of touch with clinicians’ needs (80) and more likely to place institutional interests above those of patients and staff (81).
Discussion
During the first few months of the COVID-19 pandemic, US clinicians experienced significant disruptions to their professional identities, roles and relationships. How individual clinicians and clinical teams responded to these challenges varied markedly. Some found new meaning in their work and described a spirit of collaboration, mutual respect, and shared goals among colleagues. Others felt alienated from their clinical roles and described a demoralising work environment marked by widening power differentials, value conflicts and mistrust.
The pandemic not only disrupted clinicians’ usual work environments and practices but also raised existential questions about professional identity and required them to re-evaluate core values.26 Many grappled with competing priorities in their home and work lives and encountered value conflicts with colleagues. Those in leadership positions often had to juggle conflicting obligations to protect their staff and to uphold institutional policies and mandates while also being mindful of optics and how their actions would be interpreted by others. In the midst of this personal and professional upheaval, some clinicians were able to find meaning in their work, while others felt alienated from their new roles. This kind of challenging mental work likely contributes to the emotional fatigue and psychological trauma that has been observed among clinicians during the pandemic.13 27 28
A team-based approach can be especially valuable when responding to complex and unpredictable disruption in clinical practice and care delivery.7 9 29 Key tenets of effective team-based care include collaboration, open communication, shared goals and vision and mutual respect and trust.30 31 Our findings suggest that some but not all clinical teams and organisations were able to capitalise on these strategies to support effective teamwork during the pandemic. Many of those with whom we spoke experienced a strong team mentality grounded in mutual respect, concern and empathy,32 33 in which they were able to collaborate effectively with colleagues to accomplish common goals. However, others described work environments marked by divergent priorities and ineffective communication that likely worked against a team-based approach.34 While some clinicians remarked on inclusive and collaborative styles of leadership, others encountered more rigid and hierarchical approaches in which leaders appeared less responsive to the concerns of frontline clinicians and offered few opportunities for them to help shape institutional policies. This kind of top-down approach might undermine trust and contribute to a sense of powerlessness and demoralisation among clinicians.35
These early experiences of US clinicians during the COVID-19 pandemic highlight the different ways in which clinicians and clinical teams responded to the challenges of the pandemic and may be helpful in guiding institutional responses as the pandemic continues. In addition to improving patient care, an effective team-based approach can help clinicians to find meaning and adapt to new kinds of work.36 While effective collaboration may sometimes occur spontaneously, explicit efforts to promote and cultivate practices that are conducive to effective teamwork may be especially important at times of disruption and crisis.37 Available literature on teamwork suggests that deliberate efforts to establish a shared vision and common goals, reinforce core values guiding practice, and promote open and honest communication among all team members can help to build the kind of trust and understanding needed to support flexible adaptation to change.38 39 Attention to clinicians’ personal well-being and emotional health through structured institutional programmes,27 40 41 along with informal demonstrations of caring and respect from leaders and colleagues, can also be important in building trusting relationships, monitoring for fatigue38 and maintaining personal resilience.38 42
Our results may not capture the experiences and perspectives of clinicians practising in other parts of the world, of clinicians working in regions of the USA not included in our study, or in settings, specialties or demographic groups not well represented in our study. Specifically, although we included clinicians from private practice and rural settings, the majority of participants were non-Hispanic White physicians practising at academic centres. We also recognise that participants may not have always felt comfortable sharing their perspectives and experiences on sensitive topics. Leadership roles were identified when participants reported formal titles, but many clinicians took on informal leadership roles that we do not capture in our report of participant characteristics. Finally, the dynamic nature of the pandemic means that our analysis of clinicians’ experiences early on may not reflect present or future challenges.
Clinicians’ professional roles, identities and relationships were profoundly disrupted and reshaped during the pandemic. Our findings illuminate marked heterogeneity in how clinicians and clinical teams responded to these challenges. Some clinicians were able to find new meaning in their work and experienced a spirit of collaboration, mutual respect and shared vision among colleagues. However, others felt alienated from their new roles and described work environments marred by division, value conflicts and mistrust. These findings highlight the importance of intentional efforts to support clinician well-being and promote effective teamwork during the pandemic.
Acknowledgments
The authors thank the many clinicians who volunteered their time to participate in this work and also appreciate the help of Mr Ross Burnside in contributing to interview transcription.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @KateButler, @annmohare
Contributors CRB designed the study and analysed the data, drafted the initial manuscript and made the tables and figures, contributed to the interpretation and presentation of data, revised the manuscript and approved the final version of the manuscript for submission. SPYW, EKV and CSN contributed to the interpretation and presentation of data, revised the manuscript and approved the final version of the manuscript for submission. AMO designed the study and analysed the data, contributed to the interpretation and presentation of data, revised the manuscript and approved the final version of the manuscript for submission.
Funding This work is supported by the National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (5T32DK007467-33, CRB and 1K23DK107799-01A1, SPYW), the University of Washington Institute of Translational Health Sciences (small project award, CRB) and the University of Washington, Division of Nephrology (faculty funds, AMO). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or NIDDK. The funder had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; or decision to submit the manuscript for publication.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The University of Washington Institutional Review Board approved this study and authorised verbal in lieu of written consent (study ID: STUDY00009894).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No additional data available.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.