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Abstract
Background The pandemic has upended much clinical care, irrevocably changing our health systems and thrusting emergency physicians into a time of great uncertainty and change. This study is a follow-up to a survey that examined the early pandemic experience among Canadian emergency physicians and aimed to qualitatively describe the experiences of these physicians during the global pandemic. The study was conducted at a time when Canadian COVID-19 case numbers were low.
Methods The investigators engaged in an interview-based study that used an interpretive description analytic technique, sensitised by the principles of phenomenology. One-to-one interviews were conducted, transcribed and then analysed to establish a codebook, which was subsequently grouped into key themes. Results underwent source triangulation (with survey data from a similar period) and investigator-driven audit trail analysis.
Results A total of 16 interviews (11 female, 5 male) were conducted between May and September 2020. The isolated themes on emergency physicians’ experiences during the early pandemic included: (1) disruption and loss of emergency department shift work; (2) stress of COVID-19 uncertainty and information bombardment; (3) increased team bonding; (4) greater personal life stress; (5) concern for patients’ isolation, miscommunication and disconnection from care; (6) emotional distress.
Conclusions Canadian emergency physicians experienced emotional and psychological distress during the early COVID-19 pandemic, at a time when COVID-19 prevalence was low. This study’s findings could guide future interventions to protect emergency physicians against pandemic-related distress.
- COVID-19
- emergency departments
- patient support
- global health
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Research shows that the COVID-19 pandemic was associated with psychological distress, anxiety and depression among healthcare workers.
Limited research identified factors associated with this distress.
WHAT THIS STUDY ADDS
Distress was commonly experienced by Canadian emergency physicians in the initial months of the pandemic, when rates of COVID-19 infection in Canada were low.
This distress was thought to be attributed to a combination of workplace and personal factors associated with psychological distress.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
We found multiple factors contributing to distress among emergency physicians at a time when there were minimal COVID-19 cases.
This informs our understanding of working during a pandemic.
Introduction
Frontline medical workers, such as emergency physicians, have had their lives upended by the COVID-19 pandemic. Working at the junction between the external world and the hospital, emergency physicians have had a unique experience and a singular vantage point. Much has been publicised about pandemic-related emergency physician moral injury and mental health1–3 related to treating critically ill patients with COVID-19 and inadequate resources. Our early pandemic survey among Canadian emergency physicians also reported large COVID-19 impacts on work and personal life, at a time when the Canadian COVID-19 prevalence was low.4
When designing our Canadian emergency physician longitudinal survey,4 we were mindful that an online survey would capture general themes without fully understanding the reasons behind these findings. At the outset, our survey was designed to be complemented by in-person qualitative physician interviews. The aim of the present study is to highlight how the Canadian emergency physician described their experiences during the first wave of the pandemic, and how they felt the initial part of the pandemic impacted their emotional and mental well-being.
Methods
We conducted an interview study of emergency physicians from March to September 2020. This qualitative research study followed the Consolidated criteria for Reporting Qualitative research standards of reporting.5 Our study was sensitised by the principles of phenomenology6 but applied an interpretive description7 approach for analysis, as we were aiming to best understand the experience of frontline Canadian emergency physicians during the first 6 months of the COVID-19 pandemic. Sensitisation is a process borrowed from sociological traditions that allows qualitative researchers to expand their views to examine the data using perspectives beyond their original analytic technique or theoretical framework.8 For the purposes of describing our population, we also asked participants to answer the Anxiety Symptoms Questionnaire (ASQ) and report other demographic data (age, gender, training level or years in practice, etc).
Study participants
Participants were sampled from our longitudinal emergency physician cohort. In brief, this cohort study started in March 2020 with weekly surveys during the first 10 weeks of the COVID-19 pandemic and repeat surveys at discrete intervals thereafter.4 9 Participants were recruited to the cohort by direct emails to 20 ED physician groups in seven provinces, email invitations via four key national societies associated with emergency care in Canada (Society of Rural Physicians of Canada, the Canadian Association of Emergency Physicians, Association des Médecins d’Urgence du Québec and Association des Spécialistes en Médecine d’Urgence du Québec) and via social media (Twitter @EmergWell and Facebook).
During the first wave, participants could indicate whether they were interested in further sharing experiences during the initial phase of the pandemic. An interview invitation was sent by email or text (depending on participant choice) to those indicating they would like to share their experiences. The interview invitation was sent by the survey principal investigator (KdW) up to a maximum of three times, following which, no further invitations were offered.
All physicians who work in Canadian emergency departments (EDs) were eligible to participate in our longitudinal survey. Emergency physicians in Canada work in a variety of group practice models. In general, remuneration is per patient or else per shift depending on the department funding model. Most emergency physicians work between 12 and 18 shifts per month, in addition to any academic work. Staff emergency physicians spend each shift directly assessing and managing patients as well as one-on-one supervision of medical students and residents. The data for this analysis were collected at a time when COVID-19 prevalence was low in Canada (see figure 1).10
Data obtained from Health Infobase Canada.
Study interview
The semi-structured interviews were designed in March 2020, prior to collection of survey data. The investigators aimed to cover a broad overview of work conditions, physical health as well as mental health. The interview guide can be found in the online supplemental appendix 1. The interview guide was collaboratively created and refined by the investigators. The interviewer was the lead researcher (AT, female, experienced qualitative researcher). We selected AT to conduct the interviews as she did not have any prior relationship with the participants.
Supplemental material
The interviews were conducted with video-conferencing software using our institutional license (Zoom via McMaster University), at a time to suit the participant. At the outset, the interviewer made clear that this study intended to explore emergency physician experiences during the pandemic. Participant confidentiality and anonymity were assured. Participants could choose not to answer components of the interview. A clear safety plan with resources was outlined for the interviewer to activate, should there be concerns for participant mental health safety.
Research team and reflexivity
Our research team comprised a diverse group of emergency physicians (CW, KdW, PA, SG, TM-YC), psychologist (KR), psychiatrist (CG-L), students (AT, MB), coordinator (NC) and expert academic researchers (MM, LS). The core analysis team consisted of both emergency physicians (CW, TM-YC) and one non-emergency physician (AT), but the results were presented to all team members for investigator triangulation. To ensure reflexivity, each member of the core analysis team engaged in a self-declaration process to help understand each other’s assumptions, perspectives and rationale for working on this project.
Analysis
We performed a qualitative analysis. Interviews were de-identified and transcribed verbatim. Transcripts were reviewed in totality by the interviewer to ensure their veracity and accuracy before being analysed by the research team. We sequentially analysed the interview transcripts, using interpretive description.7 Originating in the nursing literature,7 the aim of interpretive description is to generate new knowledge within applied health disciplines (such as emergency medicine) to understand clinical scenarios and contexts better.11 A unique codebook (online supplemental appendix 2) was generated by the core analysis team (AT, TM-YC, CW) based on the interviews. We continued to interview participants until our research team achieved thematic sufficiency.12 Once all analyses were completed, we triangulated our findings with those of our early pandemic survey.4 We then amalgamated our final coding schema across both sources to determine the key themes, which are presented in this final report. Finally, two members of our investigatory team (KR, CGL) conducted an audit of the data trail across all the analyses.
Supplemental material
Patient and public involvement
We studied Canadian emergency physicians. Our research design was informed by the Canadian Association of Emergency Physician research committee and the Network of Canadian Emergency Researchers.
Results
Demographics
Of the approximately 6500 practising emergency physicians across Canada, 461 physicians participated in the survey, of whom 65 received an email invitation to a virtual interview. Eighteen participants agreed to an interview and 16 participants completed the interview. Participants lived in six different provinces. We do not report the participant locations to protect their anonymity. Eleven participants were female and five were male. Participant ages ranged from 28 to 62 years (mean 43; SD 10). There were 15 staff physicians and 1 resident. ASQ scores ranged from 11 to 192 (mean 101; SD 53); one participant chose not to complete the ASQ. As a reference, the ASQ can range from 0 to 340; it functions as a global measure of anxiety, and a higher score connotes more self-reported anxiety.
Findings
The interviews lasted from 40 to 112 min (mean 68; SD 19) and yielded a total of 294 pages of transcripts. Our interviews revealed that participants were affected by a combination of workplace-based and personal factors which contributed to their distress. With regard to workplace-based distress, a major contributor was the disruption and loss of ED shift work and the stress of COVID-19 uncertainty coupled with constant information bombardment. They had concern for patient isolation, miscommunication and disconnection from care. However, during this phase, they also found that there was a silver lining in the increased team bonding that occurred during this time period. Meanwhile, many participants described greater personal life stress and emotional distress. Participant quotes illustrating themes are presented in table 1. These statements indicate exemplars of our findings, while the following sections highlight key findings from each theme.
Key quotes demonstrating themes
Disruption and loss of emergency department shift work
The first few weeks of the pandemic saw a rapidly changing work environment, both in terms of clinical shifts and operations. The beginning of the survey aligned with both the early phase of the pandemic in Canada, and spring break. There was frequent mention of cancelled shifts due to a myriad of reasons. On return from travel, many physicians were instructed to self-isolate. Physicians quarantined due to acute illness and missed shifts due to fatigue. Participants reported shift loss due to lack of childcare. There were concerns about personal finances due to the decrease in shifts. Participants noted cancellation of regular shifts due to low patient volumes, however, some sites were understaffed despite lower patient volumes.
While clinical shifts were reducing, many noted increased non-clinical duties, often non-paid work in administrative and disaster planning roles, in efforts to rapidly develop pandemic preparation plans. In other cases, lack of regular in-person teaching responsibilities was balanced by increased in situ simulation for the department COVID-19 response preparation. Other changes in work responsibilities included additional clinical work such as COVID-19 assessment clinics and telemedicine.
Stress of COVID-19 uncertainty and information bombardment
Stressors in the first few weeks initially focused on continuously changing guidelines and protocols, poor communication from administration as well as concerns about lack of appropriate use of personal protective equipment (PPE) and uncertain PPE supply. These policies and equipment shortages contributed to a feeling of an unsafe work environment and personalised the risk of being an emergency physician during the pandemic.
This stress added to fears regarding COVID-19 unknowns and how Canadian hospitals would be impacted by the growing number of cases. Efforts to keep up to date on the rapidly evolving situation manifested as information bombardment via social media and emails. The constant onslaught of updates blurred the divides between participants’ work lives and personal lives, generating a great deal of stress that made it challenging to escape a ‘work’ state of mind. Information was also often inconsistent across regional, provincial and national sources with regard to PPE recommendations and departmental protocols.
Concern for patients’ isolation, miscommunication and disconnection from care
Participants were concerned about critically ill patients staying home and avoiding the ED, potentially resulting in increased morbidity and mortality. The sustained low volume contributed to a sense of impending disaster as the surge observed in other regions had yet to be seen. Physicians also noted concern about the impact of restricted visitation policies on patients and their well-being. These visitation policies were reported to exacerbate isolation for patients, as well as create difficult circumstances for emergency physicians whereby they were required to have difficult end-of-life discussions with family members over the phone. Moreover, participants reported that PPE usage throughout their shifts introduced challenges with communication, and created barriers to providing empathetic and high-quality clinical care to their patients.
Increased team bonding
While the initial phase of the pandemic was stressful and anxiety-provoking for many emergency physicians, some participants identified benefits of the pandemic response for their clinical work. For instance, there was a sense of collegiality and teamwork where colleagues were very supportive. In addition, prioritisation of patients with COVID-19 and acute crises improved patient flow through the ED and communication with consultants.
Greater personal life stress
As the pandemic progressed, feelings around the personal impact of the pandemic began to unravel. Sustained low clinical volumes were frequently noted as a contributor of stress. There was ongoing concern for decreased income due to quarantine or cancelled shifts, while having an increased heavy burden of unpaid non-clinical work such as pandemic planning or on-call shifts. These issues increased the overall financial stress experienced by many emergency physicians.
More importantly, the fear of bringing COVID-19 home was one of the most significant contributors to personal stress. Many reported difficulties with trying to self-isolate from family both within and outside of the home. This added to the stress of the pandemic’s concomitant unknowns and the lack of adequate pandemic preparation plans in many EDs.
Emotional distress: humanity not heroism
Participants reported feeling fatigue, anxiety, anger, much of which was attributed to the uncertainty of the pandemic and the long hours of PPE usage. Frustration and tensions also arose in the workplace between colleagues regarding PPE complacency, as well as with hospital administrations and governments due to a feeling of a lack of adequate support and communication from these governing bodies. Participants also reported feeling useless in the face of COVID-19 illness.
On a personal level, participants reported intense cravings for social interaction both in and out of work, given the restrictions in social gatherings and limitations in usual outlets for stress coping, such as going to the gym. Additionally, participants reported experiencing challenges in emotionally processing how their personal and work lives were changing because of the pandemic. Notably, participants also stated that they began feeling the weight of social expectations during the later stages within this early period of the pandemic. Many remarked that they did not feel like they represented the ‘hero’ persona that many members of the public had been expressing gratitude for.
Discussion
We describe the early COVID-19 pandemic experience from the personal vantage point of emergency physicians across Canada. Although the data presented an array of experiences, key common themes emerged. We found that Canadian emergency physicians experienced loss of clinical shift work, stress from COVID-19 unknowns and information bombardment, increased team bonding, greater personal life stress, concern for patients and emotional distress during the early period of this pandemic.
We reported previously that Canadian emergency physicians experienced work-related impacts and lifestyle-related COVID-19 impacts.4 In our qualitative interviews, we explored how these changes caused participants to experience psychological and emotional distress. We identified multiple sources of distress, even though Canadian COVID-19 prevalence remained low during the first pandemic wave. Distress arising from moral injury during times of emergency triage and resource shortage likely contributes only a proportion of all personal distress experienced by emergency physicians. Our findings agree with an American College of Emergency Physician survey where almost half of the respondents reported distress from reduced hours and pay, and a quarter reported distress caused by additional administrative demands.13 Other studies have pointed to poor communication of rapid protocol changes as a major source of distress.11–16
We identified several positive pandemic effects very early in the first few weeks of the pandemic such as greater team bonding. These good experiences included the perception that familiar, inefficient systems were replaced by rapid, effective versions because of a confluence of factors. Hallway medicine disappeared and consultants were ‘at the ready’. Similar to other studies, our physicians reported colleagues17 and members of the public were respectful and thankful.18 However, the positive impacts on physician mental health were short lived and the overall sense was that participants had experienced negative mental health during the early pandemic. The mean participant anxiety score was comparable with those reported in outpatients with general anxiety, social anxiety and panic disorder.19
Limitations
While there are some strengths to our study, there are still some limitations to our findings that we must report. Our study recruited a broad, national cohort of interviewees that compliment data from a survey study and the interviews featured in our study were conducted real-time during the first pandemic wave. The main limitation was that only those who had expressed an interest in sharing their story were invited to avoid overburdening survey participants at a stressful time.
Another important limitation is that this pandemic has not been a static phenomenon. While many of our themes may resonate with us later in the pandemic, each new wave brings new sources of stress. For example, the current wave has seen increased workload with fewer additional resources for overcrowded departments and many more emergency physicians have contracted the illness.20
Conclusions
Canadian emergency physicians experienced emotional and psychological distress during the early COVID-19 pandemic, at a time when COVID-19 prevalence was low. We highlight the many adverse effects they experienced, some of which were linked to unique work setting of the ED.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
The study was approved by the Hamilton Integrated Research Ethics Board. Participants gave informed consent to participate in the study before taking part.
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
KdW and TM-YC are joint senior authors.
Handling editor Kirsty Challen
Twitter @kerstindewit, @TChanMD
Contributors KdW, MM, CW, NC, KR, CG-L, LS, SG and TM-YC planned and designed the study. KdW obtained research ethics approval and study funding. AT, KdW, CW, NC and TM-YC conducted the study. AT, CW, KR, CG-L and TM-YC analysed the data. All authors reviewed the study results and contributed to the interpretation. All study authors contributed to writing this manuscript and have approved the final version. KdW, TM-YC have agreed to serve as guarantors for the full responsibility for the work and/or the conduct of the study, had access to the data, and supervised the publication process.
Funding This study was funded by Hamilton Health Sciences, The Juravinski Research Fund.
Competing interests CG-L reports employment with the Canadian Medical Association and notes that the opinions and conclusions expressed are the writers’ own and are not those of the Canadian Medical Association.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; internally peer reviewed.
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.