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Abstract
This study examines trainees’ experiences of paediatric education and training during the COVID-19 pandemic. Paediatric trainees across the UK undertook an online survey. 368 of approximately 4000 trainees responded; quantitative and qualitative data were collected. Although the majority of trainees remained in their specialties, there was significant disruption to training events, teaching and learning opportunities. Despite this, for many, novel opportunities presented themselves that may not have otherwise been accessible. Trainees reported increased virtual learning, reflection, leadership and management opportunities. A breadth of trainee-identified web-based paediatric training resources were also highlighted. As the COVID-19 pandemic persists, these trainee experiences inform educators to adopt helpful training practices from other regions, including sharing of virtual learning regionally and acting-up opportunities. Trainees highlighted previously under-recognised areas of concern that can inform quality improvement initiatives, such as enhancing patient safety through tackling trainee fatigue, combating reduced clinical experience or instituting protected supporting professional activity time.
- COVID-19
- health services research
- qualitative research
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Introduction
COVID-19, among its other effects on healthcare provision, has significantly impacted postgraduate medical education globally.1 2 Disruption to medical education caused by the 2003 severe acute respiratory syndrome outbreak prompted adaptations including virtual learning.3 Yet, the world was unprepared for the COVID-9 pandemic.4 Undergraduate5 and postgraduate training has been affected globally, with reduced clinical exposure and disruption to career progression described in adult and surgical specialities6–10 and adverse psychological impact to trainees described.11 12 Chiel et al 13 anecdotally reflected on the impact of COVID-19 on paediatric trainee development but without empirical data. This study explores trainees’ experience of postgraduate paediatric training in the UK during the COVID-19 pandemic; the Infographic (online supplemental file 1) presents key findings.
Methods
An online national survey was undertaken between May and August 2020. Paediatric trainees were asked to describe positive and negative teaching and training experiences via multiple choice and free-text questions. Respondents were anonymous, though regional training area (deanery) and training grade were reported.
The study was conducted in accordance with the Helsinki Declaration. Formal ethical approval was waived as respondents were anonymous healthcare workers.14
The Royal College of Paediatrics and Child Health (RCPCH) agreed to the survey being conducted, which was disseminated through local paediatric schools, regional RCPCH trainee representatives, the RCPCH eBulletin and word of mouth. Descriptive statistics were used to evaluate demographic data. Free-text boxes used critical incident technique questioning to facilitate theory generation relating to the most positive and negative experiences of paediatric training during COVID-19, dual-coded by two investigators (GS/SA).
Results
Three hundred and sixty-eight responses were obtained. Three were excluded as not paediatric trainees, leaving 365. There was a balanced representation of training grades and deaneries (table 1).
Respondents’ characteristics
Impact on work and training
Change in work schedule was common, reported by 316 (87%), and some reported more than one of the elements next described. The majority of trainees, 211/365 (57%), remained in their clinical area with rota changes. Of the whole cohort (365), 65 (18%) were redeployed within paediatrics and 16 (4%) to adult services. Increased working hours were reported by 35 (10%) and 128 (35%) provided unplanned (not originally rostered) out-of-hours cover. Twenty-one (6%) required shielding (not undertaking face-to-face clinical work).
A total of 322 (88%) trainees reported cancellation of one or more of the following teaching events: statutory/mandatory training (55%); mandatory paediatric course (eg, child protection) (47%); life support course (29%); conference at which they were due to present (24%); and conference they were due to attend but not present at(31%). Teaching related to a postgraduate qualification (eg, MSc and postgraduate diploma) was cancelled for 6%.
Conversely, 68% found learning opportunities not previously available including online and social media-facilitated teaching resources. In ‘free-text’ comments, trainees reported novel opportunities to improve leadership and management skills, for example, through personal experiences managing acute changes in work environment, and increased awareness of online resources for developing these skills, including The Edward Jenner Programme.15
Opportunities for learning events, including supervised learning events (SLEs), were reduced (figure 1), with simulation and deanery-based teaching being most impacted (reduced for 75% trainees). Reflection opportunities were least negatively impacted. In fact, 28% reported increased reflection possibilities, while 23% reported increased leadership and management opportunities. There was no difference in responses between specialty trainee (ST) 1-3 (junior paediatric trainee) and ST4+ (senior paediatric trainee) groups (χ2 analysis, p=0.06–0.76). Trainees widely reported reduced exposure to procedures.
Reported impact of the COVID-19 pandemic on various educational activities. Decreased opportunity, although common was not universal, and a proportion observed increased opportunity/exposure. This was reported most commonly in opportunity for reflection. There was no difference observed between more junior medical grades (ST1-3) and more senior trainees (ST4+). CBD, case-based discussion; Mini-CEX, mini-clinical evaluation exercise; SLE, supervised learning events; ST, specialty trainee.
Attendance at virtual teaching was reported by 93% and across all deaneries. For 67%, this was department based; 64% attended deanery-based virtual teaching; 49% had teaching within their team and 40% within their hospital. Additionally, 28% of virtual teaching was from national sources and 14% from international sources. Virtual teaching was mostly initiated by seniors – consultants (68%) and middle-grade doctors (67%) rather than at deanery level (47%), SHO (ST1-3) grade (18%) or other (17%).
During the pandemic, 71% participated in supplementary online learning. The referenced online resources from this survey can be found on the Paediatric Innovation, Education and Research Network website.16
Annual Review of Competency Progression (ARCP)
Completion of required learning events in preparation for ARCP (UK system of annual appraisal for doctors in training) was anticipated by 82%. There was no significant difference between ST1-3 and ST4+ groups (χ2 p=0.179) and no difference between responses of those at a transition point – stepping up to a higher working grade with additional responsibility (eg, ST3, ST5 and ST8) compared with those not (both 82%). Those who did not anticipate completion of required learning events offered the following reasons: inadequate SLEs (65%); lack of safeguarding exposure (33%); specialty-time reduction (47%) and reduced exposure to required pathologies (33%). The reportedly affected RCPCH Progress curriculum domains are shown in figure 2.
Reported domains impacted in respondents not anticipating to meet annual requirements for ARCP. Domains are themes within the curriculum for paediatric trainees for which learning outcomes must be evidenced for each training level. ARCP, Annual Review of Competency Progression; RCPCH, Royal College of Paediatrics and Child Health.
Themes generated from trainees’ most positive and negative training experiences
Four over-riding themes epitomise trainees’ positive experiences of training during the pandemic: ‘changed practice’, ‘new skills’, ‘extra time’ and ‘teamwork’. Within reported negative experiences, four key themes were also evident: ‘training’, ‘clinical experience’, ‘safety’ and ‘well-being’. Table 2 details these with subthemes and illustrative quotes.
Themes generated from trainees’ most positive and negative training experiences
Discussion
As the first study reviewing paediatric trainees’ experiences during the COVID-19 pandemic, the results highlight that alongside significant disruption to traditional training, new learning opportunities have presented themselves.
The COVID-19 pandemic has positively impacted flexible learning opportunities with wider use of virtual platforms increasing accessibility at local, regional, national and international levels while decreasing training’s financial burden. The report of cancelled teaching by 88% of trainees may partially reflect events cancelled early in the pandemic but also that virtual learning is not always feasible. The UK’s Advanced Paediatric Life Support certification provider still require a socially distanced face-to-face course component.17 Limited course spaces and COVID-19-related travel restrictions may continue to affect trainees gaining this mandatory qualification.
Reduced opportunities for learning events (including SLEs) were reported, similar to primary care trainees.1 These events are important requirements for trainee progression. Although no minimum number, there are some mandatory events throughout training,18 and trainees need access to seniors for their completion. Reduced opportunities for safeguarding-based SLEs were highlighted as potential threats to progression, although an increase in such cases may be more likely during the pandemic.19 20
For 18%, concern was present regarding progression at ARCP despite deaneries’ assurances and the RCPCH introducing novel COVID-19 specific outcomes, 10.1 (acquisition of competencies delayed by COVID-19 but can progress to next training stage) and 10.2 (acquisition of competencies delayed by COVID-19, but trainee is at a critical progression point and additional training time is required), acknowledging the effects on training.21 The RCPCH reported to the authors that 4.1% of trainees received outcome 10.1 and 0.9% an outcome 10.2, suggesting potentially unwarranted anxiety. Trainees commonly reported cancelled events with concerns regarding progression; virtual presentations and crediting trainees for accepted abstracts despite meeting cancellations may mitigate this.
Quality improvement initiatives may use this study to improve the experience and well-being of those redeployed, shielding or with extra workload. For example, recognising the convenience of remote working, protected time to attend virtual clinics could facilitate maintenance of specialty experience. ‘Keeping-in-touch’ days may aid redeployed trainees to maintain exposure.
The survey highlighted issues impacting well-being, with morale described as ‘rock bottom’. Some trainees voiced ‘wanting [to] quit paeds training’, and understanding causes for this compromised well-being may improve retainment within training; facilitation of breaks with time off the ward was one suggestion provided that could help day-to-day well-being. Rota-related issues, including frequent rota reconfiguration with inappropriate pay adjustment and lack of in-built supporting professional activity (SPA) time, both despite RCPCH recommendations,22 23 contributed negatively to well-being.
Trainees report fatigue due to ‘relentless’ work patterns in reconfigured rotas, suggest intense out-of-hour shifts should occur only in the short term and that the burden of cover for last-minute absences be equally shared between consultants and junior doctors.
Well-being was also compromised where trainees felt inadequately informed or consulted regarding changes, which could be alleviated by ‘more communication, even if just explanation of decisions or uncertainty’ and engagement with consultants about managing workload and training. Childcare challenges additionally compromised well-being.
Trainees wanted positive changed practice to continue beyond the pandemic. For many, COVID-19 provided extra time to use more meaningfully. In contrast, some experienced a lack of SPA time, reporting having to use time outside of working pattern. Similarly, although the ability to catch-up on missed teaching via recordings or attend virtual attendance from home was widely commended, some expressed concern that this would be expected in their own time. The RCPCH23 recommends time allocated each month to trainees for SPA completion. Formalising SPA time may address these differences, further enhancing trainee well-being.
The heterogeneity in opportunities for SLEs justifies this study’s rationale to highlight areas of good practice to prompt improvement where trainees feel it is most required. Educational and clinical supervision varies between supervisors, hospitals and deaneries. RCPCH-led courses24 aim to improve quality and reduce heterogeneity, and training and appraisal are required to maintain registration on the General Medical Council (GMC) approved trainers list.25 During the pandemic, supervision was particularly criticised where senior presence was lacking, with supervisors reportedly failing to acknowledge trainee concerns or where leadership was lacking in dealing with emerging challenges.
Limitations
Limitations include the potential for both responder selection bias (extreme experiences more likely to respond, for example) and acquiescence bias. Local and national changes in training practice during the data collection period, such as the introduction of new ARCP outcomes, may have led to under-reporting of initial challenges or resolved problems through recall bias.
Concluding remarks
The heterogeneity of responses suggests differing experiences across deaneries, highlighting the importance of national collaboration in order to recognise local weaknesses and identify solutions. Furthermore, findings provide a basis for interspeciality and international shared learning.
Supplemental material
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to thank the Royal College of Paediatrics and Child Health (RCPCH) trainees’ committee for their guidance, and trainees for their time taken to complete the survey.
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 @matthewjharmer, @GenSouthgate, @raja_maduri, @ShoujaAlam
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer Views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service or RCPCH.
Competing interests None declared.
Provenance and peer review Commissioned; externally 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.