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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 54-60

A qualitative study regarding stress and coping in frontline postgraduate trainee doctors working at a COVID hospital


1 Department of Psychiatry, B.J. Government Medical College, Pune, Maharashtra, India
2 Maharashtra University of Health Sciences, Nashik, Maharashtra, India

Date of Submission29-Mar-2021
Date of Acceptance28-Apr-2021
Date of Web Publication18-Jul-2021

Correspondence Address:
Dr. Ivan Stanley Netto
Department of Psychiatry, B.J. Government Medical College, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_4_21

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  Abstract 


Context: There are few studies regarding stress and coping in postgraduate trainee doctors (PGTDs) working with COVID-19 patients during the first phase of the COVID-19 pandemic in the Indian setting.
Aims: This qualitative study examines the causes of stress, the stress experience, and the coping methods in PGTDs working with COVID-19 patients.
Setting: This study was conducted at a tertiary referral hospital with an attached medical college and a COVID-19 hospital in India.
Materials and Methods: This qualitative study used in-depth audio interviews with PGTDs.
Statistical Analysis: Content analysis was used to identify direct and latent themes.
Results: Thematic saturation was achieved with 13 participants. The major themes were related to the causes of stress, the stress experiences, and the coping with stress in PGTDs while working with COVID-19 patients.
Conclusions: There are various causes of stress reported by PGTDs while doing their COVID duties. The stress was due to external and internal stressors. Most experience some degree of stress while working in COVID-19 wards. This was more during their first duties, but subsequent ones are less stressful. Most use healthy coping mechanisms to cope with the stress. The advice they have for other COVID-19 HCWs has also been reported.
Implications: This will be useful to plan suitable interventions, training, research, and policy for PGTDs working with COVID-19 patients in the Indian setting.

Keywords: Coping, COVID-19, postgraduate trainee doctors, stress


How to cite this article:
Netto IS, Abhivant N, Shewale K, Muchala N. A qualitative study regarding stress and coping in frontline postgraduate trainee doctors working at a COVID hospital. Telangana J Psychiatry 2021;7:54-60

How to cite this URL:
Netto IS, Abhivant N, Shewale K, Muchala N. A qualitative study regarding stress and coping in frontline postgraduate trainee doctors working at a COVID hospital. Telangana J Psychiatry [serial online] 2021 [cited 2021 Dec 2];7:54-60. Available from: http://www.:tjpipstsb.org/text.asp?2021/7/1/54/321772




  Introduction Top


In December 2019, the novel coronavirus merged in Wuhan, Hubei province, China, and has now spread to different countries of the world.[1] Healthcare workers (HCWs) were under enormous stress due to the risk of infection, overwork leading to exhaustion, frustration, inadequate protection from contamination, stigmatization, prolonged periods of lack of contact with family members, and patients' negative emotions.[2] The attention capacity, understanding, and decision-making of the HCWs got affected. Many even developed stress-related disorders, which could have a long-term impact on their mental health.[3]

Frontline HCWs assess and manage both COVID and non-COVID patients in various emergencies and are at a high risk of contracting COVID-19 and developing severe acute respiratory syndrome due to SARS-CoV-2. The risk was increased by the rapid scaling up of intensive care unit (ICU) services, redeployment of clinical staff in ICUs and COVID wards, and recruitment of less experienced staff.[4]

Many HCWs have died after contracting COVID-19. This has led to many making living wills. Doctors are using altruistic coping and pushing themselves to their maximum capacity to save the lives of patients during the pandemic.[5]

We need to take care of our HCWs who are a precious and scarce resource. Many have recommended targeted interventions such as proper communication, limitation of shift hours, provision for rest, guidelines for the use of personal protective equipment (PPE), specialized training, indemnity policies, insurance, and upgrading workplace safety.[6],[7]

There are few Indian studies regarding causes of stress, experience of stress, and methods of coping with stress in postgraduate trainee doctors (PGTDs) working with COVID-19 patients during the early phase of the COVID-19 pandemic. This qualitative study examines the causes of stress, the stress experiences, and the coping methods in PGTDs working with COVID-19 patients at a COVID hospital. This will be useful to plan suitable interventions, training, research, and policy for PGTDs working with COVID-19 patients in the Indian setting.


  Materials and Methods Top


The aim of this qualitative study was to examine the causes of stress, the experience of stress, and the coping methods used by PGTDs working with COVID-19 patients. We employed a qualitative study design using the COREQ checklist and other standard recommendations.[8],[9]

Settings

The study was conducted at a tertiary care hospital with an attached medical college and a COVID-19 hospital in Western India. The study site is a recognized postgraduate training center for many years. The authors used in-depth interviews over mobile phones with all participant PGTDs. The PGTDs were doing 6 h COVID duties each day in different shifts, after which they went to a special hotel for quarantine. After 7 days of shift duties, they were sent for again another 7 days of quarantine. Then, their nasopharyngeal swabs were tested. If they were COVID negative, then only they were sent for non-COVID duties. During this period, they did not go home or visit others. Three male and five female participants were interviewed in their quarantine period, while three male and two female participants were interviewed during their non-COVID duty.

Methodology

We performed this study on a purposive sample of PGTDs. Only those PGTDs who gave consent and were undergoing their postgraduate training at our tertiary care hospital were included in the study. They were given in-depth interviews over mobile phones which were later transcribed. The PGTDs were not available for face-to-face interviews as they were either doing their duties or were in quarantine following their COVID duties.

Ethical considerations

All PGTDs who participated in this gave their verbal consent over the phone without disclosing their names or personal identity as they were in quarantine due to their COVID-19 duties. The authors were aware that all potential participants in this study were simultaneously taught and supervised by some of the study authors and thus could find it difficult to refuse consent. Hence, verbal consent was obtained at two time periods. First, participants were recruited after making them aware of the purpose of the study and obtaining informed verbal consent. Second, transcripts were forwarded via mobile phone once again to the participants for their feedback as well as approval for inclusion in the study. The study was approved by the Institutional Ethics Committee and the CTRI Trial Registration (IEC Approval no: ND-Dept 0420057-057 dated May 27, 2020, and CTRI Trial Registration Number: CTRI/2020/07/026788). In addition, we ensured confidentiality in the data analysis and use of illustrative quotes by removing all identifiers and assigning alphanumeric coding to each participant.

Interview guide

The authors used the following probes as the interview guide:

  • What are the causes of stress for PGTDs working with COVID-19 patients?
  • What are the experiences of stress in PGTDs working in a COVID-19 patient?
  • What are the coping methods used by PGTDs working with COVID-19 patients?
  • What advice do they have for other PGTDs who are going to do similar duties?


After conducting a pilot in-depth interview, the study recruitment was initiated. After completing 2–3 interviews, the authors coded and analyzed the transcripts. The authors recruited individuals and then coded and analyzed transcripts till data saturation was achieved. In their original paper on grounded theory, Glaser and Strauss (1967, p. 61) defined saturation in these terms: “The criterion for judging when to stop sampling the different groups pertinent to a category is the category's theoretical saturation. Saturation means that no additional data are being found hereby, the sociologist can develop properties of the category. As he sees similar instances over and over again, the researcher becomes empirically confident that a category is saturated. He goes out of his way to look for groups that stretch diversity of data as far as possible, just to make certain that saturation is based on the widest possible range of data on the category.”[10] Previous studies have recommended that qualitative studies require a minimum sample size of at least 12 to reach data saturation. Therefore, a sample of 13 was found sufficient for the qualitative analysis in our study.[11],[12],[13]

A total of 13 in-depth interviews were conducted on 13 PGTDs. This was in the early phase of the COVID-19 pandemic when PGTDs were not easily available for in-depth interviews. The mean duration of all interviews pertaining to probes history was approximately 45–90 min each. One participant was excluded as we did not receive consent from that PGTD who did not disclose the reason for his nonparticipation, so we finally included 13 PGTDs. We achieved thematic saturation after completing the analysis of transcripts of 13 PGTDs, and subsequently, we discontinued data collection.

Statistical analysis

We jointly analyzed the data using framework of content analysis.[8],[9] No assumptions were made before the study. We resolved disagreements by reaching consensus. We coded and used expressed words and phrases in the transcript to identify significant units of meaning. We also inferred from the underlying meaning of the text and generated an overall impression. To reduce the number of themes into categories, data were further analyzed by comparison and refinement. A set of main categories was established by grouping together all the subcategories with similar meanings. Illustrative quotations for the subcategories were chosen from the transcripts for themes.[8],[9]


  Results Top


There were in all 13 PGTDs who finally participated in the study. The study included six male and seven female PGTDs in the age group of 24–37 years of age who were currently pursuing their postgraduate training at the tertiary referral hospital with the attached medical college. All the six males were 1st-year junior residents. Five females were 1st-year PGTDs and one each was a 2nd-year and 3rd-year PGTD, respectively. One of the males was married and the rest were unmarried. One male had postponed his marriage due to his COVID-19 duties. Two of the females were married and the rest were unmarried [Table 1].
Table 1: Year of postgraduate training, age, sex and marital status of trainee doctors

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There were six male PGTDs, one each from ENT, Psychiatry, Anesthesiology, and Surgery and two from Pulmonary Medicine. There were seven female PGTDs, one each from Anesthesiology, Biochemistry, Pharmacology, Ophthalmology, Medicine, ENT, and Pulmonary Medicine. The Pulmonary Medicine, General Medicine, and Anesthesiology PGTDs were posted mainly in the COVID ICUs. The ENT PGTDs were mainly doing the nasopharyngeal swab collection. The rest were working in the COVID-19–positive patient wards, suspected COVID patient ward, or triage areas during their COVID-19 postings.

[Table 2] shows the major and minor themes with some illustrative statements under the headings of causes of stress, experiences of stress, and coping in PGTDs working with COVID-19 patients. The authors further reflected on these themes and have represented the relationship between them using a model [Figure 1]. As illustrated in [Figure 1], it is hypothesized that various causes of stress lead to an experience of stress, and then coping mechanisms are used to cope with the stress by PGTDs.
Table 2: Categories and illustrative quotes of postgraduate trainee doctors

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Figure 1: Causes, experiences and coping with stress in post-graduate trainee doctors

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  Discussion Top


We studied the causes of stress, the experience of stress, and the coping methods in PGTDs as they performed their duties of working with COVID-19 patients at a COVID-19 hospital during the early phase of the COVID-19 pandemic. During the early phase of the COVID-19 pandemic, many things were unknown about the “novel coronavirus” and about COVID-19 treatment. It was the period when standard operating procedures were being put into place and the PGTDs were experiencing the maximum stress and were not easily available for in-depth interviews as they were either going for their COVID duties and then sent for quarantine.

The findings are discussed under various heading.

Sociodemographic data of postgraduate trainee doctors

The ages of all participants were within the range of 24–36 years. There were six male and seven female PGTDs [Table 1]. All 13 PGTDs were certified medically and psychologically fit for COVID duties before joining their duties. None of them gave any written application to be exempted from duties, due to any medical or psychological reason. All of them were PGTDs at the medical college and the tertiary care hospital and also at the COVID hospital. It appears to us from the interviews that the ones in the COVID ICUs were under the greatest stress, as they were in PPEs and closest to the most infectious COVID-19 patients, but we were unable to compare both groups.

Causes of stress among postgraduate trainee doctors

External stressors

All experienced excessive heat and sweating and inability to speak properly and go to the washroom due to the PPE. Davey et al. reported heat stress due to PPE among HCWs.[14]

Internal stressors

The most common cause of stress reported initially was worry about the quality and size of PPE. Davey et al. reported heat stress due to PPE during COVID-19 duties and its impact on the performance and safety of HCWs in the National Health Service setting.[14] Inability to meet with their families and fear of family members being infected by them was also a cause of stress. One PGTD reported that her mother was suspected to have turned COVID-19 positive and that she wanted to go home to attend to her mother but could not do so because of her COVID duties which raised her stress levels. According to another male participant, on turning positive, he did not disclose this to his family so as not to alarm them, and this made him feel greatly stressed but this was not further explored. One female PGTD reported fear of contracting COVID-19 when she heard that one of her batchmates was detected to be COVID-19 positive. One male PGTD had postponed his marriage which was a source of stress, but he did not want to talk more about it. He had but resigned himself to the fact that the pandemic would soon end and he would be getting married soon. Urooj et al. and Jain et al. have reported similar expectations, fears, and psychological impact of the COVID-19 pandemic on HCWs.[15],[16] Taylor et al. have reported fear and avoidance due to an under-recognized form of stigmatization during the COVID-19 pandemic in HCWs.[17] Pappa et al. reported depression, anxiety, and insomnia among HCWs during their COVID-19 duties.[18] Sheraton et al. reported the psychological effects of the COVID-19 pandemic on HCWs globally.[19] Walton et al. highlighted the importance of mental healthcare for HCWs working with COVID-19 patients.[20] Kamran et al. and Maunder have also reported anxiety, depression, and traumatic stress among COVID-19 HCWs.[21],[22] Maffoni et al. emphasized the potential role of nutrition in mitigating the psychological impact of COVID-19 in HCWs.[23]

Stress experiences of postgraduate trainee doctors

The following were the stress experiences of PGTDs working with COVID-19 patients. Most participants reported experiencing discomfort due to excessive sweating in PPE during COVID duties. Davey et al. highlighted that poor-quality PPE can potentiate heat stress, which may have a negative impact on the wearer's performance, safety, and well-being.[14] Urooj et al. reported the fear of a poor-quality PPE among doctors may decrease their performance while working.[15]

Sleep disturbances and insomnia also were reported by some, especially by those doing daily-night shifts. One male and two female PGTDs experienced physical and mental exhaustion. Two male PGTDs felt anxiety when they were posted for COVID duties and one male had physical symptoms in the form of dryness of mouth and increased irritability. Pappa et al. reported that a considerable number of HCWs experienced mood and sleep disturbances during the pandemic and the need to take steps to mitigate them.[18] Sheraton et al. also reported a significantly higher incidence of insomnia among HCWs as compared to other non-HCWs.[19] Albott et al. reported the importance of mental healthcare of HCWs during the COVID-19 pandemic in China.[24] Albott et al. and Greenberg et al. highlighted the importance of psychological resilience interventions and the management of mental health challenges of HCWs during the COVID-19 pandemic, respectively.[24],[25] Galbraith et al. and Galbraith et al. emphasized the role of mental healthcare and resilience strategies to manage psychological distress among HCWs working with COVID-19 patients, respectively.[26],[27]

Four male and two female PGTDs reported having no significant stress at all. One male and one female PGTDs experienced a sense of pride due to the feeling of being a “corona warrior.” One female PGTD felt a sense of duty for the country and another felt a challenge to fight a new disease. One study reported that altruism was a motivating factor for some HCWs working with COVID-19 patients.[5]

Methods of coping with stress among postgraduate trainee doctors

Coping

These were the methods of coping used by PGTDs when they were doing their COVID duties or when they were in quarantine. All PGTDs stayed in touch virtually with family and friends through phone calls and video call. Most slept to recover their lost sleep as apart of coping. Many PGTDs also watched movies and listened to music. One male and two female PGTDs watched the educational webinars related to their subject. Reading and studying were used to cope up by two males and two female PGTDs. Three male and one female PGTDs performed stretching exercises. Only two female PGTDs used higher-level methods of coping such as meditation and prayer to de-stress. One male PGTD reported the regular reassurance from his head of department as very comforting. Three female PGTDs used unhealthy coping such as excessive binge eating of junk food as a way of coping with the stress. There was no substance abuse by any of the PGTDs during their COVID duties. Walton et al. reported methods of coping such as keeping in touch with family to alleviate loneliness, regular exercise, and adequate diet to address stress among HCWs.[20] Maunder emphasized interpersonal support among HCWs to mitigate the stress of the COVID-19 situation.[22] Feinstein et al. recommended an “HCWs mental health crisis line” in the age of COVID-19.[28]

Advice of postgraduate trainee doctors doing COVID-19 duties

The advice given by the PGTDs to their colleagues doing COVID-19 duties reflects to some extent the important areas of stress and the ways of coping. Assurance of a good-quality and size PPE and special care, especially while doffing the PPE, was recommended by four male and one female participants. Two males and two females emphasized on not more than 6 h per day duty shifts with adequate spacing between consecutive COVID duties. Two male and one female PGTDs emphasized supporting and helping each other during COVID duties. One male PGTD recommended support and care from seniors and colleagues if they contracted COVID-19. One male PGTD was of the opinion of the duty should be voluntary and not compulsory. Walton et al. recommended that supporting the medical staff and affiliated HCWs is a critical part of the public health response to the pandemic.[20] Greenberg et al. and Galbraith et al. also emphasized that maintaining the staff mental health is important as they will be in a better position to provide health services during the pandemic.[25],[26]

Recommendations

The authors recommend that all PGTDs should be given good-quality PPEs and proper care during COVID-19 duties. Davey et al. also stressed the importance of a good-quality PPE to improve HCWs performance while working with COVID patients.[14] If they do contract COVID-19, they should be given the best available treatment and support. Their duties should be properly and fairly arranged with a maximum of 6 h at a stretch with a period of rest to prevent exhaustion. There should be a teamwork approach so that they may feel part of a group and not alone. Albott et al. have reported a rapidly deployable psychological resilience intervention founded on a peer support model referred to as “battle buddies” for HCWs during the COVID-19 pandemic.[24] Taylor et al. recommended prevention and support from stigmatization and violence in COVID-19 HCWs.[17] After their duties, they should be given sufficient time to spend with their families and friends at least virtually. Sheraton et al. recommended family interaction for COVID-19 HCWs to reduce stress.[19]

They should receive support and counseling if they experience negative reactions from patients or negative events during their duties. Maunder advocated stress management and coping techniques such as relaxation exercises and mindfulness meditation to be taught to HCWs before their go for their duties.[22] Recreational activities, proper food, etc., should be available when their return from their duties. Chen et al. in their research suggested that recreational activities, proper food, etc., should be made available when the HCW return from their duties.[29] Medical insurance should be available. They should not hesitate to contact mental health professionals if they need help.[20] Studies by Greenberg et al. and Galbraith et al. have enlisted the measures such as peer support program for ensuring the physical and mental well-being of HCWs during the COVID-19 pandemic.[25],[26]

Strengths and limitations

This study has a strong qualitative design study and gives us insights into the cause, experience, and methods of coping due to stress in PGTDs working with COVID-19 patients. A limitation of this study is that, as the authors knew some of the PGTDs before the interviews, it is possible that the PGTDs did not reveal certain aspects of their difficulties in working in a COVID-19 Ward, especially regarding their seniors. Furthermore, this study focused only on certain limited aspects of COVID-19 wards, and discussions on other topics such administrative and personal issues did not arise during the interviews.


  Conclusions Top


The study describes the causes of stress, the stress experience, and the coping styles used by PGTDs working at a COVID hospital. The causes of stress were mainly worry about the quality of PPE, fear of contracting COVID-19, fear of infecting family members, separation from family, and worry about the availability of food and essential items. One PGTD's marriage was postponed.

The stress experiences reported were discomfort due to excessive heat, excessive thirst, insomnia due to sudden change in sleep patterns, lack of concentration, anxiety, and physical and mental exhaustion. However, one PGTD also experienced a sense of pride working for COVID-19 patients.

The coping methods used were staying in contact virtually with family and friends through mobile phones, sleeping after duties to recover lost sleep, reading, studying, and listening to music and movies. Some used higher methods of coping such as stretching exercises, prayer, and meditation. A few used unhealthy coping styles such as eating junk food to try to feel good. Most PGTDs do experience some degree of stress while working in COVID-19 wards.

The stress was more during their first duties, but subsequent ones were less stressful. The stress is due to external and internal stressors. Most use healthy coping mechanisms to cope with the stress. The advice they had for other COVID HCWs were proper selection of a good-quality PPE and special care during the doffing of the PPE, 6 hourly working shifts with adequate time for rest, support from superiors and colleagues, especially in the event of contracting COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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