Abstract
Background:
Evidence of initiatives to support General Practitioners (GPs) during the Covid-19 pandemic is scant.
Aim:
To understand the impact of a novel method of providing support in the early stages of the pandemic.
Design and setting:
A mixed-methods study of GPs working in a socially deprived area of Belfast.
Method:
A survey was distributed to GPs who had attended a series of educational meetings at the beginning of the COVID-19 pandemic. The survey incorporated the Warwick Edinburgh Mental Wellbeing Scale and questions about the virtual meetings. Follow-up interviews were undertaken with five GPs to further explore their lived experiences and their perceptions of the virtual support forum.
Results:
The Covid-19 pandemic resulted in a measurable diminution of emotional well-being in GPs in North and West Belfast. Attendees rated a series of virtual meetings highly and described the following themes (and subthemes): a sudden traumatic change (emotional response, fight or flight, painful reminders of the status of general practice in the NHS); a coming together (stepping up to take responsibility, sharing of information, feeling of affirmation); reflections on what worked (calming facilitation, careful selection of speakers, creating the right atmosphere, ownership and autonomy) and building future direction (defining future direction, capitalising on lesson learned).
Conclusion:
The virtual meetings harnessed the instinct to come together witnessed at the beginning of the pandemic, and as well as sharing valuable information, also provided emotional support along with a sense of comradeship, ownership and autonomy.
How this fits in:
GPs did not feel included or supported at the outset of the pandemic. Coming together with fellow professionals was a welcome source of support. Professional support can be delivered using a virtual platform. Continued professional development is more acceptable than explicit emotional support, but when done well can bolster resilience and emotional well-being.
Keywords: General practice, COVID-19, pandemic, peer support, emotional support
INTRODUCTION
The COVID-19 pandemic has presented the National Health Service (NHS) with a set of unprecedented challenges. Efforts to understand its impact, both on service provision and on individual clinicians, has often focused on frontline staff based in hospital 1. However, the effects are widespread and have been felt across the NHS 2. Some have expressed concern about insufficient attention on supporting primary healthcare professionals, particularly General Practitioners (GPs) 3. At the same time, there has been a public discourse questioning the degree to which General Practice is open to the public, which has resulted in negative comments directed towards GPs and their teams 4.
Against this backdrop, GP Practices across the country have sought ways to support their teams to confront these extraordinary demands. However little guidance was forthcoming about exactly what type of support was required, particularly in the early stages of the pandemic. Key leaders (CL, DC & PL) of one Belfast GP Federation initiated a series of meetings (referred hereafter as ‘Covid-Zoom meetings’) to share education and best practice with their members. The meetings were extended to a neighbouring Federation after the first few. North and West Belfast Federations are comprised of 39 Practices of varying size, and serving a population of just over 200,000 people. Speakers from a variety of professions were invited to share their knowledge and experience of Covid-19. As the series progressed, it became apparent to the organizers, largely through informal comments, that the meetings were unexpectedly providing emotional support to many of the attendees. It is on this observation that this study was conceived.
This study aims to capture the impact of COVID-19 on a group of GPs and to explore the reasons the Covid-Zoom meetings were regarded so favourably. It is hoped that by so doing, themes might be identified to allow others to gain from our insights. The project aimed to address the following questions:
What was the professional and emotional impact of COVID-19 on a group of GPs?
Did a virtual forum provide meaningful support during a time of pandemic crisis?
What was learned that might inform post COVID-19 planning?
METHOD
Study setting
This study involved General Practitioners from North and West Belfast who attended at least one of 45 hour-long Covid-Zoom meetings undertaken from March to July 2020 each of which were facilitated by PL and DC. Most of the meetings were attended by between 50 and 70 GPs.
Study sample and recruitment
Participants were identified from a register of the email addresses of 74 GPs who had attended at least one Covid-Zoom meeting. A study information sheet was e-mailed to each GP including a hyperlink to an online survey. Individuals who were interested in participating in phase two of the study were invited to identify themselves to the survey lead (RK).
Design and analysis
A two-phase mixed-methods research study was developed.
Phase one: In early July 2020, all GPs involved in the Covid-Zoom meetings (n=74) were e-mailed a link to an anonymous online survey (via ‘Qualtrics’). This survey took approximately ten minutes to complete and remained available for six weeks. The survey gathered demographic and professional information including age, gender, COVID-19 risk status, years of experience as a GP and Practice size. The survey incorporated the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) 5 which is a validated psychometric measure used to assess psychological wellbeing both in the general population 5,6 and in specific occupational groups 7,8. Questions also quantified participants’ attendance and perceived value from the Covid-Zoom meetings. Quantitative data was entered into SPSS Version 26 for statistical analysis. These findings were analysed using descriptive statistics and an independent sample T-test.
Phase two: Survey participants were invited to take part in a semi-structured interview; four volunteered do so. It was hoped to hold a focus group but at the time of data capture (a time when teams were more sparse due to staff trying to take overdue leave), it was impossible to find a time that suited everyone. One interview was conducted with two participants together and two interviews were conducted individually. Interviews took place in August and September 2020. In accordance with ethics requirements, and to afford participants with the assurance of anonymity to speak freely, only the survey lead (RK) and the interviewer (MD) knew the identity of each participant. Each interview was audio-recorded, transcribed verbatim and transcriptions were anonymised. The interviews lasted between 23 and 43 minutes and each was undertaken virtually using MS teams. The design of the semi-structured interview schedule (see Table 1) was informed both by the aims of the study and by the phase 1 survey findings. Questions focused on participants’ personal and professional experiences of COVID-19, perceptions of the Covid-Zoom meetings and ideas that might inform future provision of professional and emotional support in General Practice.
Table 1. Semi-structured interview guide.
| n | % | ||
|---|---|---|---|
| Gender | Female | 27 | 69.2 |
| Male | 12 | 30.8 | |
| Age | ≤44 | 23 | 59.0 |
| 45-54 | 11 | 28.2 | |
| ≥55 | 5 | 12.8 | |
| COVID-19 risk status | No risk | 27 | 69.2 |
| Raised risk | 9 | 23.1 | |
| High risk | 1 | 2.6 | |
| Prefer not to say | 2 | 5.1 | |
| Sessions worked per week | ≤4 | 5 | 12.8 |
| 5 - 9 | 29 | 74.4 | |
| 10 | 5 | 12.8 | |
| Years of experience | ≤10 | 17 | 43.6 |
| 11 - 20 | 15 | 38.5 | |
| 21 – 30 | 4 | 10.3 | |
| > 30 | 3 | 7.7 | |
| Number of practice partners: | ≤4 | 28 | 71.8 |
| ≥ 5 | 11 | 28.2 |
-
Please reflect on the biggest challenges you have experienced as a consequence of the COVID-19 pandemic.
What was the biggest professional challenge?
What has been the most significant emotional challenge?
-
Please reflect on your experience of attending the N&W Belfast GP Federation meetings.
How many meetings have you attended?
What have you enjoyed most?
How have the meetings helped you?
Have the meetings helped you to meet some of the professional challenges you have faced? If so, how?
Have the meetings helped you to cope with the emotional challenges you have faced? If so, how?
What has made the meetings work well?
Was there anything about the meeting that did not work so well?
Do you feel this format offers an opportunity to provide support to GPs and others in primary care in the future?
Thematic analysis 9, a flexible qualitative method without a specific theoretical foundation, was used to analyse the transcribed interviews. The research team were unable to meet in person and all communication was conducted virtually. RK, DC, GO’N and CL were trained in data coding and, along with MD, read and re-read each of the transcripts separately to become familiarised with the dataset (Step 1). A collective approach was undertaken to maximise breadth of coding. Each separately recorded their ideas and generated initial codes (step 2) which were then combined into draft themes (step 3) by MD. This draft analysis was presented by MD to the research team via Whatsapp video, before being emailed to each of member of the analysis team in written form. Thereafter a virtual meeting was held with the wider research team to agree a preliminary set of themes and sub-themes (step 4).
MD then conducted a further interview. Following transcription and coding of this interview, it was agreed by the research team that no further themes were emerging and it was concluded that data sufficiency had been achieved and that no further refinements to the analysis would be required (step 5).
JD, PL and GO’N are practising GPs and have served as Federation co-chairs and DC is a GP and subdeanery lead of a pilot project in North Belfast. CL is a GP who now works full-time in medical education. MD is a Clinical Psychologist and NH is an academic GP. RK is a trainee clinical psychologist and led the phase 1 survey. MD and NH both have experience in Thematic Analysis and other qualitative research methodologies. Each member of the research team brought a different perspective to the study and endeavoured to consciously adopt a reflexive position in respect of his or her own beliefs, judgments and practices during and throughout the research process.
RESULTS
Phase one results: Thirty-nine GPs (response rate 52.7%) completed the online survey posted in July and August 2020.
The mean score on the WEMWBS was 48.0 (SD 7.65). A wider survey of GP wellbeing undertaken in Northern Ireland in 2017 reported a WEMWBS mean score of 50.2 (SD 8.0) 10. An independent sample T-test compared the current mean WEMWBS score, with the 2017 survey and found the deterioration in mean score was statistically significant t(258)=2.0316; p<0.05. For comparison, a pre-pandemic survey of the general population survey in Northern Ireland reported a mean score of 50.8 (SD 9.0) [6]. The above comparisons suggest that mental wellbeing was significantly worse in a group of GPs surveyed during the pandemic when compared to a pre-pandemic survey.
The mean number of Covid-Zoom meetings attended was 14.7 (SD 7.50). The majority of respondents (84.6%) attended 10 or more meetings, and 28.2% attended 20 or more meetings. Participants rated the meetings highly with 94.9% agreeing that the meetings ‘helpful’ or ‘very helpful’.
Phase 2 results: The background of the 5 GPs who took part in the interviews is provided in Table 3.
Table 3. Interviewee’s Details.
| Gender | Age | Covid risk | Years of experience | |
|---|---|---|---|---|
| GP1 | F | ≤ 44 | None | 13 |
| GP2 (locum) | F | ≤ 44 | None | 11 |
| GP3 | F | ≤ 44 | Prefer not to say | 14 |
| GP4 | F | 45-54 | Raised | 27 |
| GP5 | F | ≥ 55 | None | 22 |
Analysis revealed the following themes (in bold capitals) and subthemes (in bold).
EXPERIENCING SUDDEN, TRAUMATIC CHANGE
Participants vividly described their emotional response to the onset of the Covid-19 pandemic as being essentially one of fear. Much of the language and many of the metaphors evoked were reminiscent of trauma narratives.
[GP1]: I can certainly think back quite vividly, where it felt like we were waiting for a really large tsunami and not quite understanding what was coming behind it – probably all driven by the news and the way the news kind of magnifies the problem.”
[GP3]: “I was scared, there’s no doubt, from a professional and personal point of view.”
[GP4]: “I remember the first week or so of it very clearly. It’s almost like it’s in slow motion. You can remember, sort of, small details of it all. It seemed to happen very quickly. One minute, we were doing our normal job, well, I was doing my normal job. It was busy. You were trying to fit people in and bring patients down. Then, literally in the space of a few days, we went from that to the surgery being closed, the doors shut and nobody coming down. It was such a change within a week.”
A sense of fight-or-flight and military language was often used.
[GP4]: “I remember standing in reception and getting that population text from Boris Johnson. It said, “Stay at home, do not go out.” It was that sort of text. I remember thinking, “I wish! I just want to go home and stay at home like everybody else. I don’t want to be here. I would love to be able to go and stay at home.”
[GP2]: “Not only did I want to work, I wanted to be central to things. So, there was very much a feeling of wanting to be part of an army going to war.”
Painful reminders of the status of general practice in the NHS exposed by the crisis were described.
[GP1]: “I don’t want this to be about, “poor us” but I think there’s something very sad about how lost we were within all of that. I think there’s a massive lack of understanding of what we do.”
[GP5]: ‘In general practice, small teams working away, you can feel, perhaps-, I mean, there was certainly an opportunity to feel very isolated.’
A COMING TOGETHER
Participants described how individual GPs, practices and teams joined-together in response to the crisis.
[GP3]: “Every morning, it became the norm for us to just gather in the reception area, all staff. Doctors and receptionists, everybody, and we just had a chat for half an hour every single morning about how we felt, what could we possibly do.”
[GP4]: “The health centre has several practices in it and initially we would have joined together.”
[GP5]: ‘It was just that feeling of, yes, it’s uncertain but people are starting to come together and you’re part of a whole.’
Stepping up to take responsibility for decisions about professional and personal challenges evoked a clear sense of professionalism.
[GP3]: “Generally, I think we knew what we had to do. I suppose we just did it. There was no advice from health Trusts or anybody like that. We just knew that we just had to do it ourselves.”
[GP3]: “Right, we have to keep our staff and patients safe.”
[GP4]:“At work, clinically the challenges were very real because it was a new illness. None of us really knew very much about it and obviously any guidance was probably not-, we’re very used in medicine to everything being evidence-based. Nothing really was very evidence-based. It was all fairly anecdotal. So, the challenge clinically was to get on top of what was a new illness. There just seemed to be information overload and lots of guidelines coming out. It was a challenge to try and keep on top of it, to try and keep on top of all the emails.”
[GP5]: “Had to make decisions, basically had to turn around the way we work completely.”
Participants reflected on the helpfulness of the Covid-Zoom meetings and, in particular, the benefit of sharing of information.
[GP3]: “I think it was a lot of education at the beginning. The respiratory consultants, the A&E, the palliative. All the things that we had to have to be armed with knowledge.”
[GP2]: “We came away armed with information. Most of the meetings, you came away armed with information or reassurance that what you were doing or what you were thinking of doing was going to be correct the following week.”
The Covid-Zoom meeting also provided a feeling of affirmation, in that GPs were reassured that everyone was in the same boat and that everyone was feeling and thinking similarly.
[GP2]: “Total camaraderie.”
[GP1]: “Common purpose, yeah. Also, something about an equaliser. That we’re, kind of, all at the same thing.”
[GP5]: ‘Well, for me it was a relief because I’m the sort of person who likes to do the right thing. Yeah, so that was a relief. It was a relief that, yes, this is what others are doing because you learn from other people and how they’re managing. “What are you doing?” “We’re doing this, we’re not doing this.” That relief of not being a small island of a practice with 5,000 patients and four partners in the midst of this sea of uncertainty.’
[GP3]: “It was very much sharing the fact that everybody’s in the same boat and reassuring that every practice, more or less, had the same approach as well.”
[GP4]: “ You just saw your colleagues as a human, as a person, as opposed to just a name on a page or just another doctor. You kind of realise that they all have their different situations, concerns, worries, maybe health problems. You know, everybody had their own concerns at the time.”
REFLECTIONS ON WHAT WORKED
[GP2]: “Normally where I work they don’t really come out of their rooms for lunch, or anything. They all went up for the meeting at 1:00pm. They found it so informative, so well run.”
[GP4]: “Well, the overall feeling is that they were very positive, that they did help, that I enjoyed them, that I did gain relevant information from them.”.
Participants reflected on the importance of calming facilitation
[GP2]: “The chair was very well-spoken and very well able to manage things, from the point of view of putting questions across to people, inclusive of people.”
[GP3]: “[redacted], who was chairing the meeting, she was very calm throughout. I don’t know if she felt calm but she appeared to be calm. I remember that.”
Careful selection of speakers was also referred to and it was helpful to have both familiar local and prestigious national speakers, who were empathic towards General Practitioners.
[GP1]: “I would say there was something about them being important enough that those people were really engaged and exciting. I think we can’t undervalue that part because we were being ignored in some ways in the context of the Covid response and the funding etc.”
[GP4]: “Well, I really enjoyed it and valued the opportunity to listen to someone like that but I suppose maybe it makes you feel that, yes, this is serious. These people are taking the time to address these groups of local GPs.”
Creating the right atmosphere was considered important.
[GP3]: “It was the opportunity to raise any issues and questions. That was a forum that, sort of, provided that. Although there was usually a speaker or a local Consultant, or an update from somebody, there were always maybe a few minutes at the end. “Anybody got any issues?” So, there was that opportunity for a bit of a chat.”
[GP4]: “In general, it’s fine for people to have maybe slightly differing opinions or to raise issues to get answers.”
[GP5]: You could feel relaxed and just listen, and think, yes, that’s a very good point, or whatever. Didn’t feel pressure to speak.’
There was also a sense that ownership and autonomy expressed.
[GP1]: “I just found it very empowering. That view, forewarned is forearmed. You felt like you had all the tools and were also reassured that we were all doing a similar thing.”
[GP1]: “Unity and ownership and support and teamwork. I got a total buzz out of it.”
[GP2]: “As a Locum, that felt amazing to feel included. At the start I thought, “Oh, God, I’m the Locum here. I’m going to be the only one.” Then, there were other people added in. It was really nice to feel part of something and not just, sort of, on the edge.”
BUILDING FUTURE DIRECTION
All participants agreed that this method of providing support to General Practitioners has a role to play in the future, and many offered ideas about longer-term function.
[GP5]: ‘Now, it’s all so anonymised and so much less personal. That’s where the peer group meetings, I think, are important.’
[GP1]: “I think that GPs aren’t great at selling themselves and their voice isn’t heard well. I think we really need to consider actively pursuing PR support, somebody who is our public relations representative.”
[GP5]: ‘Our services are pretty broken in Northern Ireland. I mean, they were so poor before this. I do feel there needs to be a complete turnaround. I know loads of people are working really hard at that and I do think communication between primary and secondary care is important in trying to move forward with the Service here. So, there’s that but the communication between primary and secondary care was useful.’
Participants also reflected on how to capitalise on lessons learned. There was a sense that Continued Professional Development (CPD) is more acceptable to GPs than explicit emotional support but that CPD, when done well, can be emotionally supportive. It was also considered important that the value base of General Practitioners is reflected when deciding the topics that should be covered, and that having a local focus is helpful to maintain engagement.
[GP1]: “I think now we’ve seen what we can do ourselves, we don’t necessarily need that reassurance. I think we can do it all for each other.”
[GP3]: “Short. It has to be short.”
[GP3]: “ What GPs want is to be able to sort things for their patients. If you can sort things for your patients quickly and efficiently, your life’s a lot easier.”
[GP4]: “There could potentially be a role, monthly, two-monthly, for updates or a forum for people to bring questions.”
[GP2]: “They kind of go hand-in-hand, really. I don’t know that I would value one over the other but I suppose, by our nature, as doctors you kind of like information, guidelines and facts. So, I’d probably be going with the clinical guidelines that were particularly useful in the first instance. I’m feeling that’s what I need to do my job. The other [peer support], I suppose, is also very important but perhaps you don’t recognise it as important and you think that the guidelines are the first thing that you need. But also, you do need the support as well and that’s a nice thing that comes with it.”
DISCUSSION
The findings of this study demonstrate that the Covid-19 pandemic had a measurable effect on the emotional wellbeing of a group of General Practitioners in Belfast. Memories of learning about and responding to the pandemic were expressed using the language of trauma and of war, and GPs recounted having to take responsibility for a range of professional and personal challenges. In North and West Belfast, a community of General Practitioners felt that the impact of the pandemic on primary care and on General Practice was not being given due consideration, and so came together, in the spirit of practice-based group learning11, to support one another in a virtual educational meeting. Careful consideration was given to the type of information needed by General Practitioners at the time and speakers were carefully chosen to meet the needs of the profession. As well as providing invaluable education, the virtual meetings were also a source of emotional support and affirmation. They fostered a sense of camaraderie and empathy for peers and colleagues, and the visual connection of seeing faces was clearly important. The meeting provided a sense of support and reassurance, which created unity and a flattening of professional hierarchies. The role of the facilitator in providing a calm, containing, positive atmosphere where people felt safe to remain quiet, to ask questions or to disagree with one another was paramount. Attendees felt supported by the speakers, who they perceived had empathy for them. Both the attendees and the organisers felt buoyed by taking ownership and adopting a position of autonomy in the face of a worldwide crisis.
Because of the constraints imposed by the pandemic, it was not possible for the research team to meet in person, which meant the methodology had to be adapted to suit the needs of a virtual team. Nevertheless, the themes that emerged from the interviews were strikingly consistent and as such, the analysis was straightforward. Accordingly, we believe the themes identified are broadly representative of the views of GPs who attended the Covid-Zoom meetings, though we are mindful no male GPs volunteered to be interviewed.
The call to support the resilience and emotional well-being of General Practitioners has received widespread support 12. This study demonstrates that a virtual support forum can bolster professional resilience at a time of crisis. It was felt that this type of meeting does have utility in the future, both to support general practice and individual General Practitioners.
The authors of this paper believe it is likely that GPs across the country would identify with the themes that emerged in this research. In contrast to other well-intentioned statutory support initiatives, which are often delivered top-down, this initiative harnessed the instinct to meet a crisis by ‘coming together’ with people with common links and culture. It was noted that CPD is more acceptable to GPs than initiatives explicitly providing emotional support, but that, when it is done well, CPD can be emotionally supportive. This finding is particularly important as funding for CPD has been progressively diminished over time.
Acknowledgements
The authors gratefully acknowledge the participants, peer reviewers and to Dr Emma Berry for statistical support.
Funding
The cost of transcription was met by an anonymous grant.
Ethical approval:
Ethical approval was granted by the Research Ethics Committee for the Faculty of Medicine, Health and Life Sciences, Queen’s University Belfast (Reference: MHLS 20_86).
Competing interests:
The authors have declared no competing interests.
UMJ is an open access publication of the Ulster Medical Society (http://www.ums.ac.uk).
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