Challenges of the COVID-19 Pandemic for the Work–Family Balance of Pediatric Surgeons

: The COVID-19 pandemic has been a great challenge, especially for families. We aimed to analyze the impact of the pandemic on childcare for and the work–family balance of pediatric surgeons in Germany. An anonymized questionnaire on the working and familial situation before and during the COVID-19 pandemic was sent to the members of the German Society of Pediatric Surgery and trainees in pediatric surgery (April–July 2021). One-hundred-ﬁfty-three participants (59% female) completed the questionnaire. A total of 16% of the males and 62% of the females worked part-time. Most (68%) had underage children. During the COVID-19 pandemic, 36% reported a decrease in patients and interventions, and 55% reported an increase in the organizational work-related burden. Childcare for underage children during lockdown was organized mainly with the help of institutional emergency childcare (45%), staying home (34%), one parent working from a home ofﬁce (33%), or staying home by themselves (34%). Before the lockdown, 54% reported a good work–family balance. During the lockdown, this worsened by 42%. Most of the families had to organize themselves. Different means such as a home ofﬁce, ﬂexible working hours, and different models for childcare can help to improve the situation.


Introduction
The COVID-19 pandemic caused major changes in the professional and private lives of health care workers. The virus was first detected in Germany in January 2020 [1]. The World Health Organization declared the COVID-19 outbreak as a pandemic in March 2020 [2]. Governments responded to the continuous spread of the virus with a variety of measures [3]. Schools, many daycare facilities for children, and non-essential businesses were closed. Hospitals had to reorganize outpatient consultations to minimize contacts and postponed elective surgeries, even for children. In pediatric surgery, this resulted in major changes in the work itself [4], such as the expansion of telemedicine [5][6][7], the use of triaging methods [8], and a decrease in the number of surgeries [6,9,10].
Despite the changes in daily work, the COVID-19 pandemic has been a great challenge, especially for pediatric surgeons with children. Since 1996 in Germany, every child from 3 years of age until school age has the legal right to attend kindergarten, and since 2013, there has also been a legal entitlement to childcare after the first year of age [11]. However, institutional childcare hours are often limited for both preschool and school children. Thus, families often have to organize extra time for childcare by themselves, especially for those with jobs that have irregular working hours, such as pediatric surgeons. Many daycare Surgeries 2022, 3 249 facilities for children were closed during the lockdown, and so families had to organize childcare differently.
Pediatric surgery is different from other surgical specialties regarding the proportion of men and women, work satisfaction, and work-family balance. In Germany, approximately 40% of the fully trained pediatric surgeons are females [12], which is more than in other specialties. Pediatric surgeons reported a higher rate of work satisfaction, but also a high rate of work-home conflict [13]. This is similar to another study, where only 11% of pediatric surgeons strongly agreed that they "balance(d) my professional and family responsibilities" [14].
Factors affecting the interaction between family life and work are often labeled with the term work-family balance. Although widely used, there is no uniform definition for this term in the literature. The spectrum ranges from the general harmony between work life and family life over the lack of conflicts between work and family to the accomplishment of role-related expectations [15,16]. Other studies have focused on the work-family-conflict instead [17]. These work-home conflicts can contribute to surgeon burnout [18].
While the impact of the COVID-19 pandemic on pediatric surgical services and patients has been well analyzed in the literature [9,19,20], studies regarding the work-family balance of pediatric surgeons are lacking. Some studies have focused on the impact of COVID-19 on the lives of women, but little is known about the impact on the family lives of men. We, therefore, aimed to analyze how the situation affected the work-family balance of pediatric surgeons of both genders in Germany. We focused on the potential areas of work-family conflicts, especially working conditions and childcare.

Design of Study
The study was designed as a multicenter, cross-sectional survey. The anonymous online survey was created by the members of the working group "family and work" of the German Society of Pediatric Surgery. The first set of questions was collected in an open fashion and then approved by two rounds of e-mails.
The survey was designed with SoSci [21] and consisted of 25 questions, requiring approximately 10 min for completion. The topics of the questionnaire were: general data, working situation, partnership and family, and work-family balance, both before and during the COVID-19 pandemic.
Forced choice questions were used for age-group, gender, work setting, working time, partnership, working-time partner, children, age-group children, childcare without pandemic, home-office opportunity, work-family balance during lockdown, childcare during lockdown, adaption of work time, leave for childcare, and elements to keep. Lickert scale questions were used for the effects of the pandemic on working conditions, redeployment, home-office used, home-office used by partner, work-family balance before, acknowledgement by employer, acknowledgement by head of department, impact of COVID-19 on work-family balance, and new possibilities. Fields for open explanations and comments were provided. The detailed questions, answers, and variables can be seen in Table S1.

Study Population and Time of the Study
The questions were provided to the 812 members of the German Society of Pediatric Surgery and an internal email list of 271 trainees in pediatric surgery between April and July 2021. A reminder was sent one month after the initial transmission. Thus, our survey took place at the end of the second lockdown, when restrictions were loosening. Some doctors received the survey twice, as they were in both lists.

Statistical Analysis
We conducted statistical analyses using R, Version 4.1.2. Percentages and means were calculated for the counting data. Statistical analysis to test for differences between the groups was performed using a chi-squared test or Fisher's exact test, where applicable. For the analysis of metric parameters, a t-test was performed. The significance level was set at 0.05.

Ethical Considerations
This survey was performed anonymously, and so Institutional Review Board approval was not required, which was confirmed by the local ethical committee.

Study Population
A total number of 153 questionnaires were completed, and 59% of the respondents were women (Figure 1). Most (91%) of the pediatric surgeons were in a partnership, 7% were not, and 3% did not answer the question. Most (82%) of the respondents had children, and this was equal for both genders. Men had significantly more children than women (2.1 for males and 1.5 for females) ( Table 1). Sixty-three percent of the men and 72% of the women had underage children ( Figure 2).

Statistical Analysis
We conducted statistical analyses using R, Version 4.1.2. Percentages and means were calculated for the counting data. Statistical analysis to test for differences between the groups was performed using a chi-squared test or Fisher's exact test, where applicable. For the analysis of metric parameters, a t-test was performed. The significance level was set at 0.05.

Ethical Considerations
This survey was performed anonymously, and so Institutional Review Board approval was not required, which was confirmed by the local ethical committee.

Study Population
A total number of 153 questionnaires were completed, and 59% of the respondents were women ( Figure 1). Most (91%) of the pediatric surgeons were in a partnership, 7% were not, and 3% did not answer the question. Most (82%) of the respondents had children, and this was equal for both genders. Men had significantly more children than women (2.1 for males and 1.5 for females) ( Table 1). Sixty-three percent of the men and 72% of the women had underage children ( Figure 2).

Figure 2.
Children's age groups (years) of the respondents, for both genders (differences between the groups were not significant except for those having grown-up children, with p < 0.01).  Children's age groups (years) of the respondents, for both genders (differences between the groups were not significant except for those having grown-up children, with p < 0.01).

Working Conditions
Most participants were employed at a pediatric surgical department of a university hospital (39%) or at a non-university hospital (45%). A significantly higher rate of females (62%) worked part-time than males (16%). The mean part-time working hours were significantly higher for males than for females (Table 1). Only 15% of the males and 9% of the females responded that both partners worked full-time.
In families with underage children, most women worked part-time or did not work at all, while their partners worked full-time. The situation of males was the opposite (Table 1).

Working Conditions during the Pandemic
Although 36% of the participants reported a decrease in patients and surgical interventions, 23% also had to work more because of the pandemic. Only 13% of the participants experienced new possibilities to work more flexibly, and 15% took advantage of existing flexible working conditions. The organizational burden for the job increased for 55% of the respondents. However, only 18% reported increased difficulties in work-related arrangements because of colleagues working more flexibly or working from a home office ( Table 2). Most of the respondents (77%) sustained their work at their department, while 12% (sometimes) and 3% (often) were redeployed to other departments during the pandemic. Home office options had already been available for 12% of respondents before the pandemic and were established for another 10% during the pandemic. However, a home office was only used always or often by a minority of the participants (7%), irrespective of their gender (6% of the males versus 7% of the females). Sixteen percent of the pediatric surgeons rarely, and 65% never, worked from home. Conversely, approximately 32% of the respondents' partners worked at home always or often.

Childcare
Parents played a major role in childcare for children under 1 year old and school-aged children before the COVID-19 pandemic (Figure 3).
During the lockdown, childcare for underage children was provided mainly by institutional emergency childcare (45%), one parent staying at home (34%) or working from a home office (33%). The latter was mainly accomplished by the surgeons' partners (30%) rather than the surgeons themselves (3%). Emergency childcare organized by employers was rarely an alternative (1%). For 35% of the respondents, children had to stay home alone for some time by themselves (Figure 4). There were no significant differences in childcare implementations for the male and female respondents.

Childcare
Parents played a major role in childcare for children under 1 year old and schoolaged children before the COVID-19 pandemic (Figure 3).
During the lockdown, childcare for underage children was provided mainly by institutional emergency childcare (45%), one parent staying at home (34%) or working from a home office (33%). The latter was mainly accomplished by the surgeons' partners (30%) rather than the surgeons themselves (3%). . Emergency childcare organized by employers was rarely an alternative (1%). For 35% of the respondents, children had to stay home alone for some time by themselves (Figure 4). There were no significant differences in childcare implementations for the male and female respondents.

Childcare
Parents played a major role in childcare for children under 1 year old and schoolaged children before the COVID-19 pandemic (Figure 3).
During the lockdown, childcare for underage children was provided mainly by institutional emergency childcare (45%), one parent staying at home (34%) or working from a home office (33%). The latter was mainly accomplished by the surgeons' partners (30%) rather than the surgeons themselves (3%). . Emergency childcare organized by employers was rarely an alternative (1%). For 35% of the respondents, children had to stay home alone for some time by themselves (Figure 4). There were no significant differences in childcare implementations for the male and female respondents.

Work-Family Balance with Underage Children
The impact of the COVID-19 pandemic on the respondents' work-family balance did not differ for males and females. All the differences were trends, but they were not significant. Before the COVID-19 pandemic, 58% of the women and 46% of the men reported a good work-life balance. The pandemic worsened the balance more for women (49%) than men (31%). The organizational burden to combine family and work-life increased for 69% of females and 52% of males. Nevertheless, 43% of the female respondents reported that their families grew closer together, whereas this value was 29% among male pediatric surgeons (Table 3). Specific family needs during the pandemic had been acknowledged more by the head of the department of 43% of the men and 33% of the women than by their employers (18% in men and 17% in women). Of the pediatric surgeons with underage children, 20% would prefer to keep the option of working from a home office and of changing (20%) and reducing (23%) working hours, and 21% would also prefer more days off for childcare after the pandemic.

Discussion
In times with a growing lack of surgeons [22,23], it is important to analyze working conditions [24] and factors which can alter work-life balances, with a negative impact on work. The COVID-19 pandemic altered the lives of working people around the world, especially in health care and during lookdown episodes. During the latter, the majority of shops, restaurants, and cinemas were closed, and the rate of employers working from home offices increased. Most of the daycare facilities for children were also closed, and distance learning was established for most pupils [25]. The COVID-19 pandemic was an unprecedented burden, especially for families. In the beginning of the pandemic, children accounted only for a small proportion of cases [26]. Therefore, pediatric surgeons had to face problems other than dealing with infected patients. Among health care workers, the group of pediatric surgeons was well-fitted for the purpose of analyzing work-family balance because the impact of COVID-19 on their patients was lower than in other specialties. To our knowledge, our study is the first to assess the impact of the COVID-19 pandemic on gender-specific work-family balances in pediatric surgery.
As there is no uniform definition for work-family balance in the literature [15,16], our study mainly analyzed factors that were identified to alter the work-family conflict, such as work time, home office, means for childcare, and organizational burden. Fifty-nine percent of our respondents were female, which is an over-representation of that group. In contrast, in Germany, 40% of fully-trained pediatric surgeons were female in 2020 [12], and 58% of residents in 2017 [27] were female, which is higher than in most other countries [28][29][30]. This has to be considered when comparing our data.
The mean number of children was 1.5 for women, nearly the same as the birth rate of 1.53 children per woman in Germany [31]. In contrast, the mean number of 2.0 children per man was significantly higher than that of the female respondents and higher than the mean birth rate of 1.43 for men [31]. The fact that male physicians or surgeons have more children than females is also found internationally [32,33].
There is a legal right to work part-time for reasons such as care for children or other relatives for both genders [34]. However, in our sub-cohort with underage children, we found a classic role model with more than 86% of the women working part-time or not working, while 87% of the male pediatric surgeons worked full-time. This is in line with others reporting that women working as physicians or surgeons undertake domestic work [32,33,35].
During the COVD-19 pandemic, working conditions changed, with a decrease in regular patient numbers and surgical interventions worldwide [4,9]. In our cohort, 25% of the respondents reported an increase in the amount of their work and 44% reported the contrary. The redeployment of surgeons due to less surgical and more COVID-19 patients was performed and could have caused mental stress [36]. In our study group, only a minority of pediatric surgeons were redeployed to other departments. This played a minor role in the stress factors of the COVID-19 pandemic for pediatric surgeons. However, most pediatric surgeons reported that they had to organize more to perform their work.
Families had to manage their work with school and childcare closures while simultaneously caring for and homeschooling their children. Similar to others [37], our data showed that the main burden of childcare was conferred to the parents, as they stayed home either without working or using a home office. Institutional emergency childcare was established for health care employees and other important groups in Germany during the lockdown, especially for preschool children [38]. This was reported by 45% of the families with underage children. The organizational burden to combine work and family life was high for most of our respondents for both males and females. This is comparable to a Dutch study [39], but different from other international studies where women were more affected than men [40,41].
While others reported a reduced work-life balance for women surgeons who had the same working hours as men [18], we found a trend toward an increased work-life balance for women with underage children than for men. This study cannot answer whether this is the result of the reduced working time for most females.
The COVID-19 pandemic resulted in a decrease in work-family balance. Official support was provided as parents could receive extra days off work or adapt their working hours. However, only a minority of the pediatric surgeons with underage children of both genders used these opportunities. This is in contrast to the literature where women generally reduced work hours more than men [42].
Especially in an academic setting, flexible workplaces such as home offices are appropriate for giving lectures, writing papers, or attending online conferences [43]. During the pandemic, the use of a home office was also advocated for by the German government. However, only 25% of the pediatric surgeons in our cohort worked from home sometimes, and only 3% applied this for childcare. In contrast, 30% of their partners combined childcare and a home office. Low support by the employer for their familial situation and the limited establishment of new opportunities to combine work and family worsened the work situation of pediatric surgeons. These findings show the need for support from the employers to improve the situation in an extreme situation such as the pandemic. Further research should be undertaken to find more flexible working conditions and their impacts on the work-family balance.
There are some limitations to our study. Due to its anonymous design, we could not verify whether a respondent may have answered the questionnaire twice and exclude the duplicate response. There may have been a bias in enrollment because our study only included members of the German Society of Pediatric Surgeons (DGKCH) and trainees registered with the working group of the trainees of the DGKCH. Moreover, there is a possibility of responder bias. Women were over-represented in our study. This may have led to a bias within our study. Our study might also have attracted more pediatric surgeons with children. Thus, the birth rate of our study group might be higher than that of all pediatric surgeons in Germany. Furthermore, the respondents who had problems dealing with their situation during the pandemic might have been more likely to respond to the survey, and thus they may be overrepresented.

Conclusions
Although there was an overrepresentation of women among the respondents, our study showed that the COVID-19 pandemic had a great impact on the work-family balance of pediatric surgeons in Germany. The hospitals provided some support, but most of the families had to organize themselves. Different means such as a home office, flexible working hours, and different models for childcare can help employers to improve the situation.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/surgeries3030027/s1, Table S1: questionnaire and variables of the survey. Institutional Review Board Statement: This survey was performed anonymously, and so Institutional Review Board approval was not required, which was confirmed by the local ethical committee.

Informed Consent Statement:
This survey was performed anonymously, and the respondents provided their consent by answering the questions.

Data Availability Statement:
The data of this study can be obtained from the German Society of Pediatric Surgery (info@dgkch.de).