COVID-19’s Impact on Medical Staff Wellbeing: Investigating Trauma and Resilience in a Longitudinal Study—Are Doctors Truly Less Vulnerable Than Nurses?

Round 1

Reviewer 1 Report

The topic of this paper is interesting and timely. The background review and consideration of possible factors affecting the health and well-being of health care workers is impressively comprehensive (though it could be better organized for ease of understanding). However there are at least three issues that make me think this paper has some significant limitations and/or requires significant work to be suitable for publication.

1) Generally, the way the paper is written is hard to follow. Paragraphs jump around from different important concepts and do not flow from one to the other. Sometimes seemingly contradictory results from the literature are cited, which is appropriate, however transitions and linkages are needed to help the reader see how the authors make sense of these different findings, or how they apply to the current study.

2) A more specific concern relates to methods and reporting of results. As I read it, participants were only allowed to respond once to the survey, and in fact responses suspected of being repeat responses were discarded from the data set. It is not clear why this decision was made, nor is it made clear what impact this has on the inferences drawn from the results, but I believe it is quite significant. Many of the results are written as if something changed within the doctors/HCWs over time, when (as written and described) we cannot know any individual person's trajectory of satisfaction, mindfulness, etc. (in fact, we are excluded from even attempting to know it, because multiple responses by the same person were thrown out). This choice needs to be better explained and the results more carefully written with this in mind. I appreciate that the study is described as temporal rather than longitudinal, but some of the interpretation of results tends to slip into assuming these are the same people responding over time, and this needs to be avoided. The number of respondents at all times past T0 is also much smaller, which raises a concern of how representative the later timepoint samples are. The paper does not report the breakdown of participants at each timepoint by role, so we do not know, for example, whether the relative size of each workgroup sample was different at T0 compared to T3. This matters for interpretation of some of the Figures.

3) Finally, the interpretation of results and the abstract emphasize a conclusion that more attention needs to be paid to the potential vulnerability of male doctors. The sample of doctors is just barely predominantly men (60% men vs 40% women), yet results are presented in such a way that doctors are paraphrased as men and HCWs as women (see for example the interpretation of the results off Figure 3). No analyses are presented on outcomes of interest comparing men to women doctors - why was this not done, given the interest in understanding gender as distinct from profession? Presumably the vulnerabilities of specifically male doctors could emerge even more strongly in such analyses , but they are not presented. The main gendered difference emphasized is in mindfulness scores, which as the paper discusses seem to operate over a very narrow range in the measure applied. In summary, while the discussion of the reasons why men may have distinct vulnerabilities is interesting, I don't find the results compellingly supportive, and the analysis occasionally conflates being a doctor with being a man in a way that is inaccurate and does not read well.

I found it difficult to follow the writing in this paper. This is due partly, I think, to frequent minor difficulties with the English language (incomplete sentences, unusually structured clauses) which add up to make it difficult for the reader. It is also due in part to the number of different concepts being considered, which are not woven together in a clear and compelling narrative. I think the paper needs editing partly for language and partly for clarity in general.

Author Response

1^st reviewer .

Dear reviewer, thank you for your valuable comments. We replied to them as they appear on your report.

• Generally, the way the paper is written is hard to follow. Paragraphs jump around from different important concepts and do not flow from one to the other. Sometimes seemingly contradictory results from the literature are cited, which is appropriate, however transitions and linkages are needed to help the reader see how the authors make sense of these different findings, or how they apply to the current study.

Thank you for your comment a major revision to the introduction was made to correct this fault.

• A more specific concern relates to methods and reporting of results. As I read it, participants were only allowed to respond once to the survey, and in fact responses suspected of being repeat responses were discarded from the data set. It is not clear why this decision was made, nor is it made clear what impact this has on the inferences drawn from the results, but I believe it is quite significant.

 Many of the results are written as if something changed within the doctors/HCWs over time, when (as written and described) we cannot know any individual person's trajectory of satisfaction, mindfulness, etc. (in fact, we are excluded from even attempting to know it, because multiple responses by the same person were thrown out).

This choice needs to be better explained and the results more carefully written with this in mind. I appreciate that the study is described as temporal rather than longitudinal, but some of the interpretation of results tends to slip into assuming these are the same people responding over time, and this needs to be avoided. The number of respondents at all times past T0 is also much smaller, which raises a concern of how representative the later timepoint samples are. The paper does not report the breakdown of participants at each timepoint by role, so we do not know, for example, whether the relative size of each workgroup sample was different at T0 compared to T3. This matters for interpretation of some of the Figures.

We are in full agreement with this comment. Unfortunately, the nature of the prolonged pandemic with major staff restrains, long shifts and staff been mobilized from various departments to deal with affected patients, or fall sick themselves led to many changes in the composition of the employees. Therefore, there is no consistency within group and the survey shows the trends in various professions who worked in the COVID units, during the different phases only,

We had only 5 individuals that appear in more than one T but even they appear in no more than two-time groups (for example T0 and T3 or T1 and T2). Still, we believe that looking at the results as an institution process shed an important light on the psychological impact on staff working during COVID according to role and gender.

We mention this limitation both in the introduction line 18-19, in the method; line 196-199 and specifically highlighted in the limitation lines 534-559.

In the limitation section we explained that this study started well before the breakout of Covid 19 pandemic with a large number Reponses [see line 536-539]

3) Finally, the interpretation of results and the abstract emphasize a conclusion that more attention needs to be paid to the potential vulnerability of male doctors. The sample of doctors is just barely predominantly men (60% men vs 40% women), yet results are presented in such a way that doctors are paraphrased as men and HCWs as women (see for example the interpretation of the results off Figure 3). No analyses are presented on outcomes of interest comparing men to women doctors - why was this not done, given the interest in understanding gender as distinct from profession? Presumably the vulnerabilities of specifically male doctors could emerge even more strongly in such analyses , but they are not presented. The main gendered difference emphasized is in mindfulness scores, which as the paper discusses seem to operate over a very narrow range in the measure applied. In summary, while the discussion of the reasons why men may have distinct vulnerabilities is interesting, I don't find the results compellingly supportive, and the analysis occasionally conflates being a doctor with being a man in a way that is inaccurate and does not read well.

Thank you for your comment. As you can see in lines 354-375 we looked into the gender aspect of the medical team and discussed it in lines 441-449 and 470-479

Comments on the Quality of English Language

I found it difficult to follow the writing in this paper. This is due partly, I think, to frequent minor difficulties with the English language (incomplete sentences, unusually structured clauses) which add up to make it difficult for the reader. It is also due in part to the number of different concepts being considered, which are not woven together in a clear and compelling narrative. I think the paper needs editing partly for language and partly for clarity in general.

Thank you for this comment. Regrettably, we need to inform you that the article was originally written by a British native speaker who is a psychology student. It was then revised by a professional English editor. Despite these efforts, we have submitted it for a third round of review by another professional editor. We hope that the current version of the language is now satisfactory.

Reviewer 2 Report

Manuscript traumacare-2496587 entitled "The impact of Covid 19 on medical staff mental and professional wellbeing: A longitudinal study. Are doctors really stronger than nursing staff?"

Thank you for the opportunity to review the manuscript with the title "The impact of Covid 19 on medical staff mental and professional wellbeing: A longitudinal study. Are doctors really stronger than nursing staff?". This is an important topic, particularly due to the lack of related research. Really needed in the health care field since doctors constitute a crucial workforce in the management of pandemics. Overall, it is a valuable well-thought research with many clinical implications.

Introduction

The introduction is well thought out and describes the complexity of the research undertaken. However, it could be improved by including the following:

a.       Discuss how doctors and HCW’s personal trauma and loss history may affect them professionally (10.1111/ppc.12946, 10.1097/JTN.0000000000000274).

b.      Elaborate on secondary trauma and trauma dynamics and the way these may be related to the experience of personal trauma (10.1111/ppc.12946, 10.1097/JTN.0000000000000274)

Cultural considerations

Please provide some information on the levels of health care professionals/nursing education in your country as well as education regarding the present and previous pandemics to health care professionals.  Was infection or death of health care professionals discussed in the media? Is there any information on public attitudes?

Methodology

Please describe the education level per category of health care professionals.

Discussion

Please limit result description and focus on discussing your results in the context of the literature.

Given the importance of personal trauma and loss history on HCW’ professional work, please discuss different HCW profiles and responses to trauma (10.1111/ppc.12946, 10.1097/JTN.0000000000000274)

Limitations

Discuss in this section organizational/cultural factors and professional education issues that may have influenced your results. Please discuss issues of generalizability.

Clinical implications

In your discussion you suggest that “Developing in service programs to alleviate distress burnout on the one hand but as importantly to train in mindfulness and other self-nurturing and resilience building methods is crucial”. However, examples of mindfulness-related problems (i.e., occurring in a narrow period of time in close proximity to mindfulness and causally attributable to mindfulness-related intervention by the practitioner, instructor, or both) are: psychosis, mania, depersonalization, anxiety, panic, trauma re-experiencing and other forms of clinical deterioration. The American Psychiatric Association has included in the DSM Diagnostic Manual descriptions of depersonalization and other clinical problems related to mindfulness in both the fourth and fifth editions of the manual (Diagnostic and Statistical Manual of Mental Disorders APA, 1994, 2013). Furthermore, trauma survivors often find turning attention towards their body overstimulating. Please provide alternative individual strategies for doctors coping with secondary trauma and compassion fatigue (10.1111/ppc.12946). 

Please discuss further organizational responses to doctors and HCW’ experiences (e.g. trauma informed culture, work environment spirituality) On-going education may protect infected HCWs from absorbing or internalizing unmanageable emotions which may lead to compassion fatigue and also help them to gain a deeper understanding of their communication and interactions with patients (10.1111/ppc.12946, 10.1097/JTN.0000000000000274).

Al the best with your valuable work!

Author Response

Dear reviewer ,

Thank you for your comments and many refernces that helped us to deepen our knowledge.

We hereby respond to each comment

Second reviewer

Introduction

The introduction is well thought out and describes the complexity of the research undertaken. However, it could be improved by including the following:

10. Discuss how doctors and HCW’s personal trauma and loss history may affect them professionally (10.1111/ppc.12946, 10.1097/JTN.0000000000000274).

Thank you for this reference. As we have no access to staff history we did added this valuable information as part of the literature review see line 52-56

10. Elaborate on secondary trauma and trauma dynamics and the way these may be related to the experience of personal trauma (10.1111/ppc.12946, 10.1097/JTN.0000000000000274)

Thank you for this suggestion we discussed the STS in lines 140-149.However in the current study the majority of both doctors and health care reports low stress level, and none reported high stress levels. It is noticeable that doctors STS decreased from T0 to T1 26% to 13% and then there is an increase of moderate stress at phase 2 from 26% at T0 to 38%, at T2, Among HCW decrease was noted from 21% pre covid-19 to 11%at phase 3. whilst doctors STS increased again to somewhat higher STS : T0 26% to 38% at T2 and 33% at T3. (See line 287-292)

Cultural considerations

Please provide some information on the levels of health care professionals/nursing education in your country as well as education regarding the present and previous pandemics to health care professionals. 

Thanks for this remark we added this information on lines33-38

 Was infection or death of health care professionals discussed in the media? Is there any information on public attitudes?

As much as we tried to look for this information there was no mention in the media of any death of care professionals nor an official report on it and so we can't reply to this remark

Methodology

Please describe the education level per category of health care professionals.

 Thanks for these comments please see lines 33-38

Discussion

Please limit result description and focus on discussing your results in the context of the literature.

Thank you for this comment we revised the discussion section

Given the importance of personal trauma and loss history on HCW’ professional work, please discuss different HCW profiles and responses to trauma (10.1111/ppc.12946, 10.1097/JTN.0000000000000274)

Sorry, but as we don't have any background information on loss and grief of our sample, we did not specifically discuss it.

Limitations

Discuss in this section organizational/cultural factors and professional education issues that may have influenced your results. Please discuss issues of generalizability.

Thanks for this comment we revised the limitation section and addressed your comment see lines 547-552

Clinical implications

In your discussion you suggest that “Developing in service programs to alleviate distress burnout on the one hand but as importantly to train in mindfulness and other self-nurturing and resilience building methods is crucial”. However, eexamples of mindfulness-related problems (i.e., occurring in a narrow period of time in close proximity to mindfulness and causally attributable to mindfulness-related intervention by the practitioner, instructor, or both) are: psychosis, mania, depersonalization, anxiety, panic, trauma re-experiencing and other forms of clinical deterioration. The American Psychiatric Association has included in the DSM Diagnostic Manual descriptions of depersonalization and other clinical problems related to mindfulness in both the fourth and fifth editions of the manual (Diagnostic and Statistical Manual of Mental Disorders APA, 1994, 2013). Furthermore, trauma survivors often find turning attention towards their body overstimulating. Please provide alternative individual strategies for doctors coping with secondary trauma and compassion fatigue (10.1111/ppc.12946). 

Thank you for this comment we took your advice and wrote an extensive recommendations please see line 576-585

Please discuss further organizational responses to doctors and HCW’ experiences (e.g. trauma informed culture, work environment spirituality) On-going education may protect infected HCWs from absorbing or internalizing unmanageable emotions which may lead to compassion fatigue and also help them to gain a deeper understanding of their communication and interactions with patients (10.1111/ppc.12946, 10.1097/JTN.0000000000000274)

Thank you for this comment please see line 587-623

Round 2

Reviewer 1 Report

The manuscript has been improved, and the responsiveness of the authors is appreciated. My comments are divided into issues that I think still need to be addressed, and suggestions which may be matters of opinion.

Issues requiring attention:

- The paper still does not report responses by time and by role - in other words, we do not know how many of the responses at T3 were doctors and how many were health care workers. This information should be included to help readers assess the reliability of responses presented as percentages by role. 

- There are references to "T4" in the results, which presumably is "T3" - this should corrected so as to avoid confusion, especially if "T4" is compared with "T3."

Suggestions:

- The paper's consideration of gender is more nuanced in this version of the discussion, and that is appreciated. The discussion of the reasons why male doctors may have unique challenges seeking support is warranted. Still there are places where the way the results are reported suggests the authors wish to make a point about male doctors' vulnerability that is speculative, when the results could be interpreted to be driven by professional role (admittedly in interaction with gender). An example that stands out is at lines 470-472 where the authors report the finding that female doctors had more "high" mindfulness scores at T3 (erroneously labelled T4) than male doctors, yet do not report that female doctors also had more "low" mindfulness scores (25% among female doctors versus 22% among male doctors).  For some readers, the interesting things here (and elsewhere in the results) are 1) that doctors overall, of both genders, are more stressed than other literature has found, and 2) that there might be a trend that female doctors responses appear to go more towards the extremes rather than the middle ground. This is not something the authors choose to focus on.

- Finally the title. "are doctors really stronger than nursing staff?" feels deliberately provocative, which is often a good thing in a title, but for this reader it is a little puzzling. If the title is meant to reference what might be a popular belief that doctors are stronger than nurses, it's good to challenge that - but personally as someone who has worked for a long time within primary care teams (as neither a nurse nor a doctor), I doubt that many doctors or HCWs think doctors are "stronger" than nurses to begin with (they hold more power, can be more authoritative for better or worse, assert their opinions more...). If the title is meant to refer to the literature (which is well cited in the paper) that finds greater impacts of burnout, stress, etc. among nurses compared to doctors, then perhaps a more accurate title is "are doctors really less impacted by stress than nurses?" or "are doctors really less vulnerable than nurses?" Strength is a vague term.  

The writing in the paper has been improved (and as an aside - many people whose first language is English write poorly, and others who have learned English write beautifully). The background section is easier to follow, although still a bit more of a "kitchen sink" approach to presenting the literature than weaving things together, but this is also matter of preferences to some extent. There are a few places where there are either minor grammatical errors or the sentences remain long and unwieldy (lines 25-26 of the abstract are not a sentence; other places needing a little attention are lines 372-375, 505-507, and 517-520).  

Author Response

Response to Reviewer 1 Comments

Dear Reviewer, Dear Editor,

We truly appreciate your time and effort to make this article a better one.

We hereby mention the corrections we made in accordance with your suggestions. 

Point 1:

There are references to "T4" in the results, which presumably is "T3" - this should corrected so as to avoid confusion, especially if "T4" is compared with "T3."

Thanks, all were corrected

Point 2: Suggestions:

- The paper's consideration of gender is more nuanced in this version of the discussion, and that is appreciated. The discussion of the reasons why male doctors may have unique challenges seeking support is warranted. Still there are places where the way the results are reported suggests the authors wish to make a point about male doctors' vulnerability that is speculative, when the results could be interpreted to be driven by professional role (admittedly in interaction with gender). An example that stands out is at lines 470-472 where the authors report the finding that female doctors had more "high" mindfulness scores at T3 (erroneously labelled T4) than male doctors, yet do not report that female doctors also had more "low" mindfulness scores (25% among female doctors versus 22% among male doctors).  For some readers, the interesting things here (and elsewhere in the results) are 1) that doctors overall, of both genders, are more stressed than other literature has found, and 2) that there might be a trend that female doctors responses appear to go more towards the extremes rather than the middle ground. This is not something the authors choose to focus on.

.

Response 2: Thank you for this comment we revised the paragraph as follows " Male doctors initially exhibited higher mindfulness scores at the outset (T0). However, by T3, none of the male doctors retained a high mindfulness score, while 25% of their female counterparts reported elevated mindfulness scores. Regarding "low" mindfulness scores, a slight disparity in favor of male doctors is observable 22% compared to the 25% observed among female doctors."

It seems to us that 0% vs 25% is still a stronger tendency than 22% vs 25%.  This observation contributes to the proposition that male doctors might be more susceptible than their female counterparts."

As for the 2^nd point, we couldn't say that it is the case on all the measurements

Point 3

Finally the title. "are doctors really stronger than nursing staff?" feels deliberately provocative, which is often a good thing in a title, but for this reader it is a little puzzling. If the title is meant to reference what might be a popular belief that doctors are stronger than nurses, it's good to challenge that - but personally as someone who has worked for a long time within primary care teams (as neither a nurse nor a doctor), I doubt that many doctors or HCWs think doctors are "stronger" than nurses to begin with (they hold more power, can be more authoritative for better or worse, assert their opinions more...). If the title is meant to refer to the literature (which is well cited in the paper) that finds greater impacts of burnout, stress, etc. among nurses compared to doctors, then perhaps a more accurate title is "are doctors really less impacted by stress than nurses?" or "are doctors really less vulnerable than nurses?" Strength is a vague term.  

Response 3

Thanks again for this comment.

Just like your experience, we were quite surprised by the literature suggesting that healthcare workers (HCWs) tend to experience more symptoms than medical doctors (MDs). This is particularly interesting as we have worked in general hospitals (GHs) for over three decades, where we've observed that MDs display a significant reluctance to participate in various resilience and stress management seminars.

We took your advice and that of the editor into account, we have decided to change the title accordingly. COVID-19's Impact on Medical Staff Wellbeing: Investigating Trauma and Resilience in a Longitudinal Study. Are Doctors Truly Less Vulnerable Than Nurses?"

We are open to any further suggestion for this title

Point 4

As per your question about the distribution of MDs to HCWs

 table enclosed in the attached PDF and in the revised article

Response 4

It seems that the ratio was kept almost constant throughout the study.

Point 5

Comments on the Quality of English Language

The writing in the paper has been improved (and as an aside - many people whose first language is English write poorly, and others who have learned English write beautifully). The background section is easier to follow, although still a bit more of a "kitchen sink" approach to presenting the literature than weaving things together, but this is also matter of preferences to some extent. There are a few places where there are either minor grammatical errors or the sentences remain long and unwieldy (lines 25-26 of the abstract are not a sentence;

Response 5

We appreciate your efforts to help us formulate sentences in good English. We have also made an effort to incorporate your recommendations into our writing. While English is not our first language, as previously mentioned, we have engaged two language editors to ensure that we meet the required standards.

Thanks again

We are hopeful that the following represents a more improved attempt:

. lines 25-26

The study highlights doctors' vulnerability and underscores hospital management's key role in promoting effective support for professional quality of life. This is especially important for male doctors facing distinct well-being challenges.

other places needing a little attention are lines 372-375,

We reworded it as

The observed gender-based differences suggest that male healthcare workers (HCWs) perform better than other medical team members. Male doctors STS get worse over time, and a similar pattern is seen in Burnout. Though mindfulness T-3 indicates mixed results still male doctors don't report high level at that time.

505-507, we tried to rewrite it, hoping it is better phrased

During normal times distinct roles and procedures are observed between medical doctors and nursing staff. However, this demarcation became blurred during the management of COVID-19 patients. Whereas nursing staff are used to care and do routine nursing jobs, doctors found them-selves facing nonspecific care tasks very similar to the nursing staff, no heroic medicine, and a rather passive position of "wait and see".

517-520).  We are hopeful that the following represents a better attempt:

Nurses are often perceived as having lower status and less power compared to doctors in healthcare settings. This dynamic might lead nurses to develop a higher tolerance for ambiguity in their work. As a result, they may invest more in patient care and welfare, as reflected itself in the CS.

Author Response File: Author Response.pdf