|Year : 2020 | Volume
| Issue : 2 | Page : 90-97
Surgeons in training in the face of COVID-19 pandemic in the eastern province of Saudi Arabia: A cross sectional study tackling capabilities, opportunities, and motivation
Maryam Mozafarinia1, Nikki Ow2, Kedar K. V. Mate3, Magdalena Cordoba4, Haider Alyaseen5, Layla Ajasim5, Carlos Cordoba6
1 Division of Experimental Medicine, Faculty of Medicine, McGill University; Centre for Outcome Research and Evaluation (CORE), McGill University Health Centre Research Institute, Montreal, Canada
2 Centre for Outcome Research and Evaluation (CORE), McGill University Health Centre Research Institute; School of Physical and Occupational Therapy, McGill University, Montreal, Canada
3 Centre for Outcome Research and Evaluation (CORE), McGill University Health Centre Research Institute; Chronic Viral Illness Service, Division of Infectious Diseases, Family Medicine, McGill University, Montreal, Canada
4 School of Physical and Occupational Therapy, McGill University, Montreal, Canada
5 Department of Surgery, Almoosa Specialist Hospital, Eastern Province, Kingdom of Saudi Arabia
6 Department of Plastic Surgery, Almoosa Specialist Hospital, Eastern Province, Kingdom of Saudi Arabia
|Date of Submission||19-Aug-2020|
|Date of Decision||17-Oct-2020|
|Date of Acceptance||18-Oct-2020|
|Date of Web Publication||24-Feb-2021|
Ms. Maryam Mozafarinia
Division of Experimental Medicine, Faculty of Medicine, McGill University and Centre for Outcome Research and Evaluation, McGill University Health Centre Research Institute, 5252 De Maisonneuve, H4A 3S5 Montréal
Source of Support: None, Conflict of Interest: None
Background: Urgent safety measures and management protocols of COVID-19 are continuously being updated. Surgical residents, amongst other health-care professionals, need to modify their clinical practice both in and out of the operating room. Understanding and applying the communicated guidelines are crucial to limit the spread of the virus.
Objective: To estimate the extent of association between clinical behaviors and the recommended practice guidelines, issued by national and international health agencies, during the COVID-19 pandemic among surgical residents in the Eastern Province of Saudi Arabia.
Methods: A descriptive, cross-sectional study was conducted with 52 surgical residents training in affiliated teaching public and private hospitals. Correlations were conducted to estimate the associations between knowledge, perception, motivation, and surgical residents' clinical behavior. Further cluster analysis was conducted to identify groups of people with similar patterns of clinical behavior.
Results: The response rate was 52%. Surgical residents' behavior and their adherence to practice guidelines were varied and individualized. Nearly 50% lacked some fundamental bio-medical and disease specific knowledge. Despite demonstrating a fair knowledge on the transmission aspect of the disease, less than 60% agreed on ways of infection control and usefulness of personal protective equipment and nearly 50% did not endorse the use of facemasks and gloves. High levels of stress with respect to COVID-19 was reported by 63%; 58% were confident with their personal safety techniques, and 80% needed more information about the COVID-19.
Conclusion: The results suggest a collective action is needed at both the personal and institutional level to increase compliance with the recommended guidelines.
Keywords: Behavior change, COVID-19, knowledge, surgical residents
|How to cite this article:|
Mozafarinia M, Ow N, Mate KK, Cordoba M, Alyaseen H, Ajasim L, Cordoba C. Surgeons in training in the face of COVID-19 pandemic in the eastern province of Saudi Arabia: A cross sectional study tackling capabilities, opportunities, and motivation. Saudi Surg J 2020;8:90-7
|How to cite this URL:|
Mozafarinia M, Ow N, Mate KK, Cordoba M, Alyaseen H, Ajasim L, Cordoba C. Surgeons in training in the face of COVID-19 pandemic in the eastern province of Saudi Arabia: A cross sectional study tackling capabilities, opportunities, and motivation. Saudi Surg J [serial online] 2020 [cited 2021 Apr 15];8:90-7. Available from: https://www.saudisurgj.org/text.asp?2020/8/2/90/310120
| Introduction|| |
The first case of COVID-19 in Saudi Arabia was reported on March 2, 2020., Of date, the Kingdom of Saudi Arabia has had 178,504 positive cases. Information related to the virus, symptoms, precautions, and prevention has been updated frequently by global and governmental health agencies. On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic, pointing to the continued spread of the disease. Even prior to that, health-care systems around the world have been preparing their resources for a large anticipated influx of patients. Being a novel disease, information about its management and safety measures has been continuously updated on a daily basis reflecting the uncertainty surrounding the pandemic. The latest recommendations by international and national emergency organizations are shared with the general public and specifically health-care professionals through various channels such as mass media, hospital guidelines, and communications within specialties among others.
Health-care professionals, irrespective of their specialty and clinical practice, have the basic knowledge of infection control and prevention. Given the novelty of this virus and its mode of transmission, the need to provide up-to-date information and take prompt actions to minimize the risk of COVID-19 is critical., Surgical residents specifically have to increase their level of precaution practiced during their encounter with patients who may potentially be COVID-19 positive. In addition to keeping up with developing their surgical skills, surgical residents will have to modify their clinical practice both in and out of the operating room. This might compound the already-existing stress experienced during their training.
Research into various aspects of the COVID-19 pandemic is ongoing. One area of time-sensitive and relevant research is the perceptions and behaviors of surgeons in training related to the COVID-19 pandemic. Therefore, the objective of this study was to estimate the extent of association between clinical behaviors and the recommended practice guidelines, issued by national and international health agencies, during the COVID-19 pandemic, among surgical residents in the Eastern Province of Saudi Arabia.
| Methods|| |
This is a descriptive, cross-sectional study conducted from April 1, 2020, to April 15, 2020, in the Eastern Province of the Kingdom of Saudi Arabia. Surgical residents training in affiliated teaching public and private hospitals were eligible to participate. This survey was deployed through an Eastern Province surgery forum to 100 surgical residents. This forum is an online platform that connects Eastern Province surgical residents. The survey link was uploaded onto the forum page. Approval to conduct the survey was granted by the forum administration. The survey was designed using an online survey platform (zoho.com©) which allowed respondents to be anonymous. The study was approved as exempt by our institutional review board. The survey also included an electronic disclosure describing the study and highlighting voluntary participation. Consent was implied when respondents submitted the survey.
The survey tool used in this study was inspired by the COM-B model of behavior. The model stands for “Capability,” “Opportunity,” and “Motivation” as three fundamental components interacting together to form a “Behavior.” The COM-B model helps with analyzing behavior in a meaningful systematic way. It also helps understand the potential needs, barriers, or facilitators of a certain behavior. Each component of the COM-B model is further subdivided to include all sources of behavior. Finally, the model links a total of 14 theoretical domains to its component which provides a coherent framework for understanding a behavior at any level. The survey questions were selected from the literature available,,,,,,,, to match the C, O, and M aspects of the model. [Figure 1] presents the COM-B model with all its components and sub-divisions. The “Surgical residents and COVID-19” survey consisted of the following four main sections:
|Figure 1: COM-B model of behavior. The inner circle represents three fundamental interacting elements forming a behavior. Each element is sub-divided into two components. The outer layer links different theoretical domains to each component. The outer layer shown in solid black color shows the domains used in the survey tool of this study|
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- Section 1: Sociodemographic and professional information including age, gender, living status, residency year, and specialty
- Section 2: Knowledge about the current pandemic. The items covered various aspects of knowledge from fundamental bio-medical, to disease-specific, transmission, prevention, and clinical practice (34 items)
- Section 3: Perception of the opportunities afforded by the environment (e.g., resources) or interpersonal influences or social and cultural norms (7 items)
- Section 4: Motivation. These items aimed to provide an understanding of respondents' perception with regard to their capabilities and professional role as well as perception of risk and consequences of the COVID-19 pandemic (19 items).
Each item had one of the response options: binary (e.g., true or false, yes or no), multiple choice, and 5-point Likert type for example, strongly agree; agree; neutral; disagree; and strongly disagree.
To estimate the extent to which knowledge, perception, and motivation are associated with surgical residents' behavior, correlations were conducted between theoretically linked items within all domains. The items with binary responses were correlated using point-biserial correlations, for items with binary and ordinal responses rank-biserial correlations, and for items with ordinal responses, polychoric correlations with 95% confidence intervals (CI) were conducted. Redundant or irrelevant items were removed. A total of 51 items were retained. Items that represented the domains based on the magnitude of the correlation were selected. To identify groups of people with similar behavior patterns, further cluster analyses of responses on the domains were conducted.
Knowledge is a reflective composite, with items reflecting the construct. Responses to items in the knowledge domain are presented descriptively. In order to identify profiles of people with similar clinical practice patterns in the current COVID-19 environment, a total of seven items were identified from the pool of 34 items. Further correlations were also conducted on five items related to work habits.
| Results|| |
The survey was sent to 100 surgical residents with a 52% response rate. Respondents' characteristics are presented in [Table 1]. The sample was 40% women (n = 21) and 52% were married (n = 27). Around 75% of the residents were training in general surgery and over 60% were at residency level 1–4. Nearly 50% of survey respondents reported that their center was covering COVID-19 patients. Less than 40% were involved in the care of a COVID-19 patient (e.g., consultation, clinical exam, prescribing tests). Approximately 90% reported that workload was either the same or less than before COVID-19 pandemic for the region.
[Figure 2] is a treemap that presents the results for all the items grouped under the knowledge domain and proportion of correct and/or positive answers. For clarity purpose, sub-domains are color coded.
|Figure 2: Knowledge domain TreeMap breakdown by sub-domains. Each color represents one sub-domain and the size is a display of number of items within each sub-domain. Smaller rectangular cells in each sub-domain are items and their sizes represent the proportion of correct/positive answers. Pair-wise correlation (95% confidence intervals) conducted between modification of work habit and clinical practice items|
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Of the 5 items under this domain, two items had the lowest proportion of correct answers. Nearly 38% of respondents chose the correct definition of quarantine and 50% of the respondents were able to identify individuals at risk for COVID-19 correctly.
Of all domains, disease specific-A had the lowest score. Less than 50% of respondents answered all the questions correctly. Items with the lowest correct answer were the pathogen's name with only 27% correctly answering (i.e., severe acute respiratory syndrome coronavirus 2.), followed by type and strands of the virus and diseases involving coronavirus with 52% and 58% correct answers, respectively.
Items with the least correct answers were average onset of symptoms (23%), current treatment for COVID-19 (31%), and first action in the case of resuscitation of a COVID-19 patient (50%).
In general survey respondents had fairly good knowledge on transmission of the disease. Over 80% of the respondents answered all the items correctly except one – behaviors that most commonly lead to transmission of the COVID-19 virus, with 40% choosing the correct answer “coughing, sneezing, and talking.”
[Figure 3]a shows the resident' perception on personal protective equipment (PPE) and infection control measures. Around 50% of the respondents were able to report that they know all necessary steps needed to be taken in case they develop symptoms and are suspected of being COVID-19 positive. Approximately 31% of surgical residents responded correctly on the minimum duration of hand washing (i.e., 20 s). On the use of various precautions to prevent COVID-19 transmission, including PPE, washing hands with soap and water, and disinfecting surfaces, 40% of the respondents agreed with usefulness of all these measures in preventing and minimizing transmission rate.
|Figure 3: (a) Surgical residents' perception of usefulness of personal protective equipment and infection control measures in prevention of COVID-19 transmission. *Outer garments include gowns. (b) Motivation and perception domains TreeMap breakdown by sub-domains. Percentages in the cells represent proportion of respondents who were strongly agree/agree. For “stress with respect to COVID-19” under emotion, percentage represents moderate/extreme stress. For “likelihood of being asked to work” under social influences, percentage represents highly/likely|
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Nearly 80% of respondents reported changing their work habits within the last 3 months for fear of getting infected with COVID-19. This pattern was also reflected in responses to other items with over 90% reporting use of hand sanitizers and disinfectants more than before and taking special precautions at home to limit the possibility of spreading the virus to their family members. When taking history from patients, 63% of the surgical residents reported either always or often asking about patient's contact with COVID-19-positive individual. With regard to disinfecting the stethoscope and working surfaces more than half of the residents reported doing it always or often (63% and 52%, respectively). Modifying work habit as reported by almost 80% of respondents was only associated with more use of hand sanitizers (r = 0.58, 95% CI 0.05, 1.0) and did not resonate in other precautionary actions. A heatmap of the association between modified work habits and self-reported clinical behavior has been presented in footnote in [Figure 2].
Regarding resources, more than 70% of residents agreed that their centers would supply them with PPE and that the local and national health authorities can quickly provide information and updates for their safety at work. In line with this, nearly 70% were also strongly agree or agree that they could safely commute to work. In response to the likelihood of being asked to work during the pandemic, 60% of survey respondents perceived it highly likely or likely which concurs with respondents' perception of their resources [Figure 3]b. The main source of information for surgical residents in this study was national and global health bodies (80%), hospital or departments of their rotation (70%), and social media (40%). This puts a huge pressure on public health agencies to ensure that their messages are transmitted, learned, and applied correctly.
With respect to surgical residents' perception of their capabilities, 58% were either strongly confident or confident with their personal safety techniques and 80% reported they needed more information about COVID-19. On perception of roles, 68% agreed that their role was of importance in the overall pandemic response. On willingness to work if asked to but not required to, 68% reported they would return to work. Nearly 50% of the respondents expressed they are not psychologically prepared and 63% reported experiencing moderate to extreme stress. Almost 42% of the respondents also agreed that the pandemic could have a serious effect on their health. This is while more than 70% reported being willing to work if the pandemic worsens. Over 70% of the respondents agreed for the need for postevent psychological support [Figure 3]b.
| Discussion|| |
The overall goal of this descriptive study was to estimate the extent to which the clinical behavior of surgical residents is associated with the recommended practice guidelines issued by national and international health authorities during the COVID-19 pandemic, among surgical residents in the Eastern Province in the Kingdom of Saudi Arabia. Analysis of responses on clinical behavior showed that there were nearly as many combinations of responses as people. This suggested that surgical residents' clinical practice and their adherence with practice guidelines were highly varied and individualized. This is concerning as clinical practice behaviors on infection control should be uniform.
While over 70% of the residents perceived that PPE will be made available by their hospital, the overall agreement on ways of infection control and usefulness of PPE in the prevention of COVID-19 transmission was less than 60%, with nearly 40% and 50% not endorsing the use of facemasks and gloves, respectively, outside of the operating room. The results indicated that surgical residents have a knowledge gap with respect to some aspects of the COVID-19 pandemic. Inconsistency in knowledge was specifically related to infection control. This result is similar to other studies conducted in Saudi Arabia on health-care workers' knowledge of infection control practices.,,, In addition, almost half of the respondents reported lack of confidence in their capabilities, which was consistent with their reported need for more information. Despite reporting moderate-to-high levels of stress with respect to COVID-19 (63%), which could be due to their concerns of transmitting the virus to their families, the majority of surgical residents were willing to work in the event the pandemic worsened. This resonated in their understanding of their role as a health-care provider. These findings are consistent with prior works during the influenza pandemic, reporting high perceived risk yet low compliance with precautionary recommendations among physicians in training.,
In clinical settings, interactions between health-care providers and patients are an essential part of medicine. Standard precautions including hand hygiene and use of gloves as a first tier of infection control should be routinely practiced. Other forms of recommended PPE are used to decrease the transmission of communicable diseases as a second tier of infection control. In 2010, after experiencing the influenza pandemic, the Institute of Medicine published a comprehensive updated report on status of research on issues key to improving PPE for healthcare workers. The report emphasized that the existing knowledge is sufficient to recommend appropriate use of PPE to promote a strong safety culture in health-care settings. The issue of low adherence to PPE use needs a concerted move at individual and organizational levels. The use of multimodal interventions involving training and education, increased reminders, involvement of hospital leaders and staff, showed that hand hygiene compliance increased after intervention. Individually, residents (and all health-care providers for that matter) could spend more time educating themselves on the facts or reminding themselves of the forgotten information. Hospitals could disseminate information through communication by messages and continual medical education sessions on infection control. In addition, hospitals could evaluate knowledge of health-care professionals through quality assurance activities. Given the number of patients surgical residents might visit during their working hours through different departments, adherence to standard and transmission-based precautions is strongly recommended and should be followed by all.
A potential solution could be to revisit the current training objectives of the residency programs in Saudi Arabia. The implementation of pedagogic frameworks, such as Bloom's taxonomy will help to develop learning objectives. As described in Bloom's taxonomy learning is organized as a hierarchy from remembering, to understanding, applying, analyzing, and evaluating. At the same time, this hierarchical framework displays that the basis of actions and decisions in medicine is knowledge. Recalling correct information and comprehension of the knowledge is the foundation of diagnosis and treatment. When lacking facts at the bottom of this pyramid, it might not be possible to effectively move up to the next level. For instance, not knowing or recalling commonly reported clinical finding in patients with COVID-19, one cannot apply the proper actions. This might risk spreading the virus to others. [Figure 4] depicts examples of knowledge sub-domains questions mapped to Bloom's taxonomy.
|Figure 4: Knowledge sub-domains mapped to Bloom's taxonomy. STROBE Statement – checklist of items that should be included in reports of observational studies|
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The results of this survey suggest that all protective behavior components need to be in unison to work well. As supported by previous research, health-care providers' noncompliance behavior is often based on their own personal assessment of risk or when they are not convinced of a particular issue. Hence, clear communication is important more than ever with messages clearly stating, “what is asked and expected to be done.” Now, after 4 months of work on the management of the COVID-19 and with the development of test and contact tracing strategy, it seems feasible to move from lockdown to a more targeted strategy. This new strategy, however, is dependent on greater adherence to established guidelines.
Evaluation of the behavior depends on addressing all possible sources of influence. As described in the COM-B model, behavior change does not occur in isolation. Rather, it depends upon an interaction between three key components, capability, opportunity, and motivation, at personal, group, or population levels. In this study we tried to address all three components of behavioral change to obtain a wider range of information to further map out surgical residents' behavior in response to the COVID-19 pandemic. Findings of this study might help in directing future interventions to promote adherence to practice guidelines.
This study is not exempt of limitations. The survey was only active for a short period of time due to rapidly evolving information of the pandemic and was perceived as time consuming by surgical residents. It could be that the length of the survey caused cognitive fatigue and consequently affected the response burden., The survey results, however, do emphasize the importance of developing measures to increase compliance with recommended guidelines. It is of note that at the beginning of the study there were a total of 1700 cases of confirmed COVID-19 cases in Saudi Arabia. At the end of the 2-week period, on April 15, there was almost a 4-fold increase with 6400 positive cases. This was a cross-sectional study taken at one time point. It is possible that knowledge gap with regard to infection control was already present prior to the pandemic. Our study was only limited to surgical residents and was conducted in one province of Saudi Arabia and is not representative of the entire situation in the Kingdom. Further research with a bigger sample size including different specialties, centers, and provinces would provide a better understanding of the barriers and facilitators of adherence to the established practice guidelines.
| Conclusion|| |
In order to deal with this pandemic as safely as possible, it is important to pay more attention to how people behave, and health-care providers' behavior equally matters. In the case of COVID-19, medical knowledge is uncertain, and a lot remains to be learned which is very much dependent on a context-driven approach. Despite having a small sample, our findings, reflect on the importance of identifying and disseminating effective training strategies within medical departments specifically for doctors in training to improve knowledge and understanding of all possible factors contributing in reduction or augmentation of disease in populations. Comparing the results across different settings and countries could help in defining the most effective management model by studying what did and did not work. Reports such as our study is a small step informing the adequacy (or lack thereof) of standards of practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]