“It’s impossible to do it all”: a cross-sectional observational study of pediatric faculty parents during the COVID-19 pandemic

Introduction

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, physicians have faced a prolonged dilemma: how to simultaneously attend to the escalated needs of the clinical settings where they work, the patients they serve, and their own families. This dilemma has manifested for some physician parents as increased stress, altered work schedules and workforce dropout in order to meet family needs, especially among physician mothers (1,2).

Pediatric faculty parents have been expected to balance exposure risk to their own children with service to their pediatric patients and families; to provide childcare and schooling in addition to clinical, administrative and academic work; and even to redeploy to adult units during crisis care (3-5). With over 40% of early career pediatricians also being parents, the impact has been widespread (6). Further, due to pre-existing gender expectations for women to assume more childcare and household work responsibilities than men, pediatric faculty mothers may be especially vulnerable to increased parent load and physician burnout (7-11). Pediatrics employs the highest percentage of women compared to other specialties; as a result, a much more sizable portion of pediatricians, namely mothers, may have been deeply impacted by the pandemic (12).

Experiences of pediatrician parents during the COVID-19 pandemic remain largely undocumented in the scientific literature, so we designed a mixed methods explanatory survey study to capture lived experiences of this population. We hypothesized that (I) pediatric faculty parents would experience more workload challenges than non-parenting peers; and (II) pediatric faculty mothers would be burdened more than fathers. Then, we explored how they experienced these challenges, strategies used to address challenges and suggestions for change. We present the following article in accordance with the STROBE reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-43/rc).

Methods

Study design

This mixed methods cross-sectional survey study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was determined exempt from review by the Institutional Review Board of the Albert Einstein College of Medicine (2019-10971) and consent was considered implied upon completion of the survey. This study reports findings from closed and open-ended items designed and collected specifically for one timepoint of data collected within a larger parent study that used a serial cross-sectional design. The parent study was designed as a faculty engagement survey that examined work-life domains, faculty burnout, demographic and work profile data. Detailed study design, recruitment methods and measures of the parent study are reported elsewhere (13).

Survey administration

In September 2020, we emailed a survey invitation to all pediatric faculty at a large academic tertiary-care children’s hospital in one of the early COVID-19 epicenters in the United States. ‘Pediatric faculty’ included those ranked as instructor or above with a primary or affiliated appointment in the Department of Pediatrics. Self-report data were collected via an internet-based survey hosting system (MindGarden Inc.; Menlo Park, CA, USA). The survey was accessed through an email invitation with a unique participant identifier that expired following submission and automated scoring so individual records were untrackable and anonymous. Faculty were sent weekly reminders to voluntarily respond to the survey, for the duration of 1 month.

Measures

Quantitative: our independent variable of interest was ‘parent’ status, measured as “parent or caregiver of a child under 18 years old”. Covariates included gender, age, race, ethnicity, academic rank, commute time, full-time/part-time status and having provided care to COVID-19 patients. Our outcome, difficulty meeting work commitments due to family/personal life demands (DWC), had four response categories that were dichotomized for analysis based on a theoretical cut point: ‘not at all/rarely’ vs. ‘some of the time/a great deal of the time’. Verbatim survey items can be found in Table 1.

Qualitative: we then asked three open-ended questions to further explore DWC including challenges, attempted solutions and suggestions for the future (Table 1). These open-ended items were designed with input from an expert panel of 4 pediatric faculty, 6 faculty parents and 3 hospital administrators with expertise in workplace satisfaction and burnout. Since our outcome variable and open-ended items were new to this survey, the first author pre-tested them using cognitive interviewing techniques to minimize item response error and increase content and face validity (14).

Statistical analysis

We assessed bivariate associations between independent variables and the outcome, to identify potential confounding influence on the relationship between parent status and DWC, using Chi-square and Fisher’s exact tests. We then entered all variables that were significantly associated with the outcome into a multivariable logistic regression model. We also included gender in the model based on a theoretical rationale recognizing that gender is often a factor in the way parents balance family and work commitments (7,8,10,11). There were no missing data, due to required fields. We tested for multicollinearity in independent variables using correlation tests and variance inflation factors; none was identified.

Qualitative and mixed methods analysis

Qualitative: For parents only, we inductively coded responses to open-ended items, using qualitative thematic analysis techniques to first identify repeating ideas occurring across these three items, developing and applying a preliminary codebook, then developing higher order themes. We then segmented our data by gender to explore potential within-group patterns for mothers and fathers. For open-ended items with complete response data (see Table 1, items 3 & 4), we performed counts of theme presence.

Mixed methods: We used a sequential analytic approach, first identifying the relationship between parent status and DWC and potential differences by gender. Then we explored how different parents experienced these phenomena, moving back and forth between the quantitative and qualitative items to explore emergent findings.

Results

Of 275 total faculty emailed a survey, 113 responded, and 110 affirmatively identified as women or men (3 preferred not to answer). Our final sample (n=110) included 66% [73] women; 46% [51] were parents {69% [35] of whom were women}; 86% [95] worked full-time; 40% [44] reported elevated DWC (Table 2).

In bivariate analyses, parent status and being age 41–50 years (vs. all other age groups) were independently associated with elevated DWC. Among parents, 39% [20] were ≤ age 40; 43% [22] were age 41–50; 16% [8] were age 51–60; and 2% [1] were 61–80. Race/ethnicity, academic rank, employment status, commute time, nor having cared for COVID-19 patients were associated with DWC. In the regression model, adjusting for age and gender, parents had 5.48 higher odds of elevated DWC than non-parents (95% CI: 1.9–16.1), with no differences by gender (Table 2).

Parents also described the nature of the difficulties they faced, offering insights and suggestions for the future. Three main themes emerged from responses to the open-ended items: (illustrative quotes are presented in Table 3).

Challenges of new and expanded roles

The first theme was defined by pervasive acknowledgment of new and expanded family roles that caused significant challenges for faculty parents. Parents assumed additional roles as homeschool teachers, childcare providers, and stewards of family health, ultimately acknowledging “it’s impossible to do it all.” Concerns related to distribution of responsibilities and role equity emerged between co-parents as they attempted to redistribute family and work responsibilities. One mother stated “[I have a] partner with a demanding job—now I need to miss work if children are sick due to not having usual backups available.”

Variety of sources of support

The second theme highlighted a variety of sources of support that parents received. Parents valued both family- and work-based support to manage new and expanding roles. When we counted spontaneous mentions of family or work-based supports, a gendered pattern of support sources emerged: fathers primarily reported support from spouses or other family members, and mothers primarily reported support from co-workers, administrators and/or work-based policies. Professional child caregivers (i.e., a nanny or babysitter) were highly valued for offering dedicated support inside the safety of the family home but were only mentioned as an available resource by a minority of parents. Parents who were offered flexible work arrangements generally perceived this as an indicator that their hospital departmental and/or divisional leadership was supportive. Notably, all mentions of perceived leadership support were paired with flexibility having been granted to the participant.

Finding relief in flexible work arrangements

Parents highlighted administrative strategies that were helpful in navigating challenges both at home and work. Being given the option to work from home to complete charting or other administrative tasks; incorporating telehealth into patient care; and being granted autonomy over one’s schedule were all named as critical mechanisms for providing relief and for reducing difficulties managing work commitments. For those who worked from home, reduced commute time was noted as a benefit, acting as a time saver. Working from home was not entirely a positive experience however, with some highlighting an increase in parent load or a decrease in scholarly productivity as they attempted to handle multiple demands simultaneously. Despite difficulties, parents almost universally desired the continued availability of flexible work arrangements rather than going “back to normal.”

Discussion

Long before the COVID-19 pandemic arrived in the United States, physicians of all specialties struggled to find work-life balance and avoid burnout (15,16). Since the onset of the pandemic these struggles have intensified, leaving many exhausted, burned out and even leaving the field of medicine entirely (13,17). For pediatric faculty parents additional responsibilities during the pandemic felt “impossible” to manage, especially when responsibilities clashed (e.g., attempting to conduct homeschool and telehealth visits simultaneously). This phenomenon, as described by faculty parents, closely aligns with a sociological construct pre-dating our research called ‘role conflict’: defined as distress that occurs when an individual attempts to fill multiple and conflicting social roles (18).

As we hypothesized, parents were more likely to report difficulty meeting work commitments than non-parents (i.e., role conflict), although likelihood did not differ by parent gender. Additionally, an emergent pattern in our textual data suggested that faculty mothers and fathers may receive support to manage role conflict from different sources (e.g., family, work-based or professional sources), although this finding should be interpreted with caution since parents were not systematically queried about the range of support sources available. Further research is warranted to explore different manifestations of role conflict among faculty parents and to develop remediation strategies that are sensitive to gender (19-21). Regardless of parent gender, it is important for healthcare institutions to recognize that all faculty parents may experience elevated role conflict during and beyond the pandemic, as many work-family dynamics persist. In so doing, institutions can develop, highlight and make direct supports readily available to all-gender parents; in turn, helping non-parenting faculty by increasing capacity and engagement of their parenting peers (3).

Early in the pandemic, concerns for physicians focused on physical health and short-term wellbeing. However, longer term concerns, including worsening mental health and workforce dropout, have emerged at an alarming rate and are likely to continue with the rise of new variants, pandemic fatigue and emergent family health crises (22-24). Self-care has often been promoted in workplace wellness initiatives (25,26), yet healthcare organizations must be cautious not to over-prescribe individual solutions to structural level problems, especially in the case of working parents. In our study, faculty parents lauded institutional changes driven by the pandemic such as telehealth innovation and permission to work from home to complete non-clinical duties as being especially impactful to their ability to fill multiple roles.

When hospital leadership offered flexible work arrangements, parents perceived this institutional level support as helpful. This aligns with previous research showing that when working parents’ multiple roles are accommodated by work-domain resources (e.g., schedule autonomy), parents experienced less role conflict overall and perceived their organizations as more supportive (26-28). Parents did not want to lose this pandemic-inspired innovation to their work experience: something institutions will need to consider as we emerge from the pandemic. Simply “going back to normal,” (i.e., physical presence in the clinic even on non-clinical days) has the potential to negatively impact parents’ perceptions of the presence or lack of support from their institutional leadership. While ‘flexibility’ may be appreciated mainly for its logistical benefits, it may also be perceived as an investment in employees’ integrated well-being (29). The deeper meaning and value of workplace flexibility should be further explored within healthcare organizations, specifically among physician parents. Findings can inform feasible and acceptable policies, which may help to reduce role conflict and overall distress even beyond the COVID-19 pandemic.

Since we did not collect data about parents’ partners, our ability to understand gender dynamics or norms within relationships was limited. The low response rate, although typical in faculty surveys, does limit the generalizability of the findings. However, results are suggestive of important trends among working parents during the COVID-19 pandemic that have been documented in other professions (7,23,30). Additionally, although the demographics of the survey respondents and the faculty population were reportedly similar, the findings may be influenced by self-selection bias (13). We did identify that parents in their 40s experienced the highest levels of DWC, which may reflect having younger aged children, but the small sample size limited our ability to test an age-moderated model and the lack of data on child age made it impossible to explore this post hoc hypothesis. The small sample size may have introduced type II error, potentially obscuring a true association between gender and DWC. Longitudinal survey designs should aim for larger samples both to minimize possible type II error and to allow modeling of intersectional ways that minority race, ethnicity, sexual orientation, and a broader range of gender identities may account for variation in family and work roles over time.

Future qualitative research should expand on this preliminary understanding of role conflict among faculty parents to capture further context, depth and nuance of lived experiences, unconstrained by limitations of free-text analysis (31). Our study was limited to only pediatric faculty at a COVID-19 epicenter at one point in time and, as a result, future research with faculty in other specialties and regions will be important to understand if these findings are transferable to pediatric faculty and health systems in other urban contexts and over time. Further, comparative health systems research should include hospital administrators to provide broader context about decision-making motivation, policy changes and subsequent implications for workforce retention, well-being and other targeted outcomes.

Conclusions

With uncertainty around the length of the pandemic or its aftermath, it is likely that the impact on pediatric faculty parents and their employers will be sizable. Future phases of the pandemic experience, including its aftermath, may also impact children more severely academically and/or developmentally, requiring more time and involvement of pediatric care providers and consideration for flexible administrative expectations. In order to retain this valuable and large segment of the pediatric healthcare workforce, it will be critical to holistically support pediatric faculty who are also parents dealing with their own children’s needs, addressing the many roles they fill.

Acknowledgments

Funding: This work was supported in part by the Einstein-Rockefeller-CUNY Center for AIDS Research (P30-AI124414) which is supported by the following National Institutes of Health Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIMHD, NIGMS and NIDDK.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-43/rc

Data Sharing Statement: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-43/dss

Conflict of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-22-43/coif). MDC is a member of the United States Preventive Services Task Force (USPSTF). This manuscript does not necessarily represent the views of the USPSTF. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring the questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was exempted by the Institutional Review Board of Albert Einstein College of Medicine (2019-10971) and informed consent was considered implied upon completion of the survey.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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