COVID-19 Pandemic and the Residents’ Side of the Story: A Cross-sectional Survey Study

Background: Residency training programs have been impacted by the Coronavirus disease 2019 (COVID-19) pandemic. In this study we aim to investigate and evaluate the impact of the pandemic on residents as well as residency training programs. Methods: A survey of 43 questions was prepared on Google forms and distributed among residents at a tertiary center in North Jordan in the period between October 30th and November 8th of 2020. The survey included questions that addressed the impact of the pandemic on residents’ health as well as training programs. Our cohort was stratied according to the type of residency program (surgical residents (SRs) and non-surgical residents (NSRs)). Statistical methods included descriptive analysis, Chi-square or Fisher’s exact test, and Mann Whitney U test. A two-sided p-value of ≤ 0.05 was considered statistically signicant. Results: Out of 430 residents in the institute, 255 (59%) residents responded to the survey. Participation rate among SRs was 74% (121/164) compared with 50% among NSRs (134/266). A total of 17 (7%) of residents reported being infected with COVID-19 and a signicant difference was reported between SRs and NSRs (10% vs 4%, P = 0.048). Approximately, 106 (42%) reported a decrease in the number of staff working at the clinic and 164 (64%) reported limited access to personal protective equipment during the pandemic. NSRs were more likely to be trained to protect themselves and others against COVID-19 spread compared to SRs (57% vs 37% P= 0.002, 55% vs 41% p=0.026 respectively) Conclusion: impact COVID-19 the is very thus modify t their


Background
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been identi ed in December 2019 in Wuhan, China as the cause of a highly contagious disease mainly affecting the respiratory system known as the coronavirus disease 2019 (COVID-19) (1,2). The COVID-19 outbreak was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020 (3).
In Jordan, the Ministry of Health con rmed the rst COVID-19 case on March 2, 2020 (4). Upon con rming the rst case of COVID-19 in Jordan, the government enforced national measures to limit the spread of the infection starting with activating defense laws which were followed by imposing a national curfew on March 21, 2020, and on March 15, 2020 mandatory quarantine for air travelers was imposed before completely shutting down the airport on March 17, 2020. The number of con rmed cases in Jordan since the beginning of the pandemic is 234,353 con rmed cases and 2960 deaths as of December 5, 2020 (5, 6).
Following the spread of the disease, all academic institutions have suspended on-campus teaching programs and shifted toward distant learning programs. In this regard, clinical training programs for medical students and residents have been dramatically affected as they require hands-on interaction with patients which originally takes place in healthcare facilities; mainly hospitals. In a recent study carried out in Saudi Arabia, an 84.6% reduction in training activities was reported in residency training programs (7). In our hospital, King Abdullah University Hospital (KAUH) which is the academic center a liated with Jordan University of Science and Technology (JUST), the impact of the pandemic on residency training programs was further complicated due to the fact that KAUH was designated by the Jordanian Ministry of Health as the main center for treating COVID-19 patients and one of 7 centers performing PCR testing for suspected cases (8).
This in return, restricted the medical care provided by the hospital which was limited to only emergency admissions and major elective surgeries in the midst of COVID-19 cases surge in Jordan. Within these settings and as a result to the decrease in surgical and clinical practice, residents' training has been seriously affected. Evaluating and understanding this impact will de nitely aid in better assessment of the gains and losses of such modi ed residency programs adopted in light of the ongoing pandemic. In this questionnaire-based cross-sectional study we aimed to study and evaluate the impact of the COVID-19 pandemic on the residents as well as residency training programs at KAUH.

Study design and sampling:
This is a single institution cross-sectional study, in which a self-administered online-based questionnaire was sent to all residents (n = 430) at King Abdullah University Hospital (KAUH). A convenience sampling technique was utilized in this study, as the form was distributed online to all KAUH residents. The questionnaire was set on Google forms. The inclusion criteria included any resident in training at KAUH during the COVID-19 pandemic period starting from 1st March 2020 till the time of the study.
The participants were then strati ed into two groups, surgical residents group (SRs) which included ENT surgery, general surgery, neurosurgery, obstetrics & gynecology, ophthalmology, orthopedic, and urology residents, and a non-surgical residents group (NSRs) which included all other specialties.

Instrument Development And Data Collection:
The survey included 43 questions in English, investigating the impact of COVID-19 pandemic on residency training programs at KAUH in Irbid, Jordan. The questionnaire was initially validated by a group of experts to give their judgment about the clarity and comprehension of questions and evaluation of the survey structure. The questionnaire was piloted on 15 residents before a nal version was developed and approved.
Both closed and open-ended questions were included, of which 7 questions concerning resident's mental health had a four-point Likert format, and 4 questions that allowed more than one answer. Questions addressed demographic data, training details before and during the pandemic, impact of the pandemic on residents whether related to their residency programs or to the health-related burden of the pandemic. This burden was assessed in terms of both direct impacts as in disease contraction (in residents and their close relatives or contacts) or indirect impact as in resulting mental health effects of the pandemic (depression symptoms, stress, anxiety).
Data collection was done during a period of 10 days between October 30th and November 8th of 2020, a follow up reminder was sent after four and seven days.

Statistical analysis:
Descriptive measures for categorical data included counts and proportions (%). Likert-scale data were considered as ordinal and were assigned scores, starting with "Never = 0" and ending with "Always = 3", and thus were described as medians and IQRs. In addition, questions that allowed multiple answers were presented with bar charts as well.
Chi-square tests, or Fisher's exact tests if one cell count was less than 5, were used to analyze associations between categorical data. While Likert-scale data were analyzed using Mann Whitney U tests for differences in distributions, and effect sizes (r statistics) were calculated for signi cant p-values, considering (0.10 -<0.30) as small effect, (0.30 -< 0.50) as a medium effect, and (≥ 0.50) as a large effect.
A two-sided p-value of ≤ 0.05 was considered statistically signi cant. The internal consistency of Likerttype questions related to mental health was measured using Cronbach's alpha, and a minimum value of 0.7 was set as an acceptable level of reliability. All statistical analyses were calculated using Statistical Package for the Social Sciences (SPSS) version 26 (9). This study was done in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines (10).

Ethical Consideration:
This study was approved by Institutional Review Board (IRB) at Jordan University of Science and Technology (105/136/2020). In addition, informed consent was obtained from all participants.
B. The effect of the pandemic on the clinical settings and teaching programs: When comparing changes in the clinical settings between surgical and non-surgical programs, the proportion of NSRs reporting lock-down of the clinic sometimes was signi cantly higher than the SRs group (42.5% vs 26.4%, respectively; p = .007). Similarly, the proportion reporting a decrease in the staff working in the clinic (52.2% vs 29.8%; p < .001), the proportion reporting limited personal protective equipment (PPE) (71.6% vs 56.2%; p = .01), and the proportion reporting a delay in patients' visitation to the clinic or emergency department due to fear of getting infected (57.5% vs 39.7%; p = .005) was higher among non-surgical residents. A signi cant difference was also detected in the effect on the number of on-call duties per month (p < .0001), with the most common answer in both groups being a "no change" (50.7% and 64.5%, respectively), while the second most common answer was an "increase" for the NSRs group (35.8% vs 11.6%), and a "decrease" for the SRs group (24% vs 13.4%).
As for the effect on the teaching programs, the proportion of NSRs reporting a shift toward online learning was signi cantly higher than that of the SRs group (53% vs 30.1%; p < .001).
And nally, the proportion of NSRs reporting participating in nasopharyngeal swab sampling for patients was also signi cantly higher than that of the SRs group (67.1% vs 34.7%; p < .0001).
Comparisons are provided in Table 2, gure A and B.
C. The effect of the pandemic on residents' personal life and mental health: First of all, a signi cant difference in gender between the two groups was detected, with the NSRs group having a higher proportion of females (60% vs 43.8%; p = .016).
When comparing the effect of the pandemic on the personal life of residents between the both groups, the proportion of residents reporting getting infected by COVID-19 was signi cantly higher in the SRs group (9.9% vs 3.7%; p = .048). In addition, 113 (84%) residents in the NSRs group, and 98 (81%) residents in the SRs group reported a direct contact with COVID-19 cases. A statistically signi cant difference was found when they were asked about their relation to those infected people (patients, a co-worker, or both) (p = .020), with the most common answer in both groups being "both" (66.4% and 49%), while the second most common answer was "patients" (20.4% and 24.5%), and "co-workers" (26.5% and 13.3%).
When asked about being updated about this pandemic protocol, a signi cant difference was also found (p = .004), with the most common answer in the NSRs group being "yes" (59% vs 38% , and the most common answer in the SRs group being "Not always" (44.6% vs 30.6% ), while the remaining in both groups account for the "No" answer (10.4% vs 17.4%). In addition, the proportion of residents who reported being trained to protect themselves against the virus spread was signi cantly higher in the NSRs group (56.7% vs 37.2%; p = .002). Similarly, the proportion of residents who reported being trained to protect others against the virus spread (54.5% vs 40.5%; p = .026) was also signi cantly higher in the NSRs group.
Regarding the effect on the residents' mental health, when testing the internal consistency of the Likerttype questions addressing mental health, a Cronbach's alpha of .802 (Good) was found.
When asked about feeling anxious about the pandemic based on a 4-point Likert scale, the median was 2 (2-3 IQR) in the NSRs group, vs 2 (1-2 IQR) in the SRs group, and the distribution of the two groups differed signi cantly (p = .044), but on the other hand the effect size was found to be small (r = 0.13). In addition, the proportion of residents who reported feeling anxious about an inadequacy of protective equipment in the work area was signi cantly greater in the NSRs group (90.3% vs 75.2%; p = .001), as well as the proportion of residents who reported feeling increased stress and anxiety between colleagues being also signi cantly higher in the NSRs group (88.1% vs 76%; p = .012) As for the fear of getting infected, when asked on the 4-point Likert scale, the median was 2 (1-3 IQR) in the NSRs group, vs 2 (1-2 IQR) in the SRs group, and the distribution of the two groups differed signi cantly as well (p = .049), however the effect size was found to be small (r = 0.123) Comparisons are found in Table 3 and gure C.
D. Effect of the pandemic on the surgical training program: When SRs were asked about a reduction in the number of elective surgeries, 63 (52.1%) provided a positive answer.
In addition, in a multiple-selection question, 84 (69.4%) reported a decreased in the number of surgical cases they can participate and practice on, 43 (35.5%) reported a decrease in contact with the consultants, 62 (51.2%) reported a decrease in teaching sessions, and nally 16 (13.2%) had an answer of "none of the above". Results are presented in Figure D.

Discussion
This study presents a comprehensive insight on the burden of the ongoing COVID-19 pandemic on the residents' health and the work ow of residency training programs at a major tertiary hospital in North Jordan.
The results of this survey study indicate the crucial restraints the pandemic had on residency programs at KAUH. In this regard, the closure of outpatient clinics as well as the delay of most elective and non-urgent surgical and medical procedures had signi cantly reduced residents' clinical interaction. Farid et al. reported a 86.3% reduction in global surgical activity in a surgery department at Belgium (11).
On the other side, positive outcomes of the current crises are also worth mentioning and they include the implementation of effective distant learning methods such as online seminars, recorded or live-streamed didactic lectures as well as the introduction of telemedicine in a comforting and e cient method to the patients and healthcare providers. Overall, most of these online-based methods will transcend beyond the pandemic as they have proven to be effective time-e cient tools in education and in some instances in health-related services as well (12)(13)(14).
In order to further understand the effect of the current exceptional circumstances, our sample of 255 residents was strati ed according to the nature of the residency program; 121surgical residents (SRs) accounting for 47.4% and 134 non-surgical residents (NSRs) accounting for 52.6% as residents in surgical programs undergo a more hands-on approach in the day-to-day practice and it is established that COVID-19 is more likely to spread in close human interactions (15). When considering the effect of the pandemic on the clinical settings, "limited Personal Protective Equipment" was the most frequent complaint in our cohort followed by "the decrease in the number of staff working at the clinic". In both instances, NSRs more frequently reported these complaints (72% vs 56% and 52% vs 30%, respectively). This could be explained by the increased COVID-19 related workload on NSRs as they interact more with COVID-19 patients upon ICU or inpatient admission. This is further highlighted by the signi cantly increased number of on call duties per month as well as the participation in nasopharyngeal swab sampling for patients in the NSRs cohort relative to SRs.
In our cohort 48% of residents were trained on how to protect themselves against COVID-19 spread and 48% were trained on how to protect others, this is similar to what was reported in a similar Saudi study in which 43.8% of residents had enough training for the proper use of personal protective equipment (7).
This study also reported that 7 participants out of 240 (2.9%) responders were infected with COVID-19 which is lower than what we have reported (17 infected residents out of 255 responders (6.6%)). Yet, it is worth noting that the time span of both studies is different; Balhareth et al. collected responses in the period between April 23rd and May 6th 2020 and Saudi Arabia had a total of 31938 cases by May 6th 2020 whereas responses' collection in our study was done between October 30th and November 8th 2020 and Jordan had a total of 109321 cases by November 8th as there was a surge in cases in that period (5,7,16).
Interestingly in our cohort, SRs were infected by COVID-19 more frequently than NSRs (10% vs 4%, P = .048) which could appear to be counter intuitive for a moment since NSRs are more frequently to interact with COVID-19 patients. However, we believe the psychological aspect of cautious practice in this scenario plays a crucial role, since SRs could underestimate the importance of key protective measures due to out-of-place ease when interacting with surgical patients when in fact those patients need more caution since they can be asymptomatic or silent COVID-19 patients. This difference could also be explained by the higher percentage of NSRs being both "updated with the pandemic protocol" (Answered Yes: 59% vs 38%) and "trained on how to protect themselves against COVID-19 spread" (57% vs 37%, p = 0.002). This again highlights a potential worrying cascade of events that starts with the frontline involvement of COVID-19 care being non-surgical healthcare personnel and as a result surgery-related healthcare workers will be less updated and perhaps less aware of the essential protective measures.
The more active role of NSRs in our cohort is in return re ected on the mental status of residents, as NSRs have answered question number 20 "Being anxious about the pandemic" with "Always" more frequently than SRs (29% vs 18%)). In this regard, question number 22 "being anxious about an inadequacy of protective equipment in work " and question number 23 "Increased stress and anxiety between colleagues" con rm this conclusion, since a signi cant difference was observed in the percentage of (Yes) answers in both questions (90% vs 75%, p = 0.001 and 88% vs 76%, p = 0.012, respectively). Aljehani et al. reported a 50% rate of positive scores among general surgery residents in the screening tool of generalized anxiety disorder (GAD) during the current pandemic (17). Considering these alarming high percentages of stress and anxiety among residents speci cally and healthcare workers generally, increased institutional efforts should be invested in approaching this burden to avoid further exacerbation of this issue. Suggested measures to manage this problem include providing counseling sessions, anonymous crisis hotlines and holding seminars on effective stress coping mechanisms (18).
The main limitation in our study is the limited generalizability of the results due to the implementation of the study on a single tertiary hospital in the North of Jordan that was allocated to be one of a few COVID-19 testing and admission centers. National multi-center studies involving larger samples are still needed to con rm these ndings on a large scale. In addition, the study design based on data collection by an online survey questionnaire might contribute to response bias that could not be managed and controlled adequately.

Conclusion
The impact of COVID-19 pandemic on the work ow of residency training programs is very signi cant, and as a result program director should modify their programs to t residents' needs in the most appropriate way to maintain education without any compromise in their health status. In addition, residents and healthcare workers should be given a priority in any healthcare-related crisis as they are the rst line ghters in such exceptional circumstances.

Declarations
Ethics approval and consent to participate This study was approved by Institutional Review Board (IRB) at Jordan University of Science and Technology (105/136/2020). In addition, informed consent was obtained from all participants.

Consent for publication "Not applicable"
Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
"The authors declare that they have no competing interests" Funding none Authors' contributions All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave nal approval of the version to be published; and agree to be accountable for all aspects of the work    None of the above 41 (16) 19 (14) 22 (18) .385 P*: P-values were computed using the Mann Whitney U test. Figure 3 Other work-related effects of the pandemic Figure 4 Effect of the pandemic on surgical teaching program