This study aimed to gain insight into the adaptive performance and intraPC learning of residents during the COVID-19 pandemic. The first wave of the pandemic was characterized by a collective uncertainty among all doctors involved and a high level of social cohesion and a sense of safety on COVID and ICU wards. The collective uncertainty forced supervisors and residents to adapt as they had to find solutions and create an overview within an unpredictable crisis situation. The experience of being able to adapt to uncertain, changing circumstances appeared to increase the residents’ self-confidence. The combination of collective uncertainty, a high level of social cohesion and a sense of safety, and the presence of doctors from different disciplines within COVID departments also promoted residents’ intraPC learning. Though this was not always the matter of course: due to the scope of the crisis and the huge numbers of new patients, it was sometimes difficult to collaborate with other doctors and learn from them.
Our study showed that the urgency of caring for extremely ill patients with an unknown disease created collective uncertainty and prompted supervisors and residents to adapt. This is in line with prior studies which have shown that adaptability is characterized by coping with stressful situations or emergencies and dealing with uncertainty and changing circumstances [21, 22]. In the first wave, residents working on COVID or ICU departments faced stressful, uncertain circumstances and provided care to large numbers of COVID patients within a limited time span. This turned out to be conducive to their learning process. The residents’ adaptive expertise appeared to be particularly stimulated by their growing domain-specific knowledge of COVID-19, the task complexity involved in COVID care, and their working with supportive colleagues who stimulated team learning, which is in line with earlier studies [9, 11].
In the subsequent waves, more knowledge of how to manage the disease had become available, and working practices had been laid down into protocols. After the first wave, therefore, doctors worked in COVID care with increasing efficiency, turning COVID care into a routine task. Working towards mastering COVID care by performing all necessary actions to the best of their ability and becoming “routine experts in covid care” appears to be beneficial for residents in the short term because this pushes them to perform with the greatest efficiency and effectiveness. In the longer term, however, when the innovation dimension was excluded or undervalued, opportunities for developing adaptive expertise reduced [9]. In addition, our results showed that, after the first wave, the large flow of patients and especially the performance of what had now become routine tasks appears to have led to a decreased motivation to work in the COVID department and no longer appealed to the adaptability. This supports previous research [23].
The collective uncertainty among first-wave doctors not only promoted adaptability but also contributed to intraPC learning. Previous research has shown that there are many barriers to intraPC learning, such as a high level of hierarchy in the workplace, lack of awareness of intraPC learning opportunities, and unidirectional learning [24, 25]. The presence of different disciplines in one location, therefore, does not necessarily result in intraPC learning [24]. Our research showed, however, that the presence of different disciplines in one COVID /ICU department led to lower thresholds to collaboration and encouraged residents to consult intraprofessional colleagues, both during and after the first wave.
We found two possible explanations for this. One possible explanation is that the combination of collective uncertainty, psychological proximity, and an extraordinary degree of social cohesion during work in the same department in a pandemic crisis stimulates cross-boundary teaming [26]. Our study shows that this creates a strong team spirit, which positively influences interpersonal relationships. IntraPC turned out to have improved after the pandemic, with respondents reporting that their thresholds for initiating interactions with intraprofessional colleagues, with whom they had worked with in the same COVID /ICU department, decreased once they had returned to their own workplaces. This could foster future intraPC learning.
Another possible explanation could be the occurrence of constructive power dynamics in COVID departments. Power dynamics describe “the way in which power impacts the interaction of two or more people or groups” [25, 27] and can either have an constructive or nonconstructive manifestation and, consequently, a corrosive or conducive effect on intraPC learning [25]. Our study shows that different constructive power dynamics were at work in COVID/ICU departments, such as everyone’s shared lack of knowledge of COVID-19, the distribution of roles and responsibilities based on equity without any inter-discipline supremacy, sincere and equal collaboration, and everyone’s accessibility for consultation. Positive power dynamics are a major contributor to a culture of sincere equal intraPC. However, our research also showed that intraPC learning could be limited by the high workload and various practical limitations.
Most COVID /ICU departments in the first wave were considered a safe psychological working and learning environment, which promoted both the adaptability and the intraPC learning of residents. Previous research already showed that a supportive learning climate affects learners’ motivation, self-confidence, and overall moral and academic achievements [28–30]. Our study shows that the perceived psychological safety was facilitated by the proximity of supervisors in two ways: physical proximity and, more importantly, psychological proximity. Physical proximity occurred because most supervisors were available on site rather than on call, and psychological proximity occurred because supervisors repeatedly instructed residents to approach them with questions and were explicitly transparent about their own clinical uncertainty regarding COVID patient cases.
Such psychological proximity bridges the hierarchical gap between residents and supervisors and influences the residents’ perception of clinical uncertainty. Although recognizing and coping with clinical uncertainty is part of the doctors’ job, being able to accept and deal with uncertainty is something many find challenging [31]. Mutual trust and psychological proximity can make it easier for residents to stretch themselves beyond their comfort zone. The pandemic “forced” supervisors to show themselves to be vulnerable by admitting that they were uncertain as well and did not have all the answers. Residents appreciated this vulnerability, as it confirmed to them that it was okay to feel uncertain and to ask questions. Prior research confirms that supervisors' willingness to engage collegially with residents and disclose their own vulnerabilities leads to enhanced mutual trust, which fosters learning [32]. As most postgraduate training programs consist of short rotations, in which opportunities for developing supervisor-trainee trust relations are scarce, it is recommended to explore ways to foster a culture of trust [32]. Our study provides a valuable complement by providing implications for practice, based on learning during COVID, for learning during postgraduate training in non-crisis settings.
Implications for practice
In facilitating the enhancement of adaptability and intraPC learning during postgraduate training, we believe the following ideas might be helpful.
First, create a safe learning environment by investing in social cohesion and team spirit, being easily approachable to other disciplines, and responding respectfully to questions. Show the human factor and stimulate the dialogue.
Second, create a culture in which everyone can express themselves freely and in which supervisors can express clinical uncertainty, for example, by being transparent, open, vulnerable, and honest.
Third, deliberately apply two modes of supervisor proximity: physical proximity and psychological proximity. Be close and accessible to residents as a supervisor. Listen to their questions and also encourage them to find their own solutions, perhaps with their intraprofessional colleagues.
Fourth, proactively change perspectives. Put yourself in the shoes of another discipline or role by switching positions (your discipline and another one, or as a resident and as a supervisor) and experience and learn from each other’s perspective by working in each other’s role.
Fifth, learn from uncertainty. Train your flexibility and adaptability, by doing new things, by simulating situations with many uncertainties in which supervisors and residents learn together in situations where protocols and guidelines could not be applied, or by participating in parts of the care process with which you are unfamiliar.
Strengths and limitations
A strength of this study is its three types of triangulation: a) data source triangulation: triangulation in perspectives on the residents’ learning was established by interviewing residents, supervisors, and guest doctors; b) investigator triangulation: all interviews and the coding process were performed by two researchers, thus combining two perspectives to generate a thorough analysis; and c) research group triangulation: our research was conducted in a multidisciplinary team, with the different professional knowledge domains and backgrounds operating as a form of triangulation [17].
A limitation of our research might be the time gap between when care was provided during the pandemic and when the interviews were held: some respondents were interviewed in December 2020, while the first COVID wave started in March and ended in May 2020. This may have resulted in recall bias and incomplete respondents’ stories. The scale of the pandemic, however, made it impossible to conduct interviews earlier on.