In the study, 7 categories of analysis were identified, and 7 recommendations were prioritized in a participatory action research process.
Thetraining program for family medicine and nursing residents is largely based on progressively acquiring competencies and responsibilities, practicing medicine or nursing with full supervision initially, and decreasing supervision as the residency progresses [35,36]. During the early stages of the pandemic, this supervision was quite affected due to the exceptional nature of the situation. Like other healthcare professionals, they had not experienced such a complex professional situation before, but in their case, it was compounded by their limited previous professional experience before the pandemic and within the context of a training process. This was more pronounced for residents in their first two years of specialty training. The supervision and mentoring of residents has been a topic that reflects a great variability among different environments and professional profiles, with nursing residents generally feeling more supported. Regarding medical residents, there is a higher level of supervision by their tutors in the primary care setting compared to hospital tutors, although this has also depended on therespective hospital. This contrasts with findings from another study in the United States, where most residents reported feeling adequately supervised [44]. The lack of supervision, although a common complaint among medical residents, was likely exacerbated not only by the overload of the entire healthcare system but also by a "disconnect" between educators and medical and nursing residents due to high staff turnover in all services.
One of the most unfavourable conditions identified included insecurity in the professional role when working on the front line and the fear of the situation and managing uncertainty. Unlike previous epidemics such as Ebola, where trainee professionals were removed from the front line [45], this was not the case in this instance, medical and nursing residents were frontline workers.As they were generally young and healthy, they were at a lower risk of developing a severe illness in case of infection. The need for personnel redistribution in areas with high demand and staff shortages due to the increasing number of patients and infections among healthcare workers [46] led to many medical and nursing residents being reassigned to other services during critical moments of the pandemic [47,48]. This reassignment to different services affected family and community medicine residents more than other specialties because of their more transversal and multidisciplinary training, allowing them to perform professionally in primary care centers, hospitals, and out-of-hospital.emergency services. All of this was associated with an increase in work hours, which resulted in less time dedicated to specialty training, similar to what has been described in other studies [47,49, 50], but other studies conducted in the United States reported a decrease in face-to-face working hours in some specialties [51], which in some cases was partially compensated by an increase in the number of hours worked from home [52].
During the early waves of the pandemic, learning environments were severely affected and deteriorated, consistent with findings from studies conducted in Spain and other countries in our region [47,48,53,54]. In the USA and the European Union, significantly less time was spent in hospitals, clinics, and operating rooms. In our study, it was the opposite, residents remained on the front lines both in hospitals and primary care for more hours, unlike other residents who spent more time using telemedicine, worked from home during the pandemic, and were able to dedicate time to research projects, educational conferences, non-medical hobbies, and reading The proximity to the population and providing home care also made them, along with their supervisors, witnesses to situations of social vulnerability that were accentuated during the pandemic [54].
Virtual care has been another key point in the process. Virtual care is a work method that residents in medicine and nursing, as well as experienced professionals, were not accustomed to in general, and there were no competencies regarding it in the training programs of residents in medicine and nursing [55,56]. Up until the pandemic, the training of residents in medicine and nursing in clinical encounters and communication skills had been focused on acquiring abilities for in-person care in various healthcare settings.
Additionally, this change led, similar to what has been described in other studies, to a limitation or disappearance of physical examinations, substantially reducing the capacity for learning and teaching. Similarly, the time constraints imposed by virtual modalities translated into fewer teaching moments for residents [57]. This wasworsened by the fact that the patient profile primarily consisted of respiratory cases infected with COVID-19, as described in the "COVID-19 Monograph" category, which limited their learning opportunities. While some studies have investigated the perspectives of patients and providers during the transition to virtual care, few have explored the impact of virtual care on the education of medical and nursing residents [58,59].
Besides changing the way outpatient healthcare was delivered, virtual care also altered how tutors and educators teach, and modified the learning experiences of medical and nursing residents [60]. Regarding virtual education, the findings in our study align with other research; overall, online education has been viewed as a positive tool by medical and nursing students and residents [61–63]. Regarding the negative aspects of online education, our results identified a lack of interaction in the learning process with the group of peers and the perception that virtual activities did not match the educational experience of hands-on learning in some areas. A similar sentiment is captured in the study by Kunaviktikul et al: 'But nobody answered, all silent... This is very different from when we were physically [in class], as everyone was very active in participating... I could see their expressions... I feel lonely...' [31]. Distance learning requires technological skills from both students and faculty, as well as adaptation to individual learning needs [63], aspects that were not fully implemented in many cases at the start of the pandemic."
During times of organizational chaos and continuous change, complaints tend to be directed at the top of the hierarchy for their inability to adapt quickly (64). Meanwhile, colleagues in closer proximity emerge as support and reference figures, with micro-organization among them being a structure with greater capacity to adapt to the new real needs of daily practice.
The pre-pandemic discontent with their working conditions was exacerbated by the pandemic, leading to a significant surge in advocacy and demands. For family medicine and nursing residents, their dissatisfaction cannot be separated from the weakened state of primary care in Spain, which has structural problems that were exacerbated and highlighted during the pandemic [53].
Focusing on the proposed recommendations made by the participants, two groups can be identified. The first group primarily concerns with the pandemic, emphasizing the need to participate in exceptional situations like the one experienced, planning work, and decision-making through their representatives, establishing specific competencies according to the year of residency, and compensating for lost training.Recommendations from the second group go beyond the context of the pandemic. These include improvements in spaces and safety conditions for face-to-face training complemented with virtual training; ensuring direct supervision especially in the early years; reducing the workload of tutors so they can devote more time and resources to resident training ; monitoring compliance with the agreed labor conditions after the strike; and promoting the implementation of training, research, and community health activities during working hours."
Strengths and limitations
The Photovoice technique has allowed residents of family and community medicine and nursing to be protagonists in a participatory process. The Photovoice methodology relies on the researcher's analysis and interpretation; however, in addition to being widely used to characterize the urban environment and citizen perception, it has also been an excellent tool for exploring the perception of healthcare professionals about providing care to different population groups (41,65,66). This technique allowed them to metaphorically represent what had the most significance for them. It guided researchers on which aspects are more relevant from the participants' perspective. Their debates and analysis around the impact of the pandemic on their training generated a set of recommendations to improve training aspects and potential deficits in the future. We consider that the use of photographs has been an advantage to evoke deeper elements of the lived experience and to help unlock memories that would have been more difficult to verbalize. This strength of the technique has been analyzed in comparison with word analysis or narratives (67).
In our study, conducting a participatory diagnosis has allowed us to inform decision-makers in training and healthcare planning about the recommendations developed. In addition to generating new knowledge, the participating medical and nursing residents have experienced a more enriching process of reflection and learning by sharing their experiences with others. Simultaneously, it has provided an opportunity to share experiences and stories, which has had a therapeutic effect.
The generalization of the results from our study is limited to environments that share a similar training program and healthcare system model as in Spain. The majority participation of women in the study could be considered a bias, although it is quite consistent with widely feminized professions.