In mid-January 2022, the community spread of the Omicron variant of SARS-COV-2 was detected within Aotearoa New Zealand.[[1]] Shortly after this, Te Toka Tumai Auckland Hospital enacted a hospital wide redeployment process during March and early April 2022. Eighteen resident medical officers (RMOs) were redeployed to assist with the acute medical services (emergency medicine and general medicine) within the adult emergency department (AED).

The aim of this report is to evaluate the RMOs’ experiences of being redeployed and identify areas for improvement using a feedback mechanism incorporating quantitative and qualitative data.

Methods

Participants

Eligible participants consisted of RMOs who were redeployed to acute medical services working in the AED within Te Toka Tumai Auckland Hospital. One of the 19 respondents, redeployed to general medicine, was excluded as they identified in their response they were exclusively redeployed to a different department. Of the nine eligible participants (50%) who engaged in the feedback process, 67% (six RMOs) were redeployed from the perioperative/anaesthetics department, 22% (two RMOs) from general medicine and specialty medicine departments and 11% (one RMO) from general surgery. Fifty-six percent (five RMOs) of respondents were registrars, 22% (two RMOs) were senior house officers, and 22% (two RMOs) were house officers. Sixty-seven percent (six RMOs) of eligible respondents were allocated to the emergency medicine service, and 33% (three RMOs) were allocated to the general medicine service within the adult emergency department for the purposes of redeployment.

Procedure/instrumentation

Eligible participants were identified by lists provided by the rostering team within the RMO Support Unit and the Chief Resident of perioperative medicine. Participants were emailed a link to a Microsoft Forms survey and advised that survey completion was anonymous and voluntary, and that completion of the survey would not impact current or future employment with the organisation. Individual staff responses were not able to be identified.

The report proposal was approved by the senior management team of Te Toka Tumai Auckland Hospital. The feedback survey was drafted de novo and modified after consultation with the Director of Emergency Medicine Research, the staff of the AED and other stakeholders including the Chief Medical Officer, the Clinical Director of the AED, the Director of Provider Services, the Director of Prevocational Training, and the Project Manager of Pathways and Outcomes.

As an anonymised, voluntary audit of redeployed staff to help understand how to improve the redeployment process, ethical approval was not required or sought.

Likert scales were used in the questionnaires ranging from positive to negative responses relating to six categories including overall redeployment experience, impact on relationship with emergency medicine and general medicine teams, understanding of the importance of efficient patient flow, impact on training and education, and willingness to assist in future redeployment.

The questionnaires also included free text questions based on positive and negative aspects of the redeployment experience, suggested improvements, and opportunity for general comments (Appendices 1 and 2).

Data analysis

Quantitative data analysis was performed using Microsoft Excel. The Likert scales were scored from 1 (very negative) to 5 (very positive) and mean scores with 95% confidence intervals (CIs) calculated. The qualitative data were categorised into themes and a thematic analysis was performed based on the standardised approach developed by Braun and Clarke.[[2]]

Results

Quantitative results

Overall experience

Five RMOs (56%) felt neutrally about the overall experience of being redeployed, while 44% (four RMOs) found the experience positive (33% very positive, 11% somewhat positive). Those RMOs redeployed to work with the emergency medicine service were more inclined to have a positive experience (with 67%, or four of the six RMOs, giving a very positive or somewhat positive response) compared to those allocated to general medicine (rated as neutral by 100% of this RMO subgroup).

Impact on relationship with the emergency medicine team

Six RMOs (67% of all respondents) reported their relationship with the adult emergency medicine team was impacted positively as a result of the redeployment process (five RMOs very positively, and one RMO somewhat positively). Three RMOs (33%) felt there was no impact. Of note, 83% (five out of six RMOs) of those who were redeployed to work specifically with the emergency medicine team felt the redeployment process had a very positive impact on their relationship with the emergency medicine team, whereas 67% (two out of three RMOs) from the subgroup redeployed to work with the general medicine team felt there was no impact made on their relationship with the emergency medicine team, and 33% (one RMO) felt there was a somewhat positive impact. There were similar results from this subgroup regarding the impact on their relationship with the general medicine team, with 67% (two RMOs) experiencing a somewhat positive impact, and 33% (one RMO) reporting no impact.

Impact on understanding of importance of efficient patient flow

Overall, 33% of the total respondents (three RMOs) identified that they gained somewhat more understanding of the importance of efficient patient flow as a result of the redeployment experience, and 67% (six RMOs) reported no difference. The responses between the two RMO subgroups were similar.

Impact on training

Overall, RMOs mostly reported a negative or neutral impact on training as a result of the redeployment process with 44% of the total respondents scoring somewhat negatively (three RMOs working in anaesthetics and one RMO working in general medicine pre-deployment), 33% (three RMOs) reporting no impact on training and 22% (two RMOs) reporting a very positive impact on training. It is unclear to what extent cancellation of elective surgeries contributed to the negative experiences of the RMOs redeployed from anaesthetics. The RMOs who reported a very positive impact on training were redeployed to work with the emergency medicine team.

Impact on general learning and education

The majority of overall RMOs (56%, five RMOs) reported no impact on their general learning and education, 33% (three RMOs) felt there was either a very positive or somewhat positive impact, and 11% (one RMO) identified a somewhat negative impact on their general learning and education as a result of redeployment. More RMOs who were redeployed to work with the emergency medicine team reported either a very positive or somewhat positive impact on general learning and education (50%, three out of six RMOs) compared with the subgroup of RMOs allocated to work with the general medicine team (0%).

Willingness to assist with the adult emergency department in future crisis situations

Overall, 56% (five RMOs) indicated they would be very or somewhat willing to assist with redeployment should a future need arise, 33% (three RMOs) provided a neutral response and 11% (one RMO) felt somewhat not willing.

Qualitative results

The qualitative data are represented in Table 2.

Qualitative data were categorised by positive and negative aspects of the redeployment processes, and areas for improvement with subthemes in each of these three categories.

Themes within the positive aspects of redeployment included: feeling welcomed, feeling appreciated, resource provision, enhancement of clinical skills and knowledge, insight into other services’ workloads, and balance with non-ED work.

Themes within the negative aspects of redeployment included: impact on training, disruption to usual routine, witnessed doctor–patient interactions, high acuity/service demands, under-utilisation of clinical skills/scope of practice, and lack of familiarity/orientation to environment and role.

Themes within areas for improvement included: RMO input into the redeployment process, resource provision/orientation, and communication.

Positive aspects of the redeployment process

The RMO group who was redeployed to work with the emergency medicine team provided feedback in subthemes of feeling welcomed and appreciated (including: “Great team, welcoming environment”; “The team were all very supportive and approachable”; and “SMO very appreciative of the help, enjoyed working with the team”). Both RMO groups gave feedback that referenced the subtheme of enhancement of clinical skills and knowledge (for example “there was a good variety of cases. Opportunities to practice procedural skills”, “refreshed some clinical knowledge” and “Opportunity to learn some general medicine and clerk patients in”). One of the RMOs allocated to the emergency medicine team fedback about resource provision (“I was emailed an orientation document (don’t know how widely it was distributed but it definitely helped for door codes)”). The subtheme of balance with non-emergency department work was identified with the feedback: “I liked how it was only 2 shifts a week with the rest of my time in anaesthesia as opposed to a full week of it”.

The feedback highlights the importance of a welcoming and appreciative attitude towards external staff in contributing to their redeployment experience being perceived as positive, and the educational opportunities to redeployed RMOs. The feedback about part time redeployment to the emergency department being a positive aspect is valuable for planning future redeployment rosters.

Negative aspects of the redeployment process

The most commonly reported negative experience related to impact on training time including “loss of training time”, “interrupted anaesthetics placement” and “missing out on opportunities in theatre/anaesthetics”. This feedback was raised equally in both RMO groups.

Other subthemes from negative feedback included disruption to usual routine (such as “interrupted work/life by changing roster at last minute”); underutilisation of clinical skills/scope of practice (including “often being used as a means to putting IVL that were not challenging”); the acuity of the ED (“busy environment”); witnessed doctor-patient interactions (“not isolated to ED, but it was disappointing to hear/see some members of senior staff struggling to accomodate the basic needs of our trans community, e.g., incorrect pronoun use, casting assumptions, speaking openly in an unkind manner about frequent presenters”); and lack of familiarity/orientation to environment and role (such as “minimal orientation to how the general medicine admitting service functions”).

These data provide helpful information on how to enhance the experience should there be a future requirement for redeployment, especially in relation to providing effective orientation and resources for staff who are new to an area or specialty. The negative commentary relating to witnessed doctor–patient interactions serves as a reminder of the importance of upholding professionalism, compassion and appropriate rolemodelling.

Areas for improvement in the redeployment process

Resource provision and orientation was another main subtheme in the category of areas for improvement and was raised by both RMO groups. Examples include “every service should have a redeployment orientation one pager”, and “orientation to how the departments functions and useful documents pertaining to work in AED”. One RMO provided a suggestion to have RMO input into the redeployment process (“ask staff if they’re willing to volunteer before forcing redeployment”).

Feedback in the subtheme of communication was provided, such as:

“I wish there was on central person that we could have liaised with about the whole redeployment process. Someone that was connected to the appropriate senior leadership within each affected department. Because the communication in general was frankly awful ... patchy at best, radio silent at worst … I think the actual coordination should be overseen by e.g., one of the educational fellows who is trusted and known to the RMOs. Also, zoom meetings in the middle of the work day are a pretty inconvenient way of trying to disseminate information. Emails or brief phone calls are probably better.”

From this data, it would appear there is value in developing resources to assist with orientation of redeployed staff, including an outline of how a service works during a period of redeployment, who to report to, expected scope of practice, and relevant hints and tips. This may enhance both efficiency in work and staff satisfaction/wellbeing.

View Tables 1–2.

Discussion

All of the RMOs responding to the survey either felt positively or neutrally about the redeployment experience and over half reported that they would willing to assist the AED should a crisis recur in the future. Staff related factors were highlighted as contributing to positive experiences in both the quantitative and qualitative data, with the latter focusing on a sense of being welcomed and appreciated. Both RMO groups positively highlighted the opportunity to enhance their clinical skills and knowledge through exposure to working in the ED.

There are a number of prior studies exploring the impact of the COVID-19 pandemic on junior doctor training, mostly involving surgical trainees. However, the specific impact of redeployment over general impact of the pandemic such as reduction of elective surgeries and reduced hands-on clinical teaching, was not often clarified in these studies. A scoping review of the impact of the pandemic on junior doctor education and training found eight studies mentioning redeployment, with around a quarter of junior doctors being redeployed (range 1–35%).[[3]] Although the majority of trainees reported negative impacts of the pandemic on training, the impact of redeployment was only specifically mentioned in one of the included studies.[[4]] In that study of 756 surgical residents, 112 had been redeployed (2/3 to a non-surgical specialty). Approximately half of the redeployed residents believed the redeployment had a positive impact on training while a third believed the impact was negative, the remainder being neutral.[[4]] The varying impacts of redeployment on training was also found in a study of orthopaedic trainees, which reported an even split between positive and negative experiences. Half of the respondents reported receiving no training or orientation in the new area and one trainee was not comfortable running a minor injuries unit without supervision, while another reported a good experience under a welcoming medical team.[[5]] Another survey of 60 junior doctors in training found that the 30% who were redeployed (mostly to general medicine or critical care) all had direct consultant supervision and were more likely to believe that their clinical skills, knowledge base and patient engagement were positively impacted than those who were not redeployed. Surgical skills training was impacted negatively in both groups, but more so in the redeployed group in that study.[[6]] A consistent theme in studies exploring junior doctor experience with redeployment is that being redeployed creates stress and anxiety in the redeployed staff, which can be lessened by adequate supervision, good communication, support and a welcoming attitude by the receiving department—this is consistent with our findings.[[7–8]]

• Based on our findings and those reported in prior literature, there are several concepts that may enhance a future redeployment process, namely:

Providing RMOs with a standardised orientation document outlining expectations of clinical work and scope of practice in a redeployed position as well as departmental aspects (such as access codes).

• Creating a resource to provide redeployed RMOs outlining general processes within a service, and hints and tips on how to achieve common work tasks within a particular service (a “cheat sheet”). Of note, there is a hospital-wide orientation handbook for interns (postgraduate year one and two doctors) provided at the beginning of each year which outlines the main components and tasks of working in each specialty (including emergency medicine). It is unknown whether this was provided to redeployed RMOs.

• Rostering RMOs to part time redeployment, with a limited number of shifts per week. This would allow for some ongoing exposure and consistency with usual clinical work and would lessen the impact on training.

• Involving RMOs in the redeployment planning process and seeking their agreement to redeployment in the first instance.

• Identifying a key staff member to act as a communication liaison between the redeployed RMOs and departments. Feedback indicated a preference for email and phone-based communication, as opposed to via Zoom updates.

• Given several RMOs reflected positively about the exposure to the type of patient cases and workload in the adult ED, this could be highlighted in advertising for future redeployment recruitment processes

Limitations

As a single site survey with a limited number of potential respondents generalising our findings may be problematic, although our response rate was relatively high for such a survey. Given there was no comparison group of trainees who were not redeployed at the time of the survey, the impact of redeployment vs the impact of the overall pandemic response on trainees’ beliefs about their training could not be determined. The small sample size limited the quantitative analysis to descriptive only.

Conclusion

The redeployment process used had both positive and negative impacts on the training of redeployed RMOs. Their experiences provide useful data to inform any future plans for redeployment in response to staffing and workload crises within Te Whatu Ora – Health New Zealand hospitals and have the potential to improve RMO training generally.