Experiences of a Health System’s Faculty, Staff, and Trainees’ Career Development, Work Culture, and Childcare Needs During the COVID-19 Pandemic

Key Points

Question  What are the associations of the COVID-19 pandemic with career development and what are the work culture and childcare needs of employees and trainees?

Findings  In this survey study, most participants with children did not have childcare fully available and many considered leaving the workforce and were worried about their career. Being female with children or having a clinical job role was associated with consideration for leaving the workforce and reducing hours.

Meaning  These findings suggest that a substantial number of employees and trainees experienced major stress and work disruptions because of the COVID-19 pandemic.

Importance  In March 2020, US public buildings (including schools) were shut down because of the COVID-19 pandemic, and 42% of US workers resumed their employment duties from home. Some shutdowns remain in place, yet the extent of the needs of US working parents is largely unknown.

Objective  To identify and address the career development, work culture, and childcare needs of faculty, staff, and trainees at an academic medical center during a pandemic.

Design, Setting, and Participants  For this survey study, between August 5 and August 20, 2020, a Qualtrics survey was emailed to all faculty, staff, and trainees at University of Utah Health, an academic health care system that includes multiple hospitals, community clinics, and specialty centers. Participants included 27 700 University of Utah Health faculty, staff, and trainees who received a survey invitation. Data analysis was performed from August to November 2020.

Main Outcomes and Measures  Primary outcomes included experiences of COVID-19 and their associations with career development, work culture, and childcare needs.

Results  A total of 5030 participants completed the entire survey (mean [SD] age, 40 [12] years); 3738 (75%) were women; 4306 (86%) were White or European American; 561 (11%) were Latino or Latina (of any race), Black or African American, American Indian, Alaska Native, and Native Hawaiian or Pacific Islander; and 301 (6%) were Asian or Asian American. Of the participants, 2545 (51%) reported having clinical responsibilities, 2412 (48%) had at least 1 child aged 18 years or younger, 3316 (66%) were staff, 791 (16%) were faculty, and 640 (13%) were trainees. Nearly one-half of parents reported that parenting (1148 participants [49%]) and managing virtual education for children (1171 participants [50%]) were stressors. Across all participants, 1061 (21%) considered leaving the workforce, and 1505 (30%) considered reducing hours. Four hundred forty-nine faculty (55%) and 397 trainees (60%) perceived decreased productivity, and 2334 participants (47%) were worried about COVID-19 impacting their career development, with 421 trainees (64%) being highly concerned.

Conclusions and Relevance  In this survey of 5030 faculty, staff, and trainees of a US health system, many participants with caregiving responsibilities, particularly women, faculty, trainees, and (in a subset of cases) those from racial/ethnic groups that underrepresented in medicine, considered leaving the workforce or reducing hours and were worried about their career development related to the pandemic. It is imperative that medical centers support their employees and trainees during this challenging time.

As a result of the COVID-19 pandemic, 42% of US workers, including many in academic medical centers, were quickly transitioned to working from home in March 2020, and many were simultaneously required to provide childcare and substantial assistance with schoolwork for children during their workdays.¹ Employed women, in particular, were likely to face greater burdens because they spend 22% more time on unpaid household and care work compared with their male counterparts, with Black or African American and Latina mothers spending nearly twice as much time as men on unpaid housework.² The pandemic has led mothers in heterosexual relationships to reduce their work hours 4 to 5 times more vs fathers because of the pressures of having children at home.³ Notably, women comprise 74.9% of hospital employees,⁴ many of whom are essential clinical workers; the extent of the needs and difficulties for these workers during the pandemic remain largely unknown. Employees and trainees who must present to work or training in person may face new childcare expenses for school-age children, resulting in a higher financial burden.

In addition, for those who work in a clinical setting, several studies have shown that there is substantially higher stress for health care workers during the pandemic compared with before the pandemic.^5-10 These life changes are associated with serious concerns about the impact on the careers and well-being of faculty, staff, and trainees. Several recent studies⁵ have examined the effects of burnout, stress, depression, and anxiety on frontline medical staff during the global pandemic. Numerous studies^6,7 across the globe have demonstrated the substantial burnout of frontline workers, and additional studies^8-10 conducted in the US have shown similar themes. However, many of these studies have been limited by only examining either frontline workers or physician trainees. Most studies also do not address important family-work balance issues, such as childcare needs during the pandemic, which contribute greatly to the stress and burnout of staff.⁸ To our knowledge, no previous studies have examined the work-life needs of both the clinical and nonclinical staff of a medical center.

The primary aim of this survey study was to evaluate the association of the global pandemic caused by SARS-CoV-2 with productivity, career development, and likelihood of leaving the workforce or reducing hours by employees in a tertiary care academic medical center. This study also identified factors (ie, gender, race/ethnicity, job role, and working in a clinical setting) and moderators associated with the aforementioned outcomes. The secondary aim was to describe and identify dependent care and work culture needs to inform institutional policy changes.

A Qualtrics survey was distributed via email to all 27 700 faculty, staff, and trainees (eg, professional and graduate students, residents, medical fellows, and postdoctoral fellows) at University of Utah Health between August 5 and August 20, 2020, as a quality improvement initiative to inform institutional leadership on how best to support employees. It was sent via a university-wide listserv in which recipients clicked a link to opt into the study anonymously. Because anonymity was imperative to allowing employees to speak freely, there was no system to track differences between responders and nonresponders. The initial email was sent from the CEO and SVP of the University of Utah Health, with 1 reminder email. The University of Utah institutional review board classified the study as exempt and informed consent was waived because the responses were anonymous and because the study presented minimal risk to the participants. Our results follow the American Association for Public Opinion Research (AAPOR) reporting guideline for survey studies.

The survey was developed by a multidisciplinary team of psychologists, physicians, trainees (students, residents, and fellows), and staff. Before launching the survey, a convenience sample of approximately a dozen faculty, staff, and trainees (3-4 people per role) took the survey and provided feedback to identify confusing wording and to suggest additional questions. The survey was mostly quantitative but also included several open-ended questions. The survey took 10 to 20 minutes to complete (contents included in this article are in the eAppendix in the Supplement).

Primary outcome measures were 4-fold, each scored on a Likert scale from 1 (low) to 5 (high). Participants were asked if, as a result of the pandemic, they had considered leaving the workforce, considered reducing their hours, or experienced reduced productivity and whether their career had been impacted. Secondary outcomes included what type of work culture adaptations they would find helpful while working during the pandemic (participants rated their perceived effectiveness of 8 solutions on a 4-point scale from 1 [not helpful at all] to 4 [extremely helpful], with an option for other or not applicable). For those who indicated they had dependent children, additional questions inquired about childcare needs, again with participants rating the effectiveness of potential services (assuming they were provided at an affordable cost) on a 4-point scale from 1 (extremely unlikely) to 4 (extremely likely), with an option for not applicable. Finally, participants completed standard demographic measures. Participants self-reported their race and ethnicity using US Census questions (multiple responses were allowed). Race and ethnicity were measured because we had a priori hypothesized that individuals from groups that are underrepresented in medicine and science would experience the effects of the pandemic differently. For race and ethnicity, we categorized self-reported answers into the following groups for analyses: (1) Asian or Asian American, (2) White or European American, and 3) all racial/ethnic groups that are underrepresented among faculty and trainees, including people who are Hispanic or Latino or Latina of any race, Black or African American, American Indian or Alaskan Native, or Native Hawaiian or Pacific Islander. We separated the aforementioned underrepresented groups from Asian Americans, given that those underrepresented groups are also more likely to be disproportionately affected by adverse health effects of COVID-19.¹¹

Descriptive statistics (proportions or means) are reported for respondent characteristics and primary and secondary outcomes. Four multivariable linear regressions were conducted on the continuous outcome measures. Interaction terms were selected a priori to be entered in the regression analyses. Unstandardized coefficient estimates are presented for regression analyses to represent how much the mean of the dependent variable shifts given 1-unit change in the independent variable (holding other variables in the model constant). To interpret significant moderator effects, the mean estimated value of each outcome was reported for each group.¹² In the Results section, we discuss the findings of the combined main and interaction effects when interactions are statistically significant and main effects only when interaction terms are not significant. Two-tailed tests were conducted with a significance level of P < .05. SPSS statistical software version 26 (IBM) was used to analyze the data. Data analysis was performed from August to November 2020.

Email invitations to take the survey were sent to 28 000 individuals; 300 emails were returned to sender. Of the remaining 27 700 potential respondents, 5951 (21%) accessed the survey and 5030 (18%) completed the survey and were included in the analysis (mean [SD] age, 40 [12] years). Although more women completed the survey than men (3738 respondents [75%] were women), the proportion is similar to that of women within the health system (across all roles, women typically compose 64% of the workforce, and 74.9% of hospital employees are female).⁴ Respondent characteristics overall and stratified by job role are displayed in Table 1. With regard to race/ethnicity, 4306 (86%) were White or European American; 561 (11%) were Latino or Latina (of any race), Black or African American, American Indian, Alaska Native, and Native Hawaiian or Pacific Islander; and 301 (6%) were Asian or Asian American. Of note, approximately one-half of our sample reported working in a clinical setting (2545 [51%]) and nearly one-half reported having at least 1 child aged 18 years or younger (2412 [48%]). Of the respondents, 3316 (66%) were staff, 791 (16%) were faculty, and 640 (13%) were trainees.

Table 2 presents proportions for participants’ consideration of leaving the workforce and reducing hours, work productivity, and worry about the impact of COVID-19 on career development. Overall, 1061 respondents (21%) moderately or very seriously considered leaving the workforce and 1505 (30%) considered reducing hours. Overall, 1359 respondents (27%) felt their productivity increased, whereas 1932 respondents (39%) felt their productivity decreased; 449 faculty (55%) and 397 trainee (60%) respondents showed notably high percentages for reporting decreased productivity. A total of 2334 respondents (47%) reported being moderately or very seriously worried about COVID-19 impacting their career development, with 421 trainee respondents (64%) being highly concerned.

Four multivariable linear regression models assessed associations and interactions related to each of the 4 primary outcomes (Table 3). The full regression models are shown in eTable 1, eTable 2, eTable 3, and eTable 4 in the Supplement. Participants who were younger, married, a member of an underrepresented racial/ethnic group, and worked in a clinical setting reported greater consideration for leaving the workforce. Younger, married, and Asian American participants reported a greater consideration for reducing their work hours. Participants who were younger, married, Asian American, male, and had at least 1 child reported decreased productivity, whereas participants who identified as being a member of racial/ethnic group that is underrepresented in medicine reported increased productivity. Younger, Asian American, and underrepresented participants and participants with at least 1 child reported greater worry about the impact of COVID-19 on their career development.

Statistically significant interactions were found for each of the 4 outcomes (Table 3 and Table 4). The interaction between gender and having dependent child(ren) was significantly associated with consideration for leaving the workforce (β coefficient, 0.30; 95% CI, 0.147-0.447) and reducing hours (β coefficient, 0.40; 95% CI, 0.233-0.570), suggesting that the association between parenthood and career outcomes is different for mothers and fathers. For women, having a dependent child was associated with considerations of leaving the workforce and reducing hours compared with men with a dependent child. Interactions between gender identity and job role were also significant for several of the outcomes. Women in trainee positions considered leaving the workforce (β coefficient, 0.27; 95% CI, 0.020-0.507) and reducing hours (β coefficient, 0.31; 95% CI, 0.033-0.581) more frequently than men in similar positions. For women, faculty or trainee job role was associated with increased worry about the impact of COVID-19 on their career development and greater consideration for reducing hours compared with men in similar roles and women in staff positions. Being a faculty member or trainee with nonclinical responsibilities was also associated with a perceived decrease in productivity and increased worry about the impact of COVID-19 on their career development, compared with nonclinical staff.

Of 2412 participants with children aged 18 years or younger, 1589 (66%) reported that they did not have childcare fully available, and 783 of 2747 (33%) reported being comfortable taking their child to school or a childcare facility (Table 2 and Table 5). Of 2412 participants, 1055 (44%) and 920 (38%) reported that a decrease in COVID-19 cases and the development of a COVID-19 vaccine, respectively, were the most preferred conditions to have to return their child to return to school or childcare. Most participants (1360 participants [67%]) reported they would be somewhat or extremely likely to use temporary services for home childcare (eg, babysitter) or in-person (1231 participants [70%]) and online tutoring (1218 participants [70%]) if they were offered at an affordable cost. A total of 1072 of 2435 participants (45%) felt a lot or a great deal of worry about their ability to provide care and schooling for their children once school started, and 1932 of 2456 participants (81%) reported finding it somewhat or extremely difficult to balance childcare and work responsibilities. Of 2406 participants, 1148 (49%) reported that parenting and 1171 (50%) reported that managing virtual education for children were causing them a lot or a great deal of stress. Of the techniques listed to help manage home and work-balance integration (Table 2), respondents rated the continued opportunity to work from home (2905 participants [60%]), flexibility in scheduling (3276 participants [68%]), knowledge of work-training schedule 1 month in advance (2939 participants [61%]), and a better understanding of work-life struggles by the person they report to (378 participants [57%]) as being very or extremely helpful.

In this survey of 5030 faculty, staff, and trainees of a US health system, we found widespread reported stress associated with caregiving, decreased productivity, concerns about career development, and consideration of either reducing hours or leaving the workforce 6 months after the beginning of the COVID-19 pandemic. These experiences were exacerbated for workers who provide clinical care, those with children at home, women, and people of color—especially those who identify as a belonging to a racial/ethnic group that is underrepresented among medical professionals, academics, and trainees. Faculty and trainees (most notably women) and workers with nonclinical job roles in particular reported considering leaving the workforce and reducing hours, experiencing reduced productivity, and facing greater concern about the impact of COVID-19 on their careers.

Given the disproportionate impact COVID-19 has on employees of health systems, institutions must find ways to support their employees, both in terms of workplace cultural adaptations and assistance with familial responsibilities. Most participants indicated they wanted continued flexibility in terms of when and where they work and to receive their work schedules at least 1 month in advance (presumably to make arranging childcare easier). Among workers with children younger than 18 years, we found that although some would like to place their children in temporary childcare center settings, the vast majority preferred assistance in home childcare, tutoring (either in person or virtually), or finding groups of like-minded parents (to form pods).

Although academic centers cannot single-handedly relieve many of the stressors facing employees, they have substantial opportunities to influence the employee experience. Our findings suggest that institutional policies could be developed to support all employees, including families, by addressing telecommuting policies and schedule flexibility, as well as providing expanded support options to address psychological stress of employees and trainees and the educational and direct care needs of their children. The development of new, high-impact stopgap measures, such as tutoring and resource matching, provides an opportunity to meet acute needs related to COVID-19. In addition, because most academic medical centers already offer a variety of services, expanded communication of existing resources can increase access. Finally, the COVID-19 pandemic sheds light on the longstanding difficulties of obtaining affordable childcare, particularly for ill children or when school is unexpectedly closed, providing us with an opportunity to consider longer term needs beyond COVID-19.

Our ability to generalize these data is limited because the survey was sent to employees of only 1 health system; furthermore, the response rate was too low to be generalizable for the entire health system. However, this is one of the first studies to examine the needs of all employees, allowing us to understand the varying needs of different types of employees. Other limitations include selection bias with regard to individuals who chose to complete the survey. Although the email requesting survey completion emphasized the goal for all employees to participate regardless of dependent status, it is possible that more parents of children aged 18 years or younger completed the survey than those without children. The respondents also included a low portion of racial and ethnic groups that are not representative of the US population, although this is mostly accounted for by the overall low population of such groups in the state of Utah. Furthermore, unlike staff and trainees, faculty were not explicitly asked whether they provided clinical care. In our analysis, we included all participants who reported being on the clinical track as providing clinical care, but were unable to categorize physicians who are on tenure track as to whether they provide clinical care. Thus, we may have underreported the percentage of faculty providing clinical care.

In this survey of 5030 faculty, staff, and trainees of a US health system, our results suggest that respondents were struggling during the COVID-19 pandemic. As a result, even after investing substantial amounts of time in years of training, many were considering leaving the workforce because of stress and caregiving responsibilities related to the pandemic. Health systems must develop effective strategies to ensure that the workplace acknowledges and supports employees during this unprecedented time, not only within the work environment, but also in managing unanticipated childcare responsibilities due to lack of childcare or in-person school. In doing so, health systems will improve the likelihood of retaining generations of well-trained clinicians, scientists, and staff.

Accepted for Publication: February 8, 2021.

Published: April 2, 2021. doi:10.1001/jamanetworkopen.2021.3997

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Delaney RK et al. JAMA Network Open.

Corresponding Author: Angela Fagerlin, PhD, Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 (angie.fagerlin@hsc.utah.edu).

Author Contributions: Drs Delaney and Fagerlin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Delaney, Locke, Pershing, Precourt Debbink, Tanner, Anzai, Fagerlin.

Acquisition, analysis, or interpretation of data: Delaney, Locke, Pershing, Geist, Clouse, Precourt Debbink, Haaland, Fagerlin.

Drafting of the manuscript: Delaney, Pershing, Fagerlin.

Critical revision of the manuscript for important intellectual content: Delaney, Locke, Geist, Clouse, Precourt Debbink, Haaland, Tanner, Anzai.

Statistical analysis: Delaney, Geist, Clouse, Haaland.

Obtained funding: Fagerlin.

Administrative, technical, or material support: Locke, Pershing, Geist, Precourt Debbink, Tanner, Anzai.

Supervision: Locke, Geist, Fagerlin.

Conflict of Interest Disclosures: Dr Delaney’s salary is supported by a T32 Cardiovascular Research Award outside the submitted work. Dr Precourt Debbink reported receiving grants from Reproductive Scientist Development Program Award, and her salary is supported by a K-12 Professional Development award outside the submitted work. Dr Haaland reported receiving personal fees from Prometics Life Sciences, Astra Zeneca, National Kidney Foundation, and Value Analytics Labs and nonfinancial travel support from Flatiron Health outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Jon M. Huntsman Presidential Endowed Chair (award to Dr Fagerlin).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Christina Yong, MA (University of Utah), provided editing assistance and was not compensated beyond her regular salary.