Background

The global COVID-19 pandemic has significantly impacted healthcare professions education on many levels [1]—university campuses closed [2], classes were moved to online formats and/or were significantly altered [3, 4], clinical training was interrupted and impacted [5,6,7], and in some countries, senior medical students graduated early to work on the frontlines [8].

To date, there is no clear understanding about how this pandemic impacts various aspects of learner education; including their emotions, learning activities, and career aspirations—in particular, from a global perspective.

As the pandemic affects countries and regions differently, the experiences and impact on the trainees worldwide can vary, and thus have different effects on healthcare globally.

The goal of this study was to capture students’ perceptions, experiences, and emotions at 14 universities in 11 countries, during the 2020 COVID-19 pandemic.

Understanding how worldwide health events can impact students in different parts of the world is important for healthcare professions educators and will form the baseline of a historical context for how global issues can impact learner experiences, as it can have long-term consequences for young students at both the personal and professional levels, and therefore, on healthcare professions education and the healthcare profession at large.

The compilation of these perceptions serves as a historic documentation of students’ thoughts during an unprecedented global pandemic, adds to the current literature on the effect of the COVID-19 pandemic on the healthcare profession, and serves as a baseline for longitudinal research on the professional careers of this particular generation of students.

Activity

The participants in this study were preclinical healthcare professions students (i.e., medical and dental students) who volunteered in an online international student exchange program [9].

The students were asked to share their experiences during the COVID-19 pandemic in small international focus groups. Subsequently, they submitted individual essays about their thoughts, guided by open-ended questions (Table 1).

Table 1 Questions, themes, subthemes, sub-subthemes, and students’ sentiments as reported by different schools; with select sample student quotes
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The written assignments were submitted anonymously, collected via Google Forms©, and analyzed for thematic content using a general inductive approach [10]. Five project team researchers of different ages, backgrounds, and ethnicities (A.W., V.M., R.G., C.X.Y., and H.S.) independently reviewed each submission. Specifically, the coders received anonymous essays that were blinded for originating school, gender, and age—only after the thematic coding was completed was this information revealed. The assignments were coded in two phases. In phase 1, the coders read all the essays and identified themes for each of the guided questions. All coders agreed on the themes before proceeding to the next step. In the second phase, the responses were then categorized into the coded themes using Excel©. The project team met regularly to resolve discrepancies and achieve consensus. Discrepancies included disagreement on interpretation or categorization of the content. Consensus was achieved via majority vote. If no consensus was achieved, the essay was excluded. Once all the essays were coded, the written pieces were identified and sorted by schools.

Due to disproportionate representation from each school, a comparison between schools was not possible, but striking differences were noted (i.e., when a theme was identified for all schools).

All assignments were collected between June 15 and July 15, 2020. Written consent was obtained as part of the program participation process.

Ethical approval was obtained from Columbia University (IRB No. AAA0003715), McGill University (IRB Study No. A07-E54-17B), and the National Taiwan University (IRB No. 202001069 W).

Results

Student Demographics

A total of 81 students from 14 universities participated (Table 2). Eighty written assignments were received; essays were obtained from 69 medical and 11 dental students.

Table 2 Participating universities, with student demographics. Fourteen schools participated in the program, and assignments were received from 13 schools. One school did not provide any written submissions but participated in the small group discussions about the COVID-19 pandemic
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The results of the study focused on four of the selected guided questions listed in Table 1. Table 1 depicts representative sample quotes for each theme, subtheme, and sub-subtheme.

Overall, the students’ responses revealed several overarching themes, and the majority of students each addressed a variety of emotions. The themes were grouped into positive and negative emotions. Furthermore, some themes were subdivided into subthemes and sub-subthemes.

Sentiments

A positive emotion such as pride appears to be a sentiment that was present in many schools, with different sub-subthemes (e.g., proud to be a member of a school, a member of a healthcare profession, a member of the healthcare field, a citizen of a country). Negative emotions, such as fear and anxiety caused by the pandemic, were present in all schools regardless of country (e.g., fear of the disease, of the pandemic in general, for loved ones, for the healthcare profession, and anxiety about the future and the impact on education). Anger and frustration were commonly found in select countries, subdivided into three sub-subthemes (e.g., anger at the government, at others, at the situation). Students also expressed an underlying level of guilt.

Overall, it appears that students in the USA and the UK did experience more negative emotions (e.g., fear, anger, frustration, and disappointment), when compared for example with Denmark, Finland, Germany, and Taiwan. Positive emotions in the USA and the UK focused on pride in being a healthcare professional.

Changes in Outlook on the Healthcare Profession

Respect for, and importance of, the healthcare profession dominated. Students also recognized the importance of good leadership in healthcare. Realization of the limitations of the profession, including sacrifice, risks, and undervaluation of the profession, was also found.

In some students, the pandemic experience had no effect on their view of the profession.

Impact on Career

The students felt that the pandemic affected their careers, in positive and negative ways.

Positive effects included emergence of new opportunities. Negative effects included lost opportunities, with sub-subthemes of loss of clinical education and research opportunities. Students perceived that their education was impacted, including difficulty studying, loss of knowledge, and delay in education.

For a number of students, the pandemic had little or no impact.

Country’s Handling of the Situation

Positive and negative feelings were associated with how the pandemic was managed in the respective countries. Students reported having positive feelings such as pride and satisfaction. Negative feelings found in select countries (i.e., USA, UK) included anger/criticism and disappointment. A few students had mixed positive and negative emotions regarding their country. When reviewing emerging themes, it became evident that countries that did not function well during the pandemic (summer 2020) evoked negative feelings, whereas in countries that did perform well, more students had something positive to report.

Discussion

In the present study, the authors reviewed the perceived impact of the recent COVID-19 outbreak on healthcare profession students from different parts of the world—in an observational snapshot, at a given point in time (June 15—July 15, 2020), to document the experiences of this generation of students.

Changes in study environments and school curricula, social isolation due to lockdown or quarantine, restriction of travel opportunities, and reshaping of human interaction have profoundly impacted individual and societal behaviors.

Unsurprisingly, a wide array of emotions was found that requires the attention of healthcare profession educators.

Independent of how severely the COVID-19 pandemic affected the students’ home countries at the time, all universities had representations of students’ fear and anxiety. Major disasters and pandemics in general can have a lasting psychological effect on a young person [11,12,13], and medical students’ reactions to natural disasters have been reported [14,15,16,17,18,19]. This report confirms the findings about emotions during pandemics in general [20]; particularly, during the COVID-19 pandemic [20,21,22,23]. These emotions may lead to mental health issues, such as post-traumatic stress disorder (PTSD), depression, and anxiety, but can also result in positive outcomes such as personal growth and resilience in the long term [14, 17]. Furthermore, during disasters, media exposure alone can have a psychological effect on students’ emotions [24]. This could explain the ubiquitous presence of fear and anxiety among students who live in countries that were minimally affected by the pandemic at the time. Therefore, it may be advisable for schools to offer crisis support to students of this generation, as previously suggested [25].

Professional identity formation has recently been investigated and is a several-phase process [26]. It was reassuring to see that the severity of the pandemic was not associated with students having doubts about their choice of profession.

The finding that students felt that the pandemic made them proud to be in the healthcare profession is of importance for the future of healthcare.

It appears that a significant number of students reflected on challenges inherent to the healthcare profession (e.g., danger, risk, sacrifice, importance of leadership, global health). This finding is of importance as it may prompt changes in their future career paths.

Although too early to evaluate the impact on their healthcare professions education, the students were concerned with negative effects on their careers. However, many of them were hopeful that over the long term, a delay in education/training would not be of importance. The authors suggest that universities should consider offering these students additional research and training opportunities to make up for the time lost during the pandemic, so that they can remain competitive with previous cohorts.

It will be important to follow-up with this generation of students and to assess the educational outcomes of this particular cohort. This information is particularly important, as the role of online learning might be increasing in higher education.

Notably, despite the different effects of the pandemic on their home countries, students in all countries reported a mix of positive and negative emotions, indicating the complexity of their reflections. For that reason, as part of the study, the authors included the students’ opinions of how their countries fared—to underline the intricacy of what influenced their feelings.

Although the voluntary nature of the program, the focus on preclinical students, the lack of a control group, and the small number of participants limit the generalizability of the results, the authors conclude that overall, the pandemic affected healthcare professions students. Although a likely possibility, it is too early to surmise if this experience will have a long-term effect on these students’ careers. This observational study can serve as a historic documentation of how students of this particular generation felt during a global crisis, can serve as a resource for further comparative investigations, and supports healthcare professions educators in addressing future problems.

Future Directions

After this initial observational study, focused qualitative and quantitative research with more students is underway, to investigate the impact of the pandemic on the students’ mental health and professional careers.