Medical Students’ Commitment during the SARS-CoV-2 Pandemic: Preparedness, Motivation, and Impact on Students’ Skills

Background: During the SARS-CoV-2 pandemic, many authors have suggested a commitment of medical students to support overworked health care staff. However, whether the students are prepared for such an occupation remains unclear. Therefore, the aim of this study was to evaluate medical students’ preparedness for a commitment in the pandemic and to assess the impact on their skills and attitudes. Methods: In April 2020, the CoronaPreventMainz (CPM) study was initiated to test 3300 employees with direct patient contact at the University Medical Center Mainz. To accomplish the huge logistic effort, medical students were recruited as support staff. Using a web-based questionnaire, the participating students were asked 27 questions covering six different topics. Results: Of the 75 recruited students, 63 (84.0%) participated in this survey. The median age was 24 years, and 66.6% (n = 42) were female. The vast majority agreed that students should be used as voluntary helpers during this crisis (87.3%) and had the feeling of contributing in the �ght against the pandemic (90.5%). Most of the students (80.6%) even reported an improvement in their practical skills. Fear of self-infection was low (7.9%), and overextending situations occurred for just 3.2%. However, less than one-fth (19.4%) of the students felt prepared for the SARS-CoV-2 pandemic by medical school, and two-thirds (67.7%) demanded special preparation. Conclusion: Through their commitment, the medical students felt that they were taking part in the �ght against the pandemic. However, only a few felt well-prepared by medical school and the students’ need for special preparation courses is huge. Therefore, single-center initiatives


Background
In early 2020, the SARS-CoV-2 pandemic was clearly one of the most terrifying worldwide crises in recent history.Almost all countries were impacted by a fast spreading virus and their health care systems had di culties coping with the situation (1,2).In addition to a bottleneck of urgently needed materials, a lack of health care professionals was critical (2)(3)(4)(5)(6).To deal with this, politicians and scientists suggested involving medical students to prevent a health care system breakdown (7)(8)(9)(10)(11)(12).
Students themselves asked for rapid involvement in the ght against the pandemic, and recent studies indicate that successful student recruitment and assignment to different tasks is possible on short notice during the crisis (13)(14)(15).At our University Medical Center, more than 1000 medical students responded to a pertinent call and registered themselves as voluntary helpers in a dedicated database called "I want to help" (16).
The medical students' support was urgently needed when the CoronaPreventMainz (CPM) study was initiated in April 2020.The CPM study is a large-scale SARS-CoV-2 cohort study of all employees with direct patient contact, as they have a higher risk of infection and are more likely to be virus carriers (17,18).Overall, 3300 participants were tested for current disease and antibody status at enrollment, after 2 weeks, and after 3 months.As the study was planned and initiated within only 2 weeks, great logistical effort was needed.Therefore, assistant staff were required immediately.For this purpose, 75 medical students were recruited within 3 weekdays and currently work as study assistants.
However, besides the reportedly high motivation and willingness to help, the medical students' commitment has to be discussed controversially.Whether their short training is enough to cope with di cult situations, both medically and psychologically, is unclear.The British Medical Association recently emphasized that "medical students should not work outside their competency" and warned of unsafe work practices (19).Furthermore, no su cient data are available on the students' preparedness for the commitment and the effects of this work during the crisis.
Thus, the aim of this study was to evaluate the students' preparedness for a commitment in the pandemic and to assess the impact on their skills and attitudes.

Recruitment of the participants
For this prospective survey, all medical students recruited for the CPM study at the University Medical Center Mainz were contacted via electronic mail on April 22, 2020, during their commitment in the rst stage of the CPM study (ethics committee permit number: 2020-14968).The possibility to participate voluntarily in this online survey was offered to them independent of their task in the CPM study.Furthermore, they were informed that the results of the survey would be used for further scienti c analysis, and that their anonymity was guaranteed.A reminder was sent to them via electronic mail after 5 days.
The questionnaire was closed after 7 days.

The questionnaire
The electronic questionnaire was designed using the SurveyMonkey web application (SurveyMonkey Europe UC).The students were asked about their level of agreement on various items using a 7-point Likert scale (1 = "strongly disagree", 2 = "disagree", 3 = "somewhat disagree", 4 = "neutral", 5 = "somewhat agree", 6 = "agree", 7 = "strongly agree").We chose a 7point Likert scale because it provides higher variance and reliability compared to a 5-point scaling system (20).Scaling systems with a higher range of points are not expected to yield added value regarding the information obtained, but would have strained the respondents' abstraction capabilities (21).
The questionnaire consisted of six sections, each addressing different aspects.The rst section of the survey captured the basic demographics (gender and age) of the student assistants, information on any medical apprenticeship before entering medical school, current semester, and details of the students' commitment in the CPM study (type of work within the study, average hours of work, etc.).The second section asked about their preparedness for the pandemic in medical school.In particular, they were asked for their opinion on dedicated preparation courses for pandemics and whether medical students should be used as additional health care workers during crises like the current SARS-CoV-2 pandemic.The third section comprised questions on their feelings about participating in the ght against the crisis due to their work in the CPM study and their opinion on the appropriateness of students' participation in this project.Furthermore, the students were asked about the safety precautions taken during their work and possible fear of self-infection.The fourth section asked about the students' organizational and practical skills and their potential development during the study.Section ve focused on their opinion regarding the large-scale testing, their own work within it, and the potential bene t of the study for coping with the SARS-CoV-2 pandemic.The last section of the questionnaire asked about the scienti c results of the CPM study and the impact on their own interest in doing research.The entire questionnaire is attached in the supplement (Figure S1).

Statistical analysis
After the closing date, the results of the completed questionnaires were exported as a CSV le.This le was imported into RStudio 1.2.5042 and the results analyzed using R 4.0.0 (22,23).Figure 1 was plotted using the ggplot2 and likert packages (24,25).To increase comprehensibility, the scores "strongly disagree", "disagree" and "somewhat disagree" were rated as disagreement and "somewhat agree", "agree" and "strongly agree" as agreement.P<0.05 was considered signi cant.The study followed the CHERRIES statement for reporting results of an internet e-survey (26).

Students' demographics
A total of 63 of the 75 CPM student assistants answered the questionnaire during the 1-week period, resulting in a response rate of 84%.Of these, 42 were female (66.7%) and 21 male (33.3%).The median age was 24 years (interquartile range 21 -27 years).Additional demographics and basic information on the students' work regarding the study are provided in Table 1.

Preparedness, motivation, and attitude
Of all respondents, less than one-fth (n = 12, 19.0%) felt well prepared due to medical school alone and two-thirds (n = 42, 66.7%) agreed with the statement that special preparation courses for pandemics are needed in medical school (Figure 1).
The vast majority (n = 55, 87.3%) of the participants agreed that medical students should work as additional helpers during crises like the SARS-CoV-2 pandemic.Most of the students (n = 57, 90.5%) had the feeling of participating in the ght against the crisis due to their work in the CPM study, and an overwhelming majority agreed with the statement that it is appropriate to have medical students assisting in the CPM study (n = 59, 93.7%).The majority of the students (n = 47, 74.6%) felt well protected during the study work, and the fear of self-infection was low (n = 5, 7.9%).More than half of the students said they would feel safer after nationwide testing (n = 35, 55.6%).For more details, see Table 2.

Students' skills and their development
For most of the students (n = 54, 85.7%), the expectations of them within the study work were appropriate.Overextending situations occurred for just 3.2% (n = 2).Most students stated that they possess good organizational skills (n = 61, 96.8%).More than four-fths (n = 51, 81.0%) deemed these skills useful for their study workplace.The same tendencies appeared for the medical-practical skills: 81.0% (n = 51) stated that they possess good medical-practical skills and 76.2% (n = 48) deemed these skills useful for their study workplace.Broad agreement was reached on the positive impact of the study on their own skills, as the vast majority reported that their work within the study improved existing skills (n = 51, 81.0%) and even fostered the development of new skills (n = 48, 68.3%).However, only 44.4% (n = 28) of the students thought that the skills learned in medical school helped during the commitment.For more details, see Table 3.

Opinion of study commitment and large-scale testing
For the vast majority of the participants (n = 53, 84.1%), the work in the study was fun, and most of them had their expectations satis ed (n = 49, 77.8%).Almost all students were able to imagine being part of this kind of study again (n = 58, 92.1%).In addition, there was general agreement about the usefulness of large-scale testing of health care staff (n = 59, 93.7%).More than two-thirds of the students agreed on a nationwide expansion of systematic SARS-CoV-2 testing (n = 44, 69.8%).Almost all students (n = 62, 98.4%) would participate in such testing themselves.

Impact on own motivation for scienti c research
Regarding the scienti c aspects of the CPM study, with the exception of one neutral answer, all students agreed on having great interest in the scienti c results of the study (n = 62, 98.4%).For most of the students, their commitment further motivated them to do their own research in the future (n = 40, 63.5%).More in-depth details are provided in Table 4.
Detailed results for all questionnaire items can be found in Figure 1.

Discussion
At the beginning of the SARS-CoV-2 pandemic in early 2020, the commitment of medical students as supporters of health care staff and their possible roles in the system were discussed more than ever before (8- 13,19,27).This discussion led us to perform a survey of medical students voluntarily working in a large-scale SARS-CoV-2 cohort study.Most of them had the feeling of participating in the ght against the pandemic due to their commitment.In addition, most of the students recognized it as a chance to improve their skills.However, they did not feel well prepared by medical school and demanded dedicated preparation courses on crises and pandemics.
The idea of student commitment during crises is not new; students successfully supported health care staff during the Spanish u epidemic in 1918 in Pennsylvania and the Polio outbreak in 1952 in Copenhagen (28,29).During times of increased fear of health staff shortages, the advantages of the commitment of medical students to supporting the health care system are obvious, as medical students represent a group that knows the health care system well due to mandatory internships.Depending on their progress in medical school, the students may also already have knowledge of basic skills needed for clinical patient care, such as taking histories and doing blood draws (10).Furthermore, as most of the students are young and healthy, Thomson et al. argued that they are a low-risk group regarding infection with SARS-CoV-2, especially in contrast to reactivated retired health care staff (13).
Nevertheless, not only the challenged health care system may bene t: For the medical students the help during the crisis can be seen as project problem-based learning (project-PBL) (15).Project-PBL not only broadens students' metacognitive competencies, but fosters skills relevant to medical problems and research (30).This means that the CPM study work enabled the students to further develop organizational, communication, and basic medical skills (e.g., blood or swab sampling) during a time when medical schools are closed and most courses held online without the possibility of hands-on training.Furthermore, actively taking part in the ght against the pandemic can strengthen the "sense of cohesion", which can increase the motivation of the group and further improve their performance (31).In addition, the "social connectedness" of the students may be strengthened, which is an integral part of mental health, especially in a time when contact restrictions constrain social interactions (32).Despite all of these advantages of student commitment during the pandemic, there are some drawbacks that have to be addressed.As the students are clearly not permitted to perform all tasks, their work has to be regularly supervised or even repeated by professional staff.Some authors argue that, through this redundant work, the transmission rate may be increased (27).Furthermore, this may lead to a waste of personal protective equipment, for which a shortage has already been reported (3).
Another possible source of mistakes to consider may be the insu cient preparation of the students for the pandemic by their medical school.Dedicated preparation courses are lacking.Our study underlined that the students did not feel well-prepared for dealing with the pandemic.Even though overextending situations occurred rarely, the goal has to be to further minimize them, especially as today's medical students may be rst-line ghters in the next crisis.Thus, the demand for special courses is great.To solve this problem, several training and recruitment initiatives have emerged during the current crisis (14,15).However, single-center initiatives can only be the beginning.To be better prepared for the next crisis, systematic and nationwide standardized preparation courses may be the solution.Such a program in association with a dedicated database would also allow for faster, more extensive, and especially more speci c recruitment.High motivation and a feeling of preparedness are the basis of the commitment, but not enough to make the students an indispensable support during the crisis.
Our study has several limitations.First and foremost, the students were only recruited at a single center for a dedicated SARS-CoV-2 cohort study to perform limited and clearly de ned tasks.However, the students signalized their assistance before even knowing their exact task within the study, so the in uence of this bias on students' motivation and attitude towards their commitment can be expected to be low.Secondly, the recruitment of the questionnaire participants could have led to a response bias, interested students may be more likely to have completed the questionnaire.To minimize this potential bias, we sent a reminder to the students, which eventually led to a very high response rate of more than 80%.In addition, the SARS-CoV-2-prevalence in Germany was moderate (33).A higher prevalence in a region may lead to a higher chance of having relatives and friends directly affected by COVID-19, which could lead to a more negative psychological impact and possible anxiety towards a commitment.However, it may also further increase motivation to help in the ght against the pandemic, as experiences from greater affected countries also report highly motivated students (13,14).

Conclusion
Through their commitment, the medical students have the feeling of taking part in the ght against the SARS-CoV-2 pandemic.The fear of self-infection is low, and overextending situations are rare.Furthermore, the majority reported an improvement in their practical skills and an increasing interest in performing their own scienti c research.However, only a few felt well-prepared by medical school, and the students need special preparation courses.Therefore, single-center initiatives can only be the beginning.Dedicated courses on how to support health care staff in natural disasters should be integrated into the medical curriculum to better prepare medical students for the next crisis.

Declarations
Ethics approval and consent to participate: After consultation with the responsible ethics body (Ethics committee of the Medical Association of Rhineland-Palatinate) no formal ethics approval was necessary for this particular study as it involved no patients and was completely anonymous.All students were informed that their participation was voluntary and that they could withdraw their consent anytime; respective contact information of the study group were provided.Electronic consent to participate was obtained. Figures

Table 1 :
Demographic characteristics of the participants

Table 2 :
Students' (n=63) opinions of the preparedness, motivation, and attitude towards voluntary help during the pandemic In your personal opinion, how accurate are the following statements?

Table 3 :
Students' (n=63) opinions of statements on their own skills and their development during the study work

Table 4 :
Students' (n=63) opinions of the study and their attitude towards doing their own scienti c research and development through the study workIn your personal opinion, how accurate are the following statements?