The findings indicate that medical students of the UW/H are affected by the aggression war act of Russia on Ukraine 2022. The findings are comprehensible with respect to the decreased wellbeing, stress perception and study capabilities as previously shown by the medicine student cohort during the COVID-19 pandemic with missing link to the contentment with the studies or university support alone [10]. However, students' stress perception decreased during the COVID-19 semester, whereas it increased during the time after the report of the war in Ukraine in this study. This is also shown in other cohorts of students of different study fields and may be a key argument for the structural relevance and importance of the consideration of systemic volatility in stress perception, which might decrease in times of cultural, economic and general contact restrictions during the pandemic in contrast to “just” empathy-based concernment and anticipating fear, that the war will also affect Germany in the future after the war act on Ukraine [25, 27, 40, 41]. Interesting to note is that the students of the UW/H seem to regulate their emotions (here: after a time span of 4 months) in a comparable way, showing favorable scores in wellbeing over time [10, 40, 41]. This will be discussed for further research and student support with a view to the reinforcement of media reports and crisis communication, individual affectedness of the events on the exo-level as well as individual study characteristics on the micro- and meso-level [7, 10, 13].
On the individual level, people tend to process critical information along the dimensions of attending, reacting, explaining to successfully adapt and integrate the information in used schemes [13]. The attending phase is influenced by the novelty of information and the self-relevance, which in this German sample may be assessed as highly relevant due to the lack of war acts in Europe since 1945 [42]. When self-relevant events are highly surprising and not (yet) fully explainable or controllable, they tend to be highly accessible in memory, leading to possible anxious or intrusive thoughts [43]. This may be reflected by answers to openly asked questions regarding current stressors (e.g. “It's unbelievable that there is a war going on in Europe. It is devastating and makes one feel very sad (...)”, Student 14) in this study and the negatively affected emotional state in March 2022 right after the first war events happened (#19).
The interaction of the external happenings to own competing goals and concerns influence the self-relevance of the (here: war-related) information, which may be embedded in the demanding study of medicine for the students of the UW/H in the micro- and meso-level [6]. Therefore, the adaptation results of restored wellbeing, stress perception and work engagement after 4 months in student group 2 may be explained by moderating influences of study demands and goals, which constitute more demanding self-relevant concerns as time passes by [13, 14]. The insecurity-inducing news and circumstances of the war might get more explainable and usual over time, yet are not directly perceivable, whereas the study goals stay relevant and demanding [14]. This could explain the restored levels of well-being in the second study group with the course of the war in Ukraine. Another regulation aspect may be the social amplification and risk framework, indicating that risk perception is influenced by media coverage especially when the happenings are not perceivable by oneself but transferred via media processing to a non-directly affected person [14]. Relevant here is the social communication, which constitutes a subjective interpretation of the event and may bias the message as well as the risk perception by exaggerating emotional aspects in favor of attention by keeping events and the medium current and popular [44, 45]. Individual efforts to fend off negative affectedness from media (media abstinence, #11) in this study suggest that the students are aware of the negative influence of news and might actively try to regulate their news consumption and the inducing of negative feelings, resulting in possible restored wellbeing through avoided negative news. The scope of individual consumption of media, the format and (negative) tone of the (journalistic) provider as well as social media actors in general remain unknown influencing factors for the felt affectedness of students in non-directly war-related countries [27, 15, 46].
The described risk framework may be both applicable in comparison to previous findings and related to self-relevance during the COVID-19 pandemic, from which the students may be constantly or more affected over the time, as the infection rates and the scope rose and consequences were perceived more directly [10]. This may be a key point and argument for understanding the differences in stress perception during different types of crises along individual gradients of self-relevance and ongoing event reports as well as health consequences for students [14, 47].
According to these theories, there might be another explanation for the adaptation of wellbeing, risk perception and work engagement with ongoing war events and other bad news. Due to the theory of motivation protection and trauma-like stress events, people only have limited resources of worry and will eventually numb and avoid negative news with accumulating scope and without increasing resources or possibilities to influence the events by themselves, resulting in emotionally defending the stressor events as an emotion regulation strategy [48, 49]. In this study, students of group 1 showed patterns of fear, horror, and anger (#19), along with helplessness/powerlessness (#8), indicating a high amount of negative emotional demands and limited felt self-efficacy to change the situation. This short-term regulation of well-being may demonstrate a defensive coping reaction and it might had happened in Group 2 due to limited engagement possibilities to influence the war events. Matching this on the micro- and meso-level, students of the clinical phase report a significant higher stress perception and lessened wellbeing than pre-clinical students, which is a study phase associated with increased insecurities due to patient contact and hopelessness due to increased volatility of social expectations, raising personal requirements and hierarchical work processes in the clinical work environment, especially for women [50, 51, 52]. The example quote “The structures are still (also very much abroad) clearly hierarchical and unfriendly to people. This is stressful; I have learned to distance myself." (Student 19, clinical phase) may reflect this way of emotional processing. Hopelessness and worry, according to other research, constitute a vulnerability for mental health consequences such as depression after stressful life events [cf. “learned helplessness”, 28, 48, 53, 54]. In this study, students appear to regulate their stress-related symptoms on subclinical depression scope to war events in Ukraine after wellbeing restrictions on subclinical depression scope but long-term effects of accumulated stressors and emotional numbing, especially in challenging study phases or combined with personal crises remain unclear.
In this study, the non-significant changes in work engagement even with the enduring war events within four months might reflect an interesting resilience factor for this felt hopelessness. The course of stable work engagement is comparable to that during the COVID-19 pandemic [10]. Work engagement might constitute a time-stable factor for the studies also for German private medicine students, as previously connoted as a stable and support-worthy resource for the success of job-related tasks and regulation of demands among workers [33, 55]. However, besides work-related outcomes, work engagement may have the power to increase self-efficacy, which is demonstrated as a mediating resource for the influence of stress during crises like the COVID-19 pandemic, lessening feelings of hopelessness in the face of multilevel crises [56].
Students of medicine at the UW/H already report several other strategies or resources to deal with hopelessness and other demands. These might be classified as actively problem-oriented or beneficial for the experience of self-efficacy (seeking information in the news about the war, active help for refugees) as well as passively coping-oriented or beneficial to emotion regulation (distraction and conversations with friends, media abstinence), suggesting the transferability of the findings in the light of reported theories and literature. In other studies, individual regulation from social support as well as participating and thinking solutions rather than problem-oriented, are reported as main resources for stressful events, too [57, 58]. Statements like "I try to reduce the feeling of powerlessness by taking action. (...) This helps me a bit with dealing, but the dire and uncertain situation weighs heavily on me (Student 21a) indicates at least partly successful engagement in active stress regulation behavior of students at the UW/H. In the context of the JD-R-Model, these contribution of resources to the capability to study of the medicine students as well as the unaffected work engagement may be explained, indicating a regulating effect of the described resources on individual motivation, and felt strain of the given study demands [31]. Other positive coping strategies reflected by the literature may be a positive reframing of events, humor, acceptance, or religious behavior [59, 60]. Techniques from the acceptance and commitment therapy, mindful-based therapy or cognitive behavioral therapy appear to additionally decrease symptoms of distress, anxiety, or depression in times of crisis [61]. Mindful-based techniques as a coping mechanism may already be applied by the students, reflected by statements like (...) I bought extra flowers and walked in the sun and consciously talked about other things than the war and suffering. (...) (Student 21a). Behavioral strategies may be shown by situate coping principles and active exposure behavior as statements like (…) I try to reduce the feeling of powerlessness by taking action. For example, by collecting donations, offering shelter, and volunteering to help refugees arrive (...) (Student 21a) indicate [62]. These overall findings demonstrate a stress regulation capability of medical students in times of crisis but represent support areas for the university in order to facilitate the individual engagement in medical studies with increased external hopelessness as multilevel demands may cause [31, 63, 64].
Research indicates that there might be other possible interfering factors on the systemic or individual levels influencing the wellbeing and stress perception of students, possibly limiting the given explanations and true associations to the war events [65]. On the exo-level of the universal studies, the given results indicate differences of e.g. stress perception in clinical vs. preclinical phases of medical studies (s. Figure 1). It is unclear how different factors of the clinical environment and factors of different study phases might covariate with the individual or well-being of the study cohort or stress perception and further research could try to depict influencing factors on multi levels in order to separate personal or study wise influences from those of the war events [66, 67]. On the individual level, previous research suggests covariability of wellbeing and stress perception of students in times of crises in political ideology, gender, phases of study, social media use, the individual capability of emotion regulation and endurance of insecurity as well as other resilience factors [10, 68]. Due to a personal selection process for medicine studies at the UW/H, personality factors may additionally influence individual crisis processing, possibly limiting the transferability of the findings to other samples [69, 70]. The mentioned factors may moderate the original relation of the war events, study engagement and reaction measurements, limiting generalizing statements about the effects of the war on UW/H students and their studies. To improve the validity of the findings, a suitable methodological consideration of these influences may be given by including reported possible confounding variables as media consumption, social media or media agenda in stepwise regression analyses or multilevel models to distinct inner and outer influences of stressors over study programmes on the individual [67].