Volunteers’ socio demographic profile
Of 525 students enrolled in 4th, 5th and 6h years of medical training, 286 (54,4%) subscribed in our COVID-19 Volunteer Programme. Thirty-five answers (12,2%) accounted for missing values, once we identified blank fields in the subscription form or could not include them in any category for qualitative analysis.
Regarding sample characteristics, 171 (60%) were men, 152 (53%) were enrolled in 5th grade of medical programme, 158 (55%) were 23 to 25 years old, and 111 (39%) reported they would walk to volunteer sites (Table 1).
The COVID-19 Volunteer Programme subscription form allowed students to choose between six areas of greater interest: (1) COVID-19 patients clinical assistance; (2) Non-COVID-19 clinical assistance; (3) epidemiological surveillance; (4) clinical research; (5) support to online educational activities; (6) hospital administration (Table 2).
Open-ended questions: motivation to volunteer
Concerning students’ motivations to volunteer, some themes emerged from their responses, as follows (Table 3):
(1) Altruistic reasons
Since COVID-19 pandemic started, medical students promptly offered their help as volunteers. They reported a great willingness to contribute to decrease the harm caused by the disease, from assisting patients to helping professional colleagues, without expectations of any rewards.
“I believe we are going through an unique and delicate moment of great difficulties. I would like to help and try to minimize the impacts of the COVID-19 pandemic, concerning patients and health care professionals”.
“What motivates me is to help people who are going through great suffering. I would like to help my health care colleagues who are working and exposing themselves to take care of all the patients. I am willing to do whatever work is needed”.
Some of them also left their homes in order to get closer to the hospital and protect their beloved ones from infection, in case they were recruited to help in the health services.
“I decided to volunteer for the same reasons that I have chosen the medical career. I am living far of my parents, who are from risk groups for COVID-19 infection, what makes me more available to help. I wish I could contribute, making health assistance as efficient as possible, and diminishing health professionals wordload. Regarding my limitations as a student, I am willing to help whenever it is necessary”.
Another group of students have reported they felt socially responsible for helping in the pandemic, as future health professionals. Also, being enrolled in a medical course at a public university was strongly associated with this sense of debt towards society.
“Since I study in a public university, I believe I have a social obligation in the face of such a critical moment as COVID-19 pandemic”.
“The critical circumstances imposed by COVID-19 pandemic and the challenges it brings for our health system makes me feel responsible for helping to fight against the disease”.
“I believe medical students have a great pledge to assist the population as future doctors, graduating at a public university. (...) I also volunteered as a way to confront the feeling of powerlessness I believe a lot of my colleagues are facing too”.
(2) Academic interests
Some students have reported being attracted by the opportunity to actively join the efforts to control the pandemic as volunteers, since they identified this as an unique learning experience. They were interested in learning about clinical aspects of the infection and understanding the health system organization in face of this peculiar situation.
“We are under a state of emergency - a pandemic with such proportions the world had not faced in a hundred years. I am proud of my University and Hospital for being an example for the rest of Brazil. I think the learning experience we can take out of it is huge. Medicine is the career I chose for my life and helping is a way of thanking all my colleagues currently working in the frontline against COVID-19”.
“I would like to help in the efforts against the pandemic and to put all the knowledge acquired during undergraduation into service of the population. I am also interested in learning how to manage COVID-19 cases and how the health system is organizing in the midst of this unprecedented global shift”.
Most of the responses referred to altruistic reasons to volunteer (44%), followed by duty (37%) and academic interests (19%) (Figure 1).
Open-ended questions: volunteers perceptions on their competencies
Regarding students' perceptions on their own skills, we performed content analysis of responses, based on the six competencies framework from Royal College of Physicians and Surgeons of Canada (CanMEDS, 2015) (Table 4):
Students who have reported abilities associated with establishing relationships and providing information and orientation to patients and families were categorized as communicators, as their outstanding competency, as in the following example:
“I am communicative, very easy-going and helpful. I wish I could participate in activities involving patient orientation about COVID-19 or assisting inpatients at wards (COVID-19 or not). I'd really enjoy working in those areas”.
Students who have mentioned collaborative skills defined themselves as proactive and helpful. They were willing to learn new things in order to contribute to the work team and improve patient care.
“I am willing to work wherever I can be helpful! I am committed to learn any necessary skill and give all I can in order to help my colleagues and patients throughout this pandemic. One could say that I am a committed, organized and hardworking person. I am also willing to develop new competencies to help in any kind of volunteer activity”.
Leadership could be identified in students who reported experiences with student representation on university councils or were enrolled in extracurricular activities, generally performing administrative tasks. We observed that this group also was predominantly motivated to volunteer due to a social duty awareness.
“I believe that I am able to lead and organize people in a team, which might be useful in many contexts. I have worked in a research project during an exchange program for one semester and I have developed some ability in this field also. I have been class representative for many semesters and therefore I have learned a little about students' demands related to online education, which could be useful to volunteer activities. I am only in the 4th year, so although my medical abilities are limited I am very interested in medicine and a keen learner”.
(4) Health advocate
The health advocate profile was the least common among students. This group of students showed higher awareness about the importance of public measures to contain the spreading of COVID-19. Students reported:
“I am a communicative, collaborative, resilient person. I also like to work in a team. I would like to perform activities involving patient assistance or epidemiological data assessment. I think it is very important to help the population to raise awareness about COVID-19 pandemic, in order to control it”.
A considerable number of students described themselves as academically prepared to take part in voluntary activities. They have mentioned previous knowledge and academic experiences as potential contributors to the Volunteer Programme.
“I have some knowledge from previous experience in non-COVID internships (Neonatology and Obstetrics) and a great interest in Internal Medicine and clinical reasoning, focused on treating COVID patients. I also have previous experience in scientific research (Harvard Exchange Program)”.
Students who defined themselves as reliable and ethical called attention by their professional competency. They have commonly reported commitment and seriousness as their main qualities, as follows:
“I am very helpful and committed to tasks when they are attributed to me. I am also very willing to learn new things and work in teams. I also believe that my attitude of taking things seriously and not panicking in face of negative outcomes, always helping my colleagues on their needs and challenges, are good characteristics to volunteer services”.
Regarding quantification of responses, most students defined themselves as Scholars (36%), followed by Professionals (20%), Collaborators (20%), Communicators (13%), Leaders (7%) and Health Advocates (4%) (Figure 2).
Focus group interviews: perceptions on management-related activities and development of leadership skills during graduation
The focus group interviews included seven students who participated in health-administrative activities as part of the Volunteering Program. Their discussion was organized in 4 categories, and divided into 15 issues (Table 5).
(1) Activities performed as volunteers
Students started the discussion by retrieving some experiences they had during volunteering. They highlighted activities such as remote monitoring and providing comfort to patients with confirmed diagnosis of COVID-19, which was a grateful experience. They have also reported managing a great amount of epidemiological data, which required skills such as teamwork, leadership and organization, as well as technical knowledge to critically analyze evidence about the COVID-19 pandemic. Participating in management-related activities have contributed to the development of a sense of responsibility, autonomy and innovation for students. Some examples of their speech were:
(a) Healthcare-related activities
“Many times, people who lived alone were scared, in the beginning of the pandemic, (…) they didn’t know how their disease would progress (…) so, we called and we kept calling and sometimes from one day to another we recognized the voices (…) it was gratifying to do this follow up.”
(b) Leadership and innovation
“I thought that it was [an] enriching [experience] because we worked with different people. Furthermore, we managed to work in a group to organize that huge amount of data and try to come up with some productive thing from that.”
“I think [writing the institutional COVID-19 protocol] was something very authoral, as it was our idea. [The supervisors] were just guiding us. We had weekly meetings with them and some among ourselves. With that we decided how to write. We were divided and each one was writing a topic.”
“What I found interesting was precisely [the fact] that neither we, nor them, none of us knew how to write this document. So everything was being built and [the supervisors] experience as managers helped us a lot to see what would be feasible and applicable in our reality.”
“In fact, besides thinking about new ideas, we have adapted many things to the reality of the University of São Paulo. Because whether we wanted to or not, we discussed it a lot (...) And we couldn’t find almost anything in other documents. Because USP has infinite realities. And we were in a big discussion: "How are we going to do this? Are we going to list everything?" So I think it was a great adaptation to our reality and it was really cool.”
“It was a secure experience because we talked by phone, we received the orientations, we were prepared (…) we could communicate with people and learn from them how the symptomatology presented (…) I think that in this aspect we learned and discovered the disease.”
“Firstly, we conducted research to develop the basis of the [USP COVID-19] protocol (…) knowing the evidence about social distancing, masks, PPIs, tests and trying to bring that to USP reality (…).”
(2) Importance of management and leadership skills as a curricular component
It was unanimous among students the ultimate need for including management and leadership in the medical curriculum. But they differ on the focus of teaching. Some of them consider these skills important mainly for private practicing in the future, but another group thinks that learning about public-health administration is fundamental and, coming from a public school, this is quite a moral obligation. They would also like to discuss more about political and administrative issues that affect their academic experience as future health professionals, as a curricular activity. They have reported:
(a) Private practicing
“(...) you will occasionally have some management position in your private practice, in a hospital, in the health system, public, private (…) even in the micro, if you have a small room as your office, you already have to do some management of supplies, human resources, logistics… and, in that sense, we have zero knowledge.”
“In a hospital, public or private, [having management skills] is very important and it ends up that, in Brazil, these positions used to be occupied by non-health professionals. However, we see that it is starting to change recently, [as many doctors are starting to get trained for this]. I really don't know if there is any medical school that includes [management or leadership skills] in the curriculum, but I think it is very necessary. And it is also important for private practicing in the future. We leave college without knowing how to manage our own clinic.”
(b) Public health administration
“It is interesting to see in the macro view, you know? How the hospital was in that moment, we had a good dimension of how the hospital reduced in the worst time of the pandemic (…) it was very interesting to see from that point of view.”
“In fact there should be room for [management and leadership] at graduation, especially in terms of public health. Because our university is public and we will work for most of our graduation - in fact, in full - at SUS.”
(c) Reflection on action
“I think that our teaching hospitals, for example, would be a good opportunity for including management in the undergraduate program. We went through several crises, and are still going through some of them, in terms of hiring issues and lack of personnel, excessive demand, participation of private initiatives and so on. There are so many contradictions in terms of management and in terms of public health, but I feel that our teachers take very little responsibility for discussing this with us.”
(3) Motivation to volunteer
The sample of students invited to participate in focus group interviews showed very similar motivations to volunteer to the universe of volunteers. They reported altruistic reasons, academic interests and exploring new opportunities. Some examples were:
(a) Exploring new opportunities
“I have chosen volunteering in management because I thought it could be an opportunity to learn something new that I would not learn during graduation. Although I felt unprepared by that time, I think it was a great experience.”
“(...) At the beginning, I was afraid of the administrative field, so much that it was not my first option for volunteering. I have never felt capable, maybe because during graduation we do not have so many experiences like that. (...) Despite that, the volunteering program was a great opportunity to take the risk and overcome fear.”
(b) Altruistic reasons
“(…) The idea of contributing in some way to help in this moment of pandemic was of interest to me. As I was far away and that could be made (…) I wanted to help (...)”
“I believe that we, as future doctors, need to develop a sense of leadership and responsibility, and the fact that I study in a public university makes me feel like I have a moral obligation to return what was invested in me to society.”
(c) Academic interests
“I applied for almost every project at Volunteering Program, because I did not wanted to stay at home during the pandemic. (...) I find it very difficult to learn by reading books or attending theoretical classes. I need to apply things. And that is the way I learn best.”
(4) Acquired skills from volunteering in management and leadership-related activities
This session also resulted in similar issues, compared to all volunteers responses (see "Open-ended questions: volunteers perceptions on their competencies"), highlighting some CanMEDS competencies such as the Collaborator, the Communicator, Scholar and Professional. However, a new issue came up, which was Resilience. Students reported developing an ability to cope with frustrating situations, such as characteristic delays on referrals in the health system, as they could empathize with professionals and watch closely the work involved in managing such issues. Here are some examples to better understand this process:
“From the moment we jumped into this management thing, we learned to deal with the frustration of an uncontrolled environment, not controlled by ourselves or our team.”
“(…) because we are used to only criticize the public administration and the way the things are done especially in critical situations that nobody has answers (...) so understand and live the limitations (…) made people sympathize with other that are in that position, being more comprehensive with the limitations (…).”
“I think that what I will carry with me, what most touched me in this voluntary process in the vigilance area was the importance of communication.”
“(…) (it) showed the necessity of organization, management of people, like the colleagues that were also participating in the vigilance (...) It was a great work that we did together, we felt what were the difficulties and built solutions to those challenges.”
“I think there was some technical learning involved, for example: I had never performed a review of literature before; and all the work of choosing and reading articles, to create a large group of references.”