COVIDAssist: Exploring the perspectives on student assistance during the COVID‐19 pandemic

COVID‐19 resulted in medical students volunteering to join the health care workforce. Our study aimed to evaluate the perception of clinical staff on the benefit of students' pandemic response. The secondary aims were to (i) evaluate medical students' team working skills, (ii) identify specialties where medical students were most effective, and (iii) identify areas for further training.

in the deficit in workforce and tackle missed teaching opportunities. 8[11] The COVID-19 pandemic caused an unprecedented disruption in health care systems worldwide, stretching the already overworked health care workforce.
8][19] These challenges may have inadvertently resulted in an increased workforce burden.Hence, the true effectiveness of student response in alleviating the workforce burden remains unclear in the current literature.Most of the articles that have analysed student response during the pandemic have done so from a student perspective, [17][18][19] potentially introducing a sample bias.
The dearth of data on the perspective of health care staff (doctors and nurses) who worked alongside students poses a crucial gap in the literature, as their perspectives can provide a less biased perspective whether the student response was able to meet the requirements of the workforce and, if not, how this could be better met.Assessing the effectiveness of student response during the pandemic and identifying areas where students performed well or vice versa can provide important insights into how service delivery can be better adapted in future health care crises.Moreover, analysing student response during the pandemic provides an opportunity to explore the shortcomings of current medical education.We hypothesised that student response was largely beneficial for the workforce during the pandemic, but postulated certain pitfalls based on the available literature.Thus, the primary aim was to evaluate the perception of clinical staff on the benefit of student assistance during the pandemic.The secondary aims were to (i) evaluate medical students' team working skills outlined by General Medical Council (GMC) outcomes for graduates, 20 (ii) identify specific health care specialties in which medical students were most effective, and (iii) identify areas for further training for medical students.The results of the study and their implications were discussed using a competency-based approach, an approach that enables learners to be more independent and autonomous over their learning. 21This approach was better suited to analyse the intersection between service delivery and medical education.
The primary aim was to evaluate the perception of clinical staff on the benefit of student assistance during the pandemic.

| Research approach
This research was conducted within the paradigm of pragmatism. 22ven the current study is investigating the experiences of doctors and nurses in working with medical students during the pandemic, we aimed to develop a methodology that captured both quantitative and qualitative data to generate a rich and wide range of data.

| Study design
We conducted a national, multi-centre, cross-sectional survey of doctors and nurses.This was conducted in-line with a pre-specified protocol through InciSioN UK (International Student Surgical Network UK).InciSioN UK is a student and junior-doctor organisation promoting global surgery via research, education and advocacy. 23All health care workers employed within National Health Service (NHS) trusts and general practitioner (GP) practices, who worked alongside medical students were eligible to participate.
We conducted a national, multi-centre, cross-sectional survey of doctors and nurses.

| Questionnaire design
The survey was designed following AMEE guidance on questionnaire design. 24A scoping review of current literature on medical student pandemic response was used to develop a preliminary questionnaire.This questionnaire was disseminated to medical students within the Incision UK student network who took part in the student response during the pandemic, and students were asked to provide feedback on aspects of the questionnaire such as question structure, form and content.This The questionnaire comprises three main sections: demographic and background information of respondent (section 1), behavioural (section 2) and performance (section 3) questions with Likert scaledresponse and behavioural questions with Likert-scaled response, free text questions to investigate scope for improvement in exposure of pandemic response amongst medical students.Cronbach alpha test for the behavioural section (section 2) and performance section (section 3) of the survey showed high reliability with a score of 0.97 and 0.96, respectively.

| Questionnaire distribution
The study questionnaire was hosted on the Qualtrics platform, and the link to the questionnaire was delivered by a collaborative of medical students according to a previously used model. 25Collaborators' dissemination and recruitment were regularly monitored through weekly meetings to ensure the responses collected were representative of a national population.Furthermore, the link was also disseminated through social media channels of the three research collaboratives that led the study.Data collection was between 22 February 2021 and 8 June 2021.

| Data analysis
Quantitative and qualitative data analysis was used for this study.
Quantitative analysis involved converting the Likert scale responses to numerical value (strongly disagree, 1; somewhat disagree, 2; neither agree nor disagree, 3; somewhat agree, 4; strongly agree, 5).Quantitative data analysis was done on R 4.1.2,and descriptive statistics were reported. 26A Kruskal-Wallis test was applied to test for correlation between specialty that respondent worked in and the questions of section two which consisted of behavioural questions.
Qualitative data coding, management and analysis was conducted.Qualitative analysis used Braun and Clarke's reflexive thematic analysis approach. 27Two authors (VV and BH) familiarised themselves with the data and independently generated initial codes through an inductive process.Any differences in interpretation were discussed and agreed by mutual agreement.Respondent data were interpreted and summarised.Codes of similar information were merged leading to a series of phenomena that appeared increasingly representative of the respondent's perspectives.To reduce researcher bias and refine the synthesis of the result, regular team discussions occurred to maintain an awareness of preconceptions and constantly link the emergent themes to the interview data.Priority was given to fairly representing all the different perspectives about the phenomena under investigation to produce a respectful and balanced judgement of the themes from the quotes of the respondents.The research team consisted of authors from a wide spectrum of medical professionals that were representative of the areas where medical students were working.Where respondents indicated a preference to not answer, responses were removed.

| Reflexivity
The authorship team comprised a mixture of medical students who were volunteers and non-volunteers, junior doctors and medical educationalists across multiple institutions and varied backgrounds.The diversity in perspective of the authorship team allowed a wellbalanced and critical analysis and interpretation of the data.
T A B L E 1 Demographic of respondents.The largest group of respondents were junior doctors.Self-reported speciality was diverse across the cohort of respondents, with 'medical specialities' being the most reported.
A total of 12.7% of respondents (n = 36) reported that they were responsible for coordinating the recruitment and deployment of medical students.Of the 36 respondents, 41.7% (n = 15) was responsible for this coordination at a hospital level, while the remainder were responsible for the coordination at a ward level.

| Recruitment and deployment of students
The medical student volunteering process was not often formalised, with only 36.4% respondents (n = 103) reporting a structured process at their hospital/primary care practice.Fourteen (38.9%) of the 36 respondents who were responsible for coordinating the student response somewhat agreed or strongly agreed to having a nationally coordinated student recruitment and deployment.Most respondents disagreed or strongly disagreed with the question 'I felt patient safety was compromised by student volunteers' (79.7%, n = 237) (median 1, IQR 1-2).A breakdown of the responses to all the questions is shown in Figure 2.

| Evaluating student competencies
An independent-samples Kruskal-Wallis test comparing how respondents from different specialties (primary care, medicine, surgery, anaesthetic/ITU, academic, surgery and other) responded to the questions in sections 2 and 3 revealed no meaningful correlation, suggesting that students were generally useful across all specialties.

| Qualitative analysis of responses
The questionnaire had three free text questions as follows: • What positive effects did students have in the roles you observed above?Specify any particular roles where students had a positive impact, to a maximum of 3 roles.
• What negative effects did students have in the roles you observed above?Specify any particular roles where students had a negative impact, to a maximum of 3 roles.• What additional training should medical students have received as part of their induction?
The three free text questions received a total of 375 responses from 138 respondents.Thematic analysis was performed on these three questions.
Four themes were identified from the free text questions (Table 3); these included (i) impact on health care service, (ii) interacting with health care staff and patients, (iii) student's professional development and (iv) additional training that students require.

| Positives of student response
First, 'students improved service and promoted good clinical practice'.
The diverse professional background of students allowed them to Likert scale responses to section 3 questions on skills of students (based on GMC outcome for graduates and specific pandemic related skills).
F I G U R E 2 Likert scale response to section 2 questions on impact of student response.
undertake a variety of different roles, such as nurses, health care assistants, vaccinators and volunteers.Students were also able to help in a variety of ways from delivering food to the community to improving service evaluation.
Second, students had a positive impact when 'interacting with Difficulties with coordination and management 'Sometimes there was actually more staff available than necessary on a particular day and some medical students may have felt their role was redundant.''Sometimes they did not have logins and so computer tasks ( teamwork skills and gain skills that were useful to being a foundation doctor.

| Negatives of student response
There was a small number of respondents who thought that students lacked the competence or knowledge required for their role (Figure 2).
The large influx of students created difficulties in coordination and management, such as rota management and infection control.Furthermore, there were issues related to access management due to students lacking smartcards and computer logins.
Second, students were faced with conflicting roles as primary learners and as volunteers.Students at times required sign offs for their skills or teaching, which was difficult to deliver due to the pressures on staff.Concurrently, students themselves had to change and adapt to the pandemic, whether that was through their volunteering or their education.Students had to get used to the restructuring of health care service and manage expectations that were placed on them as student volunteers.The effect of responding to the pandemic on students' psychological well-being was highlighted, with students described to have felt overwhelmed and lacking awareness of

| DISCUSSION
1,14 Our study found that students supported a wide range of health care units by engaging in a variety of tasks, and the additional support they provided was perceived as a useful component of the pandemic workforce by most respondents (76.8%).The student response demonstrated competence based on the GMC outcomes for graduates and their response was positively received by health care staff without compromise to patient safety.Moreover, they were also found to improve team morale and clinical practise.

| Implications on medical education
While student response was generally well received, a conflicting dichotomy was noted in students as they were forced to balance their role as a doctor or volunteer while attempting to fulfil their training requirements.Given the impact of COVID-19 on medical education, 12,19 students may have been more motivated to seek out learning opportunities while volunteering. 28,29[32] Forced to balance their role as a doctor or volunteer while attempting to fulfil their training requirements.
Although health care services are largely returning to normal after the pandemic, the burden on NHS workforce is consistently increasing. 33,34Although students may not be expected to formally volunteer as they did during COVID-19, implementing learning programmes within a stressed health care system may yield unfavourable outcomes for both students and staff.Byrne et al. highlighted a similar phenomenon in their study, where they discussed the integration of clinical support roles within medical curriculum, and the potential conflict with existing educational opportunities. 35While clinical support roles can be beneficial to a student's learning, our study demonstrates that balancing this with their role as a learner can prevent students from being an active member of a health care team and reduce the efficiency of the health care team in general.
Instead, having clinical support roles and ward-based learner roles as exclusive and independent scheduled sessions within a placement timetable can enable students to enter their placement with more well-defined roles and aims.
Clinical support roles and ward-based learner roles as exclusive and independent scheduled sessions within a placement timetable.
Integrating this into a competency-based framework for students in their clinical years enables a student to acquire competencies at their own pace and utilise those competencies effectively to be a more active member of a health care team.For example, ward-based learning time can provide students the opportunity to seek out learning opportunities for specific competencies and be supervised or signed off for these competencies.In their clinical support role, they would be able to practise their signed off competencies and be an active member of the health care team, while playing a role that will be beneficial to their learning and future career.

| Implications on future health care crises response
Our study also found several notable downsides to the student response.The sudden influx of student workforce resulted in lack of coordination and management, causing staffing redundancies, reduced service efficiency and uncertainty in student roles and limits, precipitated by deficiencies within the system such as lack of preparedness for the pandemic. 36There was significant heterogeneity in student volunteering, with many respondents noting a lack of formalised volunteering process for students and highlighting the need for such a formalised process.While the UK Foundation Programme Office (UKFPO's) interim foundation programme provided a formalised platform for final-year medical students to enter employment early, 37 medical students of other years responded without any nationalised processes for trusts or medical schools to follow. 12,38e sudden influx of student workforce resulted in lack of coordination and management.There was significant heterogeneity in student volunteering.
A small number of staff felt that students worked outside competencies at times.Although our quantitative data suggest this only applied to a minority of students, as 78.9% of respondents felt that students were competent in their role, and 84.1% felt students undertook their competencies and escalated appropriately.This was predicted in an opinion piece by Rainbow et al, which discussed the possibilities of students working outside of competencies due to the pressures on the NHS. 12 Any adaptation of service delivery to integrate medical students during a health care crisis can be better conducted if done locally, owing to medical students being more familiar with the health care infrastructure and teams within the hospitals they are training in. 39,40ganising service delivery through a competency-based approach can allow services and departments requiring additional workforce to be classified based on the competencies they require.Thus, medical students can be deployed to the appropriate areas based on their competencies.
Service delivery to integrate medical students during a health care crisis can be better conducted if done locally.

| Limitations of study
There are a few limitations in this study.First, given that this survey is self-reported, some of the findings can be subjective, and for a truly objective assessment of student response, local initiatives need to be undertaken to evaluate service efficiency during student response.
Second, as this was a nationalised survey, there will be some heterogeneity in staff perception of student response as guidance and processes regarding student response may have varied between each hospital.Moreover, some hospitals may have received more responses than others; hence, the results may not be generalisable to the overall population of doctors and nurses.As student collaborators disseminated the survey to staff who worked alongside medical students, this may have introduced a sample bias of respondents who have a generally positive perception of the student response.However, this was an intentional study design to target and capture the perception of staff who worked closely with students.Finally, our survey had a high Cronbach alpha value, indicating a large level of overlap between questions.However, due to the rapidly changing research landscape mandated by COVID-19, we opted for a higher level of granularity in our questions and accepted the high Cronbach alpha value.

| CONCLUSION
Our data shows that students were an effective part of the workforce during COVID-19 and that health care staff stated that they would want to have students integrated within their team even within a non-pandemic setting.However, without appropriate definition of a student's role within a clinical setting, students may be forced to balance learning and service provision, negatively impacting their own learning and the general efficiency of the team.Providing students with dedicated clinical support roles and ward-based learning roles with a competency-based approach not only holds potential to be a powerful learning tool but can also strengthen health care systems to face future health care crises.
Students were an effective part of the workforce during COVID-19.
pilot questionnaire and feedback from respondents helped refine the questionnaire and establish face, response and construct validity.Based on the response and feedback collected, a final questionnaire was developed with key items from the General Medical Council (GMC) outcomes for graduates (GMC outcome 1 'professional values and behaviours' and GMC outcome 2 'professional skills') integrated into it.The study was validated by members of Incision UK, The Royal Society of Medicine Students Section and medical educationalists who had no part in the inception and write up of the questionnaire.
Most respondents either agreed or strongly agreed that students were competent in communication (median 4, IQR [interquartile range] 4-5), escalating (median 4, IQR 4-5), and donning and doffing of PPE (median 4, IQR 4-5).Overall positive responses were also present for being able to admit to making mistakes (median 4, IQR 4-5) and politeness towards patients (median 5, IQR 4-5).Most respondents agreed or strongly agreed to the questions 'I felt students were competent performing the roles they were given' (78.9%, n = 187) (Figure1).There were six questions in section 2 of the questionnaire that focussed on the overall impact of student response, with all responses being recorded in Likert scales.Most respondents agreed or strongly agreed to the question 'I felt students had a positive impact on the healthcare teams during the pandemic' (76.8%, n = 250) (median 4, IQR4-5).This offers a key insight into the positive impact students had during the pandemic and the potential they hold in future pandemic type scenarios, which will be focussed on more in the discussion section.
healthcare staff and patients' by improving team morale and a positive work ethic.Students helping in tasks such as clerking and observations allowed staff to focus on more pressing matters.Students also had more time to communicate with patients, resulting in a positive effect on communication and continuity of care between patients and staff.Moreover, students contributed to improved patient care and comfort by helping patients communicate with their relatives remotely.Finally, there was a positive impact on student's professional development.The experience of responding during a pandemic allowed students to develop their communication skills, developing T A B L E 3 Qualitative themes identified by the free text responses.Impact on health care service Students improved service and promoted good clinical practise '(Students) maintained patient safety when nursing ratios were totally abnormal.''(Students) helped decrease waiting times to be seen and increase bed space by clerking patients in triage.'Students had limited competency and were uncertain in their role 'Students were left to observe patients and monitor patients in the absence of a competent ICU nurse when ratios were stretched during the pandemic.''At times they (students) appeared lost as to what to do, and had no given role.' training that students required, five subthemes were identified: students require trust-specific training such as local guidelines and IT training, students require pandemicspecific training on knowledge and skills, students need training on particular clinical skills and knowledge, students require training of soft skills such as human factors and communication and students require mental health support.
Observed student demographics as reported by study respondents.
T A B L E 2