Effect of the COVID-19 Pandemic on the Performance of Undergraduate Healthcare Students During Their Internship in Saudi Arabia

Introduction

The Kingdom of Saudi Arabia (KSA) announced the first case of the coronavirus illness 2019 (COVID-19) on March 2, 2020. Saudi governmental officials had implemented social distancing measures, including curfews and the suspension of large gatherings, even prior to the confirmation of the country’s first COVID-19 case.¹ Approximately 1600 COVID-19 cases were reported by the end of March, and by the end of April, that number had increased to 24,100 cases.^2,3

Numerous facets of human existence have suffered greatly as a result of this epidemic. Numerous research has looked at how it has affected different healthcare professional (HCP) groups.^4–7 Amidst this vast body of data, healthcare interns are a segment of the healthcare system that, despite the pandemic’s profound effects on them, has gotten relatively little attention in the literature.^6,8 The one-year supervised hospital training program required to get a bachelor’s degree in medicine and allied health care professions is referred to as an “internship” in the Kingdom of Saudi Arabia (KSA).⁹

There were significant challenges for students finishing their final-year internships because to the COVID-19 pandemic.⁵ To limit the infection, some institutions closed, which resulted in the suspension of internship programs. Students found themselves in a challenging predicament because completing an internship is frequently necessary to graduate.^5,6 Despite these challenges, the students showed perseverance in overcoming them. Very few studies explicitly address the challenges faced by final-year internship students; the majority of material presently in publication focuses on the broader implications of COVID-19 on the education system.^5,6,10

Bugis, 2021 discussed the impact of COVID-19 pandemic on the internship activities at health organisation in Saudi Arabia. Data from 101 healthcare interns from various health organisations were secondary evaluated for this study. Sixty-two percent of interns began their internships or received training at public health facilities. Private health organizations made for 6.12% of the total, while other medical institutions accounted for 29.59%. During the Covid-19 epidemic, a majority of health organizations (76.53%) chose to continue internships, while 23.47% chose to cease training. In response to various challenges during the pandemic, health organizations adopted a range of strategies and approaches. This research illuminates the adaptability employed by health organizations to support the medical interns but also further stresses the need for variety of more strategies to be implemented to support the medical interns on internship preparation.¹⁰

In a study conducted via Balay-odao et al, a thematic approach was employed to explore the experiences of Saudi nurse interns during the COVID-19 pandemic. The participants completed their internship in five cities in Saudi Arabia. The study identified five themes: passion, lack of knowledge and skills, concern for their families, caution, and disorientation. As a result, they concluded that the lack of knowledge among interns, concerns about the safety of their families, and the workplace environment were the main challenges faced by nurse interns during the pandemic.¹¹

Based on the points mentioned earlier, the internship year is a critical period as it enables students to acquire the necessary skills before graduating.¹⁰ Regrettably, there are only a few studies available in the literature that have assessed the performance of undergraduate healthcare students during their internships. As a result, the purpose of this study is to comprehensively explore the effect of the COVID-19 pandemic on the mental, social, and leadership aspects of undergraduate healthcare students as they undergo their internships in Saudi Arabia.

Methodology

Study Design

A national cross-sectional survey was conducted by targeting all the interns at healthcare programs in Saudi Arabia to evaluate the effect of COVID-19 on their performance during their clinical rotations.

Settings, Target Participants, Sampling Technique and Procedure

The study was carried out between August and December 2021 among the interns at healthcare programs in Saudi Arabia. A non-probability convenient sampling technique was utilized in this study. The inclusion criteria for this study were all the interns at undergraduate healthcare programs accredited via National Commission for Academic Accreditation and Assessment (NCAAA). The study excluded students who have been diagnosed with acute or chronic mental health disorders, as well as those who refused to provide informed consent.

Thirty-one government universities and 20 private colleges were invited to participate in our study. The research team reached out to each university and college to obtain the Email addresses of program directors. Subsequently, an Email was sent to them containing a letter of solicitation explaining the purpose of the study, along with a Microsoft Form survey link. The program directors were asked to forward this letter to their interns and encourage their participation. The approach was designed to ensure that the survey reached all the interns, aiming to gather honest and unbiased feedback. Furthermore, reminder emails were sent to the program directors every week for two months.

Sample Size Determination

The study’s sample size was calculated using G-Power software, which recommended a sample size of 236 based on a medium effect size of 0.37, an alpha (α) of 0.05, and a power of 0.80. This sample size is essential for accurately analyzing the correlation coefficients between the study’s domains and the independent variables.

Research Tools

A self-administered questionnaires was used to answer the research questions. The survey consisted of two parts. The first part consisted of demographic profile: gender, university types, university name, speciality, degree, number of rotations, hospital types, and training period. The second part consisted of three domains: mental health, social life, and leadership. The mental health domain consisted of five statements adapted from current evidence in the literature.^12,13 The social life domain consisted of three statements adapted from current evidence in the literature.¹³ The leadership domain consisted of three statements adapted from current evidence in the literature.^14,15 This survey utilized 5 points Likert scale: never, rarely, occasionally, frequently, and always. Three experts on the related field were invited to evaluate content validity of this tool. In addition, Cronbach’s α alpha was measured to evaluate coefficient of reliability of tool, and the reliability scores were 0.72, which indicated high internal consistency of the used tools.

Data Analysis

Statistical Package for Social Sciences (SPSS) version 27 was utilized to analyze data and a statistical significance level of 0.05 was employed. First, data were downloaded and cleaning to be suitable for analysis and then transferred it to SPSS. The data were stored in a flash drive and stored at principal investigator office to assure data integrity. Second, the normality test was used to determine normality of the sample. Third, descriptive statistics were used to analyse demographic profile and each questionnaire item. Third, the correlation coefficients between the study’s domains and the independent variables (ie, gender, university type, specialty, degree, hospital number, hospital type, and training period). The point-biserial correlation is used to measure the correlation between a dichotomous variable and a continuous or ordinal variable. In addition, the Kruskal–Wallis one-way analysis of variance (ANOVA) is used to compare the medians of three or more independent groups.

Ethical Issues

The IRB committee of King Abdullah International Medical Research Center approved this study (SP21J/076/03). The participants were informed prior to participating to have a right to withdraw from the study at any time without any consequences. Participants chose to participate voluntarily, and their anonymity and confidentiality were guaranteed. In this study, guidelines outlined in the declaration of Helsinki were followed.

Results

Demographics

A total of 328 responses were received; however, 241 participants were selected in this study based on the inclusion criteria. Out of these participants, 130 (53.9%) were female and 111 (46.1%) were male. The majority of individuals in the sample come from public universities, accounting for 92.5% of the total. In contrast, private universities represent only 7.5% of the sample. The distribution of universities in the sample is quite varied, with some institutions being more prominently represented than others. For instance, KSAU-HS stands out as the most common university among the respondents, making up to 28.6% of the sample. However, there’s a noticeable variation in the representation of other universities, with several institutions having only a minimal presence in the sample. For the specialty, medicine, nursing, and respiratory therapy are the most common, each representing around 17.8%, 14.9%, and 14.1%, respectively. The vast majority of respondents in the sample hold a bachelor’s degree (96.7%), while a smaller fraction possesses an associate degree (3.3%). The majority of interns did their clinical rotations in one hospital (49.4%), while 2.5% did their clinical rotations in more than 4 hospitals. The majority of interns did their clinical rotations in public hospitals (86.3%). For the training period, 72.2% of the interns did clinical rotations around one year (Table 1).

Table 1 The Frequency and Distribution of the Sample’s Socio Demographic Characteristics (N = 241)

Normality Test

The Kolmogorov–Smirnov tests for mental health, D (241) = 0.07, p = <0.0001; social life, D (241) = 0.09, p = <0.0001; and leadership D (241) = 0.18, p = <0.0001 showed significant deviation from normal distribution.

Mental Health Domain Responses Findings

Table 2 presents the outcomes of the mental health domain in the questionnaire items from all interns. The majority of interns reported that they occasionally (36.9%) or frequently (37.3%) have problems with relaxation while 2.5% of the interns said never have problems with relaxation. When it comes to getting easily angry or upset, 36.1% of the interns said they easily got angry. When the interns asked about mentality during the pandemic, 45.2% positively having a good mentality during the pandemic, and their performance had not decreased. Only a few interns 3.3% had bed performance during pandemic. When it comes to the feeling of having no time to do anything, the distribution of responses reveals that a substantial number of interns occasionally 27.8% and frequently 36.9% experience this perception. A significant portion indicated they rarely 23.7% feel this way. A smaller group mentioned they never 3.7% or always 7.9% have this sentiment. Finally, the statement regards frequent headaches, the interns reported that they rarely 32.8% or occasionally 29.5% experience headaches during a clinical rotation. A significant proportion mentioned they frequently 23.2% have headaches. A smaller but still considerable percentage stated they always 3.7% have headaches, while a few respondents reported never 10.8% experiencing this problem.

Table 2 The Answers Distribution Summary of the Mental Health Domain (N = 241)

Social Life Domain Responses Findings

Table 3 presents the outcomes of the social life domain in the questionnaire items from all interns. This domain contains three statements: “I feel like I do not have someone to talk with about my daily life”, “I have been distanced a lot from my family during the pandemic due to my work environment”, “I feel that I need to go through hard things in life all alone”. In response to the first statement, a significant portion of interns 53.9% felt isolated while 10.8% felt the opposite. In response to the second statement, 66.8% of the interns have been distanced from their family due to pandemic. In response to the third statement, 76.4% of the interns showed a significant challenge that need to be overcome alone, while 1.2% of the interns could have support to overcome challenges.

Table 3 The Answers Distribution Summary of the Social Life Domain (N = 241)

Leadership Domain Responses Findings

Table 4 presents the outcomes of the leadership domain in the questionnaire items from all interns. This domain contains three statements: “I have good working relationship with my supervisor”, “Healthcare providers at hospital support me whenever I need them”, “I do not get sufficiently paid in reflect to the amount of work I do”. In response to the first statement, 65.2% of the interns indicated that they always and frequently have a good working relationship with their supervisors. About 26.1% of the interns had positive working relationship with their supervisor occasionally. A few interns 1.7% had negative working relationship with their supervisor. In response to the second statement, the majority of the interns 57.7% indicated that they always and frequently received support from the healthcare providers whenever they need it while 1.2% of the interns indicated that they never received support from the healthcare providers. In response to the third statement, 50.7% of the interns disappointed about the salary they received compared to the amount of work they do.

Table 4 The Answers Distribution Summary of the Leadership Domain (N = 241)

Correlation Coefficients Findings

For mental health domain, there was a negative significant correlation with gender, r = −0.25, p= <0.0001 (Figure 1). As the correlation coefficient was negative, it suggested that mental health tended to decrease as the gender changed from female to male. The mean of the female score in mental health was 16.08 which was higher than the mean of male score in the same domain 14.29. In contrast, there was no significant correlation between mental health domain and the university type, r = −0.021, p = 0.74; the speciality, H = 12.17, p = 0.51; degree, r = 0.10, p = 0.11; a number of hospitals during the clinical rotations, H = 2.56, p = 0.63; the hospital type that intern performed clinical rotations, H = 1.090, p = 0.78; training Period; H = 3.87, p = 0.27.

Figure 1 Box plot (gender and mental health).

For social life domain, there was a negative significant correlation with gender, r = −0.13, p = 0.039 (Figure 2). It suggested that social life tended to decrease as the gender changes from female to male. Th mean of the female scores in social life was 9.48 which was higher than the mean of male score in the same domain 8.86. In contrast, there is no significant correlation between social life domain and the university type, r = −0.038, p = 0.55; the speciality, H = 9.72, p = 0.72; degree, r = −0.006, p = 0.93; a number of hospitals during the clinical rotations, H = 2.45, p = 0.65; the hospital type that intern performed clinical rotations, H = 3.20, p = 0.36; training Period; H = 0.801, p = 0.84.

Figure 2 Box plot (gender and social life).

For leadership domain, there was a significant correlation with specialty H = 44.10, p= <0.0001 (Figure 3). Then, a post hoc test performed between the specialty variable and the leadership domain. Those who were medicine major showed negative impact towards leadership compared to emergency medical services, respiratory therapy, and anesthesia technology majors. In addition, the nursing had negative impact towards leadership compared to anesthesia technology. In contrast, there is no significant correlation between leadership domain and gender, r = 0.10, p = 0.11; university type, r = −0.063, p = 0.32; degree, r = −0.073, p = 0.25; a number of hospitals during the clinical rotations, H = 4.88, p = 0.30; the hospital type that intern performed clinical rotations, H = 5.96, p = 0.11; training Period; H = 7.66, p = 0.053 (Table 5).

Table 5 The Correlation Coefficients Between the Study’s Domains and the Independent Variables (N = 241)

Figure 3 Box plot (specialty and leadership).

Discussion

The study conducted to explore effect of COVID-19 pandemic on the mental, social, and leadership style of the undergraduate healthcare students during their internship in Saudi Arabia.

On the mental health domain, the majority of the participating felt overwhelmed due to intensive workload. In fact, the outcome of this study highlighted the gender disparities in the mental health domain, particularly within professional settings. The level of stress, anxiety, and insomnia symptoms for the female students were higher than male. Unfortunately, increased psychological burden can adversely affect their performance, especially during critical periods such as COVID-19.^11,16 These outcomes lead to emphasize the need for preventative actions to foster healthy coping strategies and establish an institutional culture that prioritizes the mental health of medical professionals.^17,18 Generally, it’s essential to address each individual difficulties; however, the complications appeared through these tough experiences should be acknowledged via organizations for many factors such as reduced cost of treatment, safety of the undergraduate students, and the students. Therefore, numerous studies in the literature support the findings of this study by emphasizing the need for an integrated mental health framework within healthcare systems to ensure the well-being and sustainability of the healthcare workforce.^19–21

In the social life domain, our study indicated that the majority of the participants experienced feelings of isolation, longing for their loved ones, and struggling to overcome challenges especially for female participants. In fact, the nature of daily activities for undergraduate students, especially young adults who are still young and not fully prepared for such a challenging experience, has left them severely impacted by the lockdown.²² Interestingly, the influence of the culture was playing a crucial role in this study. In Saudi Arabia, the strong bond between the family members is essential in their cultural tradition. They make it a priority to visit and communicate on a daily and weekly basis. Consequently, the pandemic helped the people to be connected strongly to their families.²³ Our study confirmed that participants who worked during these tough experiences faced potential challenges, as they had to be away from their families to keep them safe and prevent the spread of infection to them. Numerous studies in the literature support our findings and suggest implementing community health and wellness programs.^13,24,25

The hospital environment requires significant attention and collaboration among healthcare professionals due to the immense work pressure.²⁴ For undergraduate students beginning their work experiences and transitioning from the traditional classroom to real-life settings, there is a crucial need for careful guidance, particularly from their mentors. Unfortunately, due to the current pandemic crisis, the responsibilities of supervisors/mentors have increased even further in order to effectively prepare students for these unique circumstances.^25–27

In the leadership domain, our study focused on how interns perceive their relationship with their supervisors and the support they received from the hospital. Overall, most interns had a positive relationship with their supervisors and felt supported by the hospital. In accordance with our findings, al Kuwaiti et al conducted a study to evaluate internship training program in Saudi Arabia. They found high satisfaction rate among medical interns towards relationship with superior and hospital supports.²⁸ In addition, a few schools in Saudi Arabia decided to suspend training program during pandemic to overcome stress and anxious that may affect interns.¹⁰ Generally, the support and collaboration within the healthcare organizations in Saudi Arabia greatly influences the experiences of healthcare professionals, particularly interns.¹⁰ However, despite the positive environment, it was found that the majority of respondents feel that their income is insufficient. This can be attributed to the educational system in Saudi Arabia, where interns are considered undergraduate students and the internship is part of their study plan. The financial support they receive is not considered a salary, but rather an incentive from the Ministry of Education. Therefore, the amount of incentives is fixed for all students in Saudi Arabia.²⁹ As mentioned previously, the interns had positive perceptions towards supervisors and health organization services. It is important to highlight that there was a divergence in opinions regarding leadership domain across various specialties, including medicine, emergency medical services, respiratory therapy, anesthesia technology, and nursing. The potential disparity in viewpoints and actions among health organizations may arise from the varying level of exposure to COVID-19 patients within each specialty.

Study Limitations and Future Works

This study provides useful information, it is nevertheless necessary to acknowledge its limitations. Response biases might be induced because of the cross-sectional design and the self-reported nature of the data. The cross-sectional methodology employed in this study is undoubtedly valuable for obtaining a snapshot of the respondents’ experiences. However, it limits our comprehensive comprehension of the dynamic challenges encountered by various groups of healthcare professionals. Despite the sample’s diversity, it may not be a true representation of the whole healthcare profession. Underrepresentation of variations in experiences is based on contextual factors like geography or specific healthcare responsibilities.

Future research may include stratified sample techniques to ensure a more thorough understanding of the challenges faced by different groups in the healthcare workforce. Longitudinal study may provide a deeper understanding of the changing nature of these challenges. Furthermore,

A qualitative study can provide a profound understanding of the perspectives and experiences of healthcare practitioners. This kind of study will assist universities and healthcare organizations in establishing concise guidelines to prepare the next generation of healthcare professionals for future crises.

Conclusion

In conclusion, this study explores important aspects of the well-being of undergraduate healthcare students during internships. The focus of this study was on the mental, social, and leadership aspects of interns. Mentally, the intern students experienced stress and anxiety during the pandemic. The intern students experienced feelings of social isolation due to their decision to prioritize safety by maintaining distance from their loved ones. In fact, the female students faced difficult time compared to the male students. The interns’ perceptions towards their supervisors and health organization services during pandemic were incredibly positive. However, they were not happy with the incentives they were received. Moreover, the interns had positive perceptions towards supervisors and health organization services. The findings of this study highlight the significance of creating comprehensive strategies that tackle mental, social, and leadership aspects in order to improve the resilience and overall well-being of undergraduate healthcare students during internship.