key: cord-0312907-dr761o53
authors: Byrne, M. H. V.; Ashcroft, J.; Wan, J. C. M.; Alexander, L.; Harvey, A.; Schindler, N.; Brown, M. E. L.; Brassett, C.
title: Examining Medical Student Volunteering During The COVID-19 Pandemic As A Prosocial Behavior During An Emergency
date: 2021-07-07
journal: nan
DOI: 10.1101/2021.07.06.21260058
sha: 3e2cd20e7e476dc60e206e35b8d4aef7ec3ff35e
doc_id: 312907
cord_uid: dr761o53

Introduction: COVID-19 has caused major disruptions to healthcare, with voluntary opportunities offered to medical students to provide clinical support. We used the conceptual framework of prosocial behavior during an emergency - behaviors whose primary focus is benefiting others - to examine volunteering during COVID-19. Methods: We conducted an in-depth, mixed-methods cross-sectional survey, from 2nd May to 15th June 2020, of medical students studying at UK medical schools. Data analysis was informed by Latane and Darley's theory of prosocial behavior during an emergency and aimed to understand students' decision-making processes. Results: A total of 1145 medical students from 36 medical schools completed the survey. While 947 (82.7%) of students were willing to volunteer, only 391 (34.3%) had volunteered. The majority (92.7%) of students understood that they may be asked to volunteer; however, we found that deciding one's responsibility to volunteer was mitigated by a complex interaction between the interests of others and self-interest. Further, concerns revolving around professional role boundaries influenced students' decisions over whether they had the required skills and knowledge to volunteer. Deciding to volunteer depended not only on possession of necessary skills, but also seniority and identification with the nature of volunteering roles offered. Conclusions: We propose two additional domains to Latane and Darley's theory of prosocial behavior during an emergency that students consider before making their final decision to volunteer. These are 'logistics' - whether it is logistically feasible to volunteer - and 'safety' - whether it is safe to volunteer. This study highlights a number of modifiable barriers to prosocial behavior that medical students encounter and provides suggestions regarding how Latane and Darley's theory of prosocial behavior can be operationalized within educational strategies to address these barriers. Optimizing the process of volunteering can aid healthcare provision and may facilitate a safer volunteering process for all.

strategies to address these barriers. Optimizing the process of volunteering can aid healthcare 25 provision and may facilitate a safer volunteering process for all. 26 All rights reserved. No reuse allowed without permission.

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On 24 th March 2020, the UK Secretary of State for Health and Social Care announced plans 28

for medical students to assist in the COVID-19 pandemic 1 . In response to this, medical 29 schools accelerated the graduation of over 5000 final year medical students to act as interim 30

postgraduate year one doctors 2 , and volunteering opportunities were created for non-final 31

year students 3 . As clinical placements were cancelled and medical school examinations 32 postponed or replaced, there was the potential for many students to volunteer 4,5 . 33

Volunteering is a form of prosocial behavior -behavior which provides help to others where 35 a direct personal benefit is not a necessity but self-interest is considered 6,7 . As such it can 36 have positive benefits for both doctors and patients 7 . Prosocial behavior is an important 37 professional value in medicine 8, 9 . Indeed, the Situational Judgement Test that final year 38 medical students in the UK must pass prior to graduation examines prosocial decision making 39 (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted July 7, 2021. ; https://doi.org/10.1101/2021.07.06.21260058 doi: medRxiv preprint Studies prior to the COVID-19 pandemic have reported the readiness of medical students to 52 volunteer in hypothetical disasters and infectious disease outbreaks 13, 14 , and early studies 53 into COVID-19 indicate that the majority of students appear willing to volunteer 15, 16 . 54 Rasmussen et al. showed that a high percentage of medical students from a single centre in 55

Denmark wanted to volunteer (82.4%) 15 . However, other studies have shown that, whilst 56 students are willing to volunteer during COVID-19, fewer students have actually done so 17-57 19 . A single centre study of 137 German medical students demonstrated that 70.1% were 58 willing to volunteer, but only 25.0% of students did 18 . Despite this discrepancy between 59 motivation and practice, minimal literature exists on the factors motivating students to 60 volunteer during COVID-19 18,20,21 . Understanding the factors that influence prosocial 61 behavior during the current pandemic is essential, as over 40,000 medical students who are 62 studying in the UK could represent a valuable asset if empowered and mobilized as 63 volunteers 22 . 64

In view of the above, we conducted an in-depth, mixed-methods survey to explore 66 volunteering among UK medical students during COVID-19, using the conceptual 67 framework of prosocial behavior described by Latane and Darley, and Baron et al. 6, 12 . 68

Through developing an understanding of students' motivations to volunteer, we aimed to 69 identify educational strategies which support prosocial behaviors during emergencies to 70 support medical education volunteering pathways. 71

This research was conducted within the paradigm of pragmatism. Pragmatism concerns itself 74 with problem solving, and often utilizes mixed-methods approaches 23 . In line with our 75 pragmatic orientation, we chose not to forefront considerations of epistemology and ontology 76 24 , and focused on designing an effective study expeditiously within the new research 77 landscape mandated by COVID-19. As such, an online survey was selected for data 78 collection for ease of dissemination and wide reach. Questions were asked with both 79 quantitative and qualitative outputs to provide broad and rich data reflective of a wide range 80 of experiences 25 . 81

We conducted a cross-sectional survey from 2 nd May to 15 th June 2020 of students studying 83 at UK medical schools, following the STROBE guideline for cross-sectional studies 26 . The 84 survey consisted of 53 questions assessing previous clinical experience, attitudes to 85 volunteering, motivation and barriers, volunteering role, medical education, issues currently 86 faced, and safety (Appendix 1). Survey development was informed by a systematic review of 87 existing literature on volunteering during pandemics and disasters, and previously used scales 88 27 . Questions were then developed by MHVB and JA with expert input and consultation with 89 medical students, and final questions were reviewed by medical students to establish face 90 validity. The survey was hosted on Google Forms with no identifiable data collected, and 91 data were held on a secure server. 92 All rights reserved. No reuse allowed without permission.

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We used a convenience sampling approach to recruit medical students. Medical schools listed 94 on the UK Medical Schools Council website were invited via email to distribute the survey to 95 their students 28 . Messages were posted once a week to Twitter and Facebook asking medical 96 students to complete and share the survey to recruit more participants via a snowball 97 approach. 98

Ethical approval for the study was obtained from the University of Cambridge Psychology 100

Research Ethics Committee (PRE.2020.040). 101

We asked students to indicate their level of agreement using a 5-point Likert scale 103 (1=strongly disagree; 5=strongly agree) on items representing volunteering, role, clinical 104 skills, motivation/barriers to volunteering, issues with volunteering, and risk and safety. 105

Statistical analysis was performed by JW using R (version 4.0.1) 29 . Data are presented as 106 mean ± standard deviation (SD) and as percentages in each category of the Likert scale. 107

Correction for multiple testing was performed using a Benjamini-Hochberg correction in R 108 using the rstatix package. 109 110 Multiple linear regression of predictors for 'I am willing to volunteer (Likert)' was performed 111 in R using lm(). For this model, the variables used were 'year at medical school' and survey 112 responses around beliefs for the prediction of volunteering status. Data for subgroups were 113 analysed separately and included in the multiple regression model. These groups were chosen 114 to ascertain whether attitudes differed between years at medical school and if any differences 115 existed between those who chose to volunteer and those who did not. Entries with missing 116 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. ; https://doi.org/10.1101/2021.07.06.21260058 doi: medRxiv preprint data were excluded from the analysis using the na.omit function in R. Backward stepwise 117 model selection was performed using stepAIC() from the MASS package. 118

Thematic analysis was used to analyse qualitative responses using the six-step approach 120 described by Braun and Clarke 30 . Two authors (LA and MHVB) familiarised themselves 121 with the data, and created initial inductive, descriptive codes for all data. To identify themes, 122 a semantic approach was used. Initial codes were analysed for patterns, grouped, 123 summarised, and interpreted. Themes and subthemes were checked against the initial codes 124 and the data set as a whole, and any interpretative discrepancies explored and resolved by 125 consensus. Themes and subthemes were then reviewed, discussed, and agreed by all authors. 126

To analyse how our data applied to Latane and Darley's theory of prosocial behavior during 129 an emergency, we used a theory-informing inductive data analysis approach 31 . We did not 130 impose our definition of prosocial behavior during an emergency upon participants, instead 131 allowing them to express their own views in response to questions. We first performed our 132 quantitative and qualitative analysis, later applying Latane and Darley's theory to our data as 133 a 'sensitizing concept'. Though sensitizing concepts originate from the methodology of 134 constructivist grounded theory 32 , they have since been applied as part of reflexive analysis in 135 a way that aligns with Varpio et al.'s 'theory informing inductive data analysis' approach 33 . 136 This is the way in which we utilized theory within this study. 137

Data were reviewed using this theoretical framework by MHVB and MELB, and areas of 138 concordance and conflict explored and highlighted, then discussed and agreed by all authors. 139 All rights reserved. No reuse allowed without permission.

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The authors of this study comprise a diverse range of doctors in training, medical students, 141 medical education researchers, and consultants across multiple educational institutions. The 142 range of experiences at different stages and institutions permitted a wide scope of viewpoints 143 regarding the data, thus enriching analysis. 144

Demographics 146

A total of 1145 students from 36 medical schools were represented in this study ( Figure S Noticing something is abnormal and interpreting the situation as an emergency 157

The majority of students (92.7%) recognized that medical students might be asked to 158 volunteer due to COVID-19. We interpret this as widespread recognition of an abnormal, 159 emergency situation. 160

Across all year groups, 947 out of 1145 students (82.7%) strongly agreed or agreed with the 162 statement 'I would be willing to volunteer to work', which suggests that most students felt 163 responsible for helping ( Figure S 2) . The reasons for this were complex, with a wide range of 164 motivating and barrier factors for volunteering (Table 1) . Factors influencing the 165 responsibility to volunteer can be divided into two groups: in the interest of others and self-166

interest. The former included altruism, moral obligation, family or social commitments, 167 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. ; others' safety, societal expectations, medical school expectations, and peer pressure; the latter 168 included professional development, academic and work commitments, personal safety, 169 psychological impact, discrimination, and financial implications. 170

While most students were willing to volunteer, less than half of the students felt they should 171 be encouraged to volunteer (Figure S 2) . 172

Eighty percent of students felt they would have a positive impact by volunteering. We 174 assessed students' preference for specific volunteer roles, and their confidence in the skills 175 required for these roles. 176

We asked students to indicate the roles they were willing to perform as volunteers. Twenty-177 six percent of students strongly agreed or agreed that they were willing to perform the full 178 clinical role of a doctor, whereas 857 (75.3%) and 882 (77.7%) were willing to undertake an 179 assistant medical role or provide indirect medical care (such as providing meals or moving 180 patients), respectively. The majority of students were willing to perform the same role on a 181 ward with patients with COVID-19 (n=943, 82.3% strongly agreed or agreed, Figure 1 ). 182

Senior students were more willing to perform the full clinical role expected of a doctor but 183

were less willing to provide indirect medical care ( Figure S 3) . 184

We looked at student confidence in skills required for these roles using a Likert scale ( Figure  185 1). Across all year groups, students were most confident in clerking new admissions 186 (mean=3.4/5, 95% CI=3.3-3.5) and performing venepuncture (mean=3.4/5, 95% CI=3.3-3.5). 187

Students were least confident in prescribing medication (mean=2.0/5, 95% CI=1.9-2.0) and 188 initiating management plans for patients (mean=2.1, 95% CI=2.0-2.1). For all skills except 189 for donning and doffing PPE, there was a significant positive correlation between the 190

respondents' year group and their confidence in performing them (Benjamini-Hochberg 191 adjusted P<0.05). 192 All rights reserved. No reuse allowed without permission.

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At the time of the study, 391 of 1145 students (34.3%) had volunteered during the pandemic 194 (Table S 1) . 201

The strongest predictors of willingness to volunteer using multiple linear regression were the 203 beliefs that volunteering to work would benefit a student's medical education 204 (estimate=0.35±0.03, adjusted P<0.001, Table S 2) and that the student would make a 205 positive impact (estimate=0.33±0.03, adjusted P<0.001). Students who believed there were 206 ethical issues with asking medical students to volunteer were less likely to volunteer 207 (estimate=-0.08±0.02, adjusted P<0.001), as were those who had begun considering a career 208 outside of medicine because of the pandemic (estimate=-0.08±0.02, adjusted P=0.001). 209

Increasing age was a significant negative predictor of willingness to volunteer, independent 210 of medical school year group, after correction for multiple testing (adjusted P=0.043). 211

Across all year groups, the median self-estimated probability of contracting COVID-19 was 213 50.0% (IQR = 20.0%-65.0%, n = 962), which was not influenced by year or volunteering. 214 43.5% (n=475) felt there was a lack of information regarding volunteering opportunities 215 available. 216 All rights reserved. No reuse allowed without permission.

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Our qualitative analysis focused on the later stages of the decision-making process. We asked 218 students what ethical concerns they had about volunteering and the issues they anticipated 219 they would face while volunteering (Table 2) . We defined five themes: Pressure to volunteer; 220 Education; Professional practice; Safety; and Logistics. 221

Two themes were relevant to deciding responsibility: pressure to volunteer and education. 223

Students expressed feelings such as guilt, obligation and, even a sense of coercion. There 224 were concerns that opportunities may not be promoted in a neutral way and that it should be 225 students' own choice to volunteer rather than due to pressure from external organizations 226 (Table 2) . 227

The theme of education was also relevant to deciding responsibility. Some students felt that 228 volunteering was an opportunity to replace disrupted teaching opportunities, whereas others 229 found there was a conflict between volunteering and studying for their medical degree, which 230 was compounded by a perceived lack of training for volunteers (Table 2) . 231

Regarding skills or knowledge required, we identified concerns surrounding the themes of 233 professional practice and safety. Students were concerned about their competency and 234 questioned the usefulness of inexperienced medical students, as they might constitute a 235 burden. These concerns were closely linked to safe practice -that patient care might be 236 affected due to working outside of competency, especially if there was a lack of supervision 237 or clarity regarding the professional role boundaries of new doctors. 238 239 All rights reserved. No reuse allowed without permission.

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The theme of safety also played a key role in decision making. This included considerations 241 of personal safety, the risk of contracting COVID-19 (particularly with inadequate PPE, or 242 for students with pre-existing health issues), as well as the psychological impact and stress of 243 working during a pandemic. Students were concerned about transmitting COVID-19 to 244 others, the risk posed to vulnerable family members, or disruption to pre-existing caring 245

Our qualitative analysis revealed a final barrier not accounted for by Latane and Darley's 247 theory: 'logistics'. These were concerns of support outside of work, and difficulties with 248 transport, accommodation, and administration. 249 250 All rights reserved. No reuse allowed without permission.

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In this study, we identified that 82.7% of medical student respondents would be willing to the applicability of prosocial behavior to their role 11 , our study shows this does not appear to 263 be the case during COVID-19. The majority of students did recognize that COVID-19 was an 264 abnormal situation, that it was an emergency, and that they may be responsible. This may be 265 due, in part, to widespread media coverage, but is also likely a result of clinical placement 266 suspension, and students witnessing the vast number of healthcare staff involved in 267 responding to the pandemic. Time to reflect on a situation 35 , as well as the presence of others 268 providing help, has been shown to influence likelihood of a decision to help 36 . 269

The gap between an intention to volunteer and volunteering in practice could be explained by 271 the ways in which students decided their responsibility to volunteer during in the pandemic. 272

This decision was complex, and influencing factors can be conceptualized as a balance 273 between the interest of others and self-interest. Although 82.7% of students were willing to 274 volunteer, prosocial behaviors can be influenced by others 37 . This is shown in our cohort by 275 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. ; https://doi.org/10.1101/2021.07.06.21260058 doi: medRxiv preprint a 'pressure to volunteer'. Prosocial peer norms 38 , and external influences (such as school and 276 parents) have been shown to motivate prosocial behavior 37 . Individuals are more likely to 277 volunteer with "in-groups" (those close to them) rather than "out-groups" (those distant to 278 them) 39 . Thus, increased social distance between helpers and those being helped reduces 279 prosocial behavior 40 , as does social exclusion 41 . For medical students, academic and clinical 280 studies were interrupted -especially for those in later years used to high levels of patient 281 contact -with many medical students returning home because of COVID-19. This may have 282 increased the perceived social distance between patients, as well as between peers, shifting 283 the balance of prosocial behavior towards self-interest. 284

Latane and Darley suggest that, after having assumed responsibility, people decide whether 286 they have appropriate skills to help during emergencies 12 . Similarly, we found that medical 287 students make a series of 'competency' judgements regarding volunteering, which includes 288 considerations as to how their level of ability relates to the proposed volunteering role and 289 level of supervision, and how these factors might influence patient safety. There was an 290 incremental increase in their confidence in the required skills and their willingness to perform 291 more advanced roles as the year of the student increased, such that final year students were 292 less willing to provide indirect care even though they had the skills to do so. Our data suggest 293 that this decision depends not only on the skills required, but also on the roles offered and the 294

year of the student. We posit that this is a domain which could result in a large decrease in 295 prosocial behavior during COVID-19. Our qualitative data showed that students felt 296 uncertain as to the professional role boundaries of volunteers; they perceived a lack of clarity 297 regarding voluntary roles and were worried that they might be asked to perform tasks outside 298 of their competence. Concerns surrounding roles could also reflect the variation of roles 299 across the country 42-46 . Clarity regarding roles and necessary skills could facilitate prosocial 300 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. ; https://doi.org/10.1101/2021.07.06.21260058 doi: medRxiv preprint behavior amongst medical students during emergencies. Presenting students with more 301 options involving a wider range of roles could also help, as having a number of options by 302 which one could help has been shown to facilitate prosocial behavior 47 . 303 304 Finally, in Latane and Darley's theory, an individual weighs the above considerations and 305 makes a final decision 12 . We found that significantly fewer students who were intercalating 306 (taking time out of medical school to complete an additional degree) volunteered. This lends 307

weight to our observation about social distance, as intercalating students may be further 308 removed from patients, healthcare professionals, and medical schools. We also showed that 309 far more final-year students had volunteered than first-year students. This supports our 310 arguments about role and skills alignment. Students in higher years are likely to possess a 311 higher level of self-efficacy -the ability to overcome barriers to achieve a goal -which can 312 influence prosocial behavior 6,48 . Interestingly, in contrast to this finding, Burks and Kobus 313

found that prosocial values decrease as students' progress through training 7 . We posit that 314 the main reason for the difference between this study and Burks and Kobus' research is that 315

final year students had a clear interim postgraduate year one role that they could fulfil, which 316 students in other years lacked. Regarding barriers to volunteering, 43.5% of respondents felt 317 there was lack of information on volunteering opportunities available. 'Logistics' was the 318 first of two areas that had not been explained in Latane and Darley's theory of prosocial 319 behavior during an emergency. Our data would indicate that -a volunteer must decide 320 whether logistically they can volunteer. Previous literature surrounding the willingness of 321 medical students to volunteer in a disaster relied on the assumption that in a crisis there 322 would be an established framework and infrastructure for mobilizing medical students. 323

However, this was not the case in the UK during the early part of 2020. Early narrative work 324 All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The second key area that had not been adequately encapsulated by Latane and Darley's 328 theory concerned 'safety'. Although considerations of safety may take place within decisions 329 of responsibility, or of skills and knowledge, our data demonstrate that concerns regarding 330 safety were an integral part of volunteering decision-making. We posit that medical students 331 must also decide whether it is safe to volunteer -in the interests of themselves and others. 332

We present our conceptual framework for medical student volunteering during COVID-19 in 333 Understanding the factors that influence prosocial behavior during COVID-19 can support 336 future decision-making around the infrastructure and processes that must be put in place to 337 effectively facilitate the mobilization of students during the current pandemic and in any 338 future crises. Creating a comprehensive strategy for how to manage and implement 339 volunteers is beyond the scope of this article. We have provided suggestions in Table 3 of 340 how our conceptual framework can be used in educational strategies to facilitate medical 341 student prosocial behavior during pandemics and disasters 51 . These could be introduced 342 using pre-existing frameworks for innovation, and could be used to develop a flexible 343 structure that is organized at a local level with national oversight, which could allow for a 344 rapid goal-orientated coordinated response 52,53 . Developing this infrastructure is even more 345 important in view of the 'second wave' of COVID-19 cases 54,55 in Europe 56 , and high 346 numbers of cases in the USA 57 . 347 All rights reserved. No reuse allowed without permission.

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To expedite survey distribution, we did not perform focus groups and cognitive interviews as 349 part of our survey development, and this may have limited how participants interpretated the 350 questions 58 . However, medical students were involved throughout the survey development 351

process. As we were unable to identify the survey response rate, our data may not be wholly 352

representative of the whole UK cohort. We tried to mitigate this by distributing the survey 353 through multiple channels. There is selection bias, as the types of medical student who opt to 354 fill in the survey may be more willing to volunteer. Further, the transferability of our findings (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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This study demonstrates that Latane and Darley's theory of prosocial behavior during an 362 emergency can be applied to medical student volunteering during COVID-19. This study 363 expands on existing theory through addition of the domains of safety and logistics in the 364 decision-making process. We identified a number of modifiable barriers to prosocial behavior 365 encountered by medical students during COVID-19 and provide suggestions of how our 366 conceptual framework can be used within educational strategies to address such barriers. 367

Optimizing the process of volunteering can aid workforce planning and healthcare provision, 368 and may facilitate a volunteering process that is safer for students, staff, and patients. 369 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 7, 2021. ; https://doi.org/10.1101/2021.07.06.21260058 doi: medRxiv preprint doi:10.3109/0142159X.2014.889814 520 521 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. Senior Tutor. She is also the University Clinical Anatomist. She is directly involved in the 560 changes being made to medical student teaching during the COVID-19 pandemic. 561 All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. ; "Some medical students will have underlying medical conditions that may put them at risk of contracting or having more serious consequences from COVID-19" PPE "Lack of PPE leading to medical students being exposed to danger" Psychological impact "Medical students, especially younger years may not have had much clinical experience yet and may experience quite upsetting scenes" Other's safety Vulnerable family "Transmitting to vulnerable family members I live with" Viral transmission to others "The greater number of medical students that work, the more the virus spreads through them to their homes" Caring responsibilities "Extra experience for those able to do unpaid work, while those who are carers … are not able" Safe practice Patient safety "Is patient safety being put at risk by graduating doctors that haven't sat finals" Working outside of competence "Inability to say no to tasks I am not confident in" Support Supervision "Not having sufficient support due to overworked supervisory staff." Staffing issues "Low staff numbers"

Pressure to volunteer General pressure "Students should not feel pressured when being asked." Coercion "I would only be concerned if people felt that they had no choice but to volunteer to work" Obliged "I don't think asking medical students to volunteer is a problem, but it may cause some students to feel obliged to volunteer" Promotion "I think the option should be offered, but in a very neutral manner" Own choice "If students come forward, asking if they can help, that's their decision" Guilt "It is easy to feel guilty about not working in hospital" External pressure "Universities pressuring students to volunteer"; "Peer pressure"

Competence Inexperience "Students may have insufficient experience" Burden "Some students may be beneficial to the NHS while others may need too much support and supervision etc and therefore be a hindrance at this time." Usefulness "I am currently a junior medical student so I worry I would not be as useful as students who are more senior" Professional role boundaries Unclear role for staff and student "Blurred lines of responsibility and expectations for medical students" Ask outside of competence "Concerned we will be asked to work beyond our capacity." Discrimination Discrimination by not volunteering "Discrimination against Medical Students that did not volunteer."

Career prospects "Pressure on students who think they need to work in case it negatively affects their career if they don't."; "expectations for future career interviews if someone did/did not volunteer and that being used against your application"; "need to ensure that there were no penalties for these students who did not volunteer". Ethnicity "with the recent issue of BAME healthcare workers being disproportionately affected from Covid-19 … I worry that medical students volunteering may be disproportionately affected as well."; "Patients may be racist, refusing help from Chinese medical students" Legal Indemnity "Lack of a protective union for students in particular"; "Insurance coverage should we make a mistake" Contract "Starting work without a contract" Work Concerns about work "Job will be boring/'unglamorous'" Hospital issues "Working in stretched system"

Logistics Accommodation "Will need new accommodation, won't be able to stay at home" Transport "I don't have a car and would be unsure whether public transport would be appropriate -I live far out from major hospitals." Administrative "Admin issues" Support Support outside of work "Not being able to see my friends and family outside of my house will be difficult"; "Lack of peer and colleague support"; "Lack of university support" Financial Lack of pay "I think if students are asked to join the workforce during a pandemic then they must be paid something." Financial difficulties "Students are considered financially vulnerable for clinical trial purposes, similar ethical concerns exist around paid volunteer opportunities"

University education Educational disruption "If we choose not to volunteer, we risk being under skilled compared to our contemporaries who do volunteer"; "Even further loss of study time" Work-educational balance "Volunteering can take students away from their focus on the degree"; "we have exams imminently and have been told if we choose to volunteer we are expected to still perform in exams, and the exams will still contribute towards deciles … Many of All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted July 7, 2021. Lack of training "Inappropriate clinical training"; "Without proper training/preparation, harm may also be done to patients or healthcare staff supervising students" Learning how to work "The 'learning' time it takes to learn how the job works" 5 6 7 All rights reserved. No reuse allowed without permission.

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Situational judgement tests in medical education 396 and training: Research, theory and practice: AMEE Guide No. 100

How do undergraduate medical students perceive 399 social accountability?

The Unresponsive Bystander: Why Doesn't He Help? New 402

York: Appleton-Century Crofts

Toward Volunteering in Emergency Situations

Disaster Preparedness Medical School Elective: Bridging 407 the Gap Between Volunteer Eagerness and Readiness

Medical students for 410 health-care staff shortages during the COVID-19 pandemic

Support for mobilising medical students to join the covid-19 pandemic emergency 414 healthcare workforce: A cross-sectional questionnaire survey

Chinese medical students' interest in COVID-19 417 pandemic