Psychiatry clerk reflections on the disruption of their clinical training during COVID-19 pandemic

Purpose – The COVID-19 pandemic has had a significant impact on medical education and training, with many medical schools and training programs having to adapt to remote or online learning, social distancing measures and other challenges. This paper aimed to examine the disruption for clinical training, as it has reduced the opportunities for students and trainees to gain hands-on experience and interact with patients in person. Design/methodology/approach – Theethnographicqualitativeresearchdesignwaschosenastheresearch methodology. Using Gibbs ’ reflective cycle, the researcher explored the psychiatry clerks ’ (final-year medical students) reflections on the disruption of their clinical training during the COVID-19 pandemic. Findings – The findings demonstrated that the students had a significant psychological impact on their coping capacities as the crisis progressed from shock and depression to resilience. The students being the key stakeholders provided a concrete foundation for the development of a framework for improving practices during uncertain times. Originality/value – Students ’ reflections provided valuable insight into the pandemic ’ s impact on their psychosocial lives with uncertainty and incapacity to cope up with changing stressful dynamics. The results will assist in planning how to best support medical students ’ well-being during interruptions of their educational process brought about by similar future crises.


Introduction
The COVID-19 pandemic has had a significant impact on medical education and training, with many medical schools and training programs having to adapt to remote or online learning, social distancing measures and other challenges. This has been particularly disruptive for clinical training, as it has reduced the opportunities for students and trainees to gain hands-on experience and interact with patients in person (Hauer, Gradisar, & Chen, 2020).
There have been several studies published in the literature that has addressed the impact of the COVID-19 pandemic on medical education and training. For example, a study published in the Journal of the American Medical Association in 2020 found that the COVID-19 pandemic led to significant disruptions to clinical training, with many programs experiencing delays, reductions in the number of clinical rotations and other challenges. Another study published in the Lancet in 2020 found that the COVID-19 pandemic had a negative impact on the quality of medical education, with many students and trainees reporting decreased opportunities for hands-on learning and reduced access to patients. It is likely that the disruption of clinical training during the COVID-19 pandemic has had a significant impact on the experiences of psychiatry clerks and other medical trainees (Movahed & Sadeghi, 2020).
The COVID-19 pandemic is a global crisis that has impacted the world's health, economy and education (World Health Organization, 2021). To ensure the safety of medical students in the beginning stages of the pandemic and to restrict the spread of the virus, suspending clinical rotations was strongly supported by the Association of American Medical Colleges (Association of American Medical Colleges, 2020) and similar organisations across the world. Medical students' involvement in the clinical environment is an integral and fundamental part of their education, and it is vital in planning how future physicians are prepared to take on their clinical roles (Ramani and Leinster, 2008). Protection of medical students and patients is always the priority, but the continuity of the medical education process, particularly clinical training of students, is necessary to fulfil their objectives of becoming doctors and to provide healthcare organisations with much-needed newly qualified physicians (Association of American Medical Colleges, 2020). Medical students are prone to poor health status and an increased risk of mental illness compared with the general population (Bergmann et al., 2019;Lyons et al., 2020). An important aspect of the ongoing transformation of medical education following the challenges of the COVID-19 global pandemic is to focus on students' psychological well-being and address worries about the completion of their undergraduate education (Cao et al., 2020).
The College of Medicine and Medical Sciences (CMMS) of the Arabian Gulf University (AGU) was established in 1980 in Bahrain by the General Council of Ministers of Education in the Gulf Cooperation Council (GCC) countries. The CMMS offers a six-year Doctor of Medicine (MD) bachelor's programme for students from GCC countries. The first batch of students was received at the pre-medical program of the College in 1982, and the first class graduated in 1990. The CMMS follows a problem-based learning (PBL) curriculum, and the programme is divided into three phases. Phase 1: Basic Sciences, Phase II: Medical Sciences and Phase 3: Clinical Clerkships. A psychiatry clerkship is a 4-week placement of final-year medical students in psychiatry where they rotate through various clinical sites and have a daily didactic seminar covering all areas of psychiatry and its sub-specialities. Clinical clerks, while doing their psychiatry rotation, must generate possible research ideas and complete a formal Gibbs' reflective practice about their experience in psychiatry. The reflective practice experience has been implemented in psychiatry since 2016. Students had to submit their reflections to MOODLE, the AGU's learning management system (Moodle: an open-source learning platform j Moodle.org, 2021).
Gibbs' reflective cycle is a tool that is commonly used to capture reflective practice in medical education (Gibbs, 1988). Deliberate reflective practice is a process of continuous learning whereby students critically analyse their cognitive and behavioural responses to a certain experience to assure deeper understanding and learning of the experience and themselves (Sch€ on, 1983;Loughran, 2002;Ament Giuliani Franco et al., 2020).
The impact of the COVID-19 crisis on medical education interruption has been significant worldwide, particularly for final-year medical students transitioning to become doctors (Lyons et al., 2020;Choi et al., 2020;Khalil et al., 2020;Ela et al., 2021;Dhahri et al., 2020;Hayat et al., 2021;Tempski et al., 2021). To protect student safety and avoid further disruptions in the education process, the majority of educational institutions worldwide made an unplanned shift to online teaching, resulting in psychological distress to students exacerbated by limited social connectedness, prolonged home confinement and uncertainty in the face of rapidly changing information (Choi et al., 2020;Khalil et al., 2020;Ela et al., 2021;Dhahri et al., 2020;Hayat et al., 2021).
Several studies have examined COVID-19's impact on students' psychological wellbeing, the medical education process and the transition to online teaching. A qualitative study of college students in Bangladesh showed stress and anxiety following an extended lockdown, resulting in financial constraints and delayed graduation (Ela et al., 2021). Another study of medical students in Australia discovered that 63% of students experienced a decline in mental well-being as measured by the Kessler psychological distress scale K10, with no difference in severity between junior and senior students (Lyons et al., 2020). Similar results have been described in a cross-sectional study of final-year medical and dental students in Pakistan, with 63% experiencing depressive symptoms related to experiencing COVID-19 symptoms, a delay in starting online training and studying in a private institution (Dhahri et al., 2020). Studies of students' attitudes towards online teaching have varied reports, with some supporting it as a time-saving practical model with technical and methodological difficulties (Khalil et al., 2020;Tempski et al., 2021;Schr€ opfer, Schmidt, Kus, Koob, & Coenen, 2021;Utama et al., 2020), while others opposing it due to deficient resources, unequal access and variable faculty virtual literacy (Ela et al., 2021;Hayat et al., 2021). The effect of COVID-19 was not unique to medical students; nursing students in Croatia have included common fears and worries experienced during the COVID-19 pandemic, in particular concerns about the safety of their families and community (Lovri c, Far ci c, Mik si c, & V cev, 2020), leading to compliance with essential protective public health measures.
Our study examined final-year medical students' formal reflections on various aspects of the COVID crisis in the Gulf region using Gibbs' reflective cycle. The lessons learnt from our students' reflections provide valuable insight into the pandemic's impact and will assist in planning how to best support medical students' well-being during interruptions of their educational process brought about by the pandemic or similar future crises (Emanuel, 2020).

Design
This qualitative study used an ethnographic approach to explore students' perceptions of their experience during the COVID-19 pandemic. Ethnographic research is used to enable the researchers to observe and/or interact with the study participants' real-life experiences and collect related data. The researcher is the primary instrument and explores the participants and the settings while being immersed in the context. The researchers' bias is minimised by actively engaging in the context of the research and keeping a log of their previous personal experiences and diaries.

Participants
Participants were final-year medical students who attended the psychiatric rotation from March to June 2020. Due to the retrospective analysis approach and the fact that there were no physical or situational risks expected in this research, an informed consent waiver was applied from the ethics board of the institution.

Data collection and analysis
Data were collected retrospectively from the students' reflection essays for information related to the pandemic. To ensure anonymity, reflective essays were given an identificatons code comprising letters & numbers.

Psychiatry clerk reflections
A pool of 40-50 students' reflections was taken into consideration for analysis. Data saturation was achieved after analysing the reflection essays of 37 students. Descriptive statistical analysis of demographic variables and characteristics of reflective essays was carried out using SPSS (statistical analysis software) 26.0. For qualitative data, data management software, ATLAS.ti (version 8.1.0) was used.
Qualitative data analysis was carried out in three phases. First, the research team reviewed the transcripts several times, searching for "recurring themes". The researchers highlighted quotes and phrases from the essays that were significant to the study. Using the constant comparative method, the researchers repeatedly reviewed the transcripts, exploring emerging consistent and distinctive categories. The researchers named these categories, coded the transcripts and placed sections in labelled folders representing each category. Second, the researchers brought together the coded essays looking for relationships within the data source. A table was developed to compare various coded essays. Third, the researchers integrated and refined the categories until themes were solidified. Given that the major themes of the data were based on student responses to each stage of the Gibbs cycle, describing their perceptions and experiences adjusting to the COVID-19 global crisis, the results can be interpreted according to cognitive behavioural and crisis theories. To increase the trustworthiness of the study's findings, the researchers supported themes with participant quotes.

Results
The reflections of 37 students were included in the analysis. The male-to-female ratio was 1:3, with 10 males and 27 females. The median age was 25 years. The majority of students (80%) completed the reflection assignment with varying lengths and complexity. During analysis, the emerging themes from the six stages of the Gibbs cycle were identified and classified into three major themes; (1) Psychosocial impact & crisis perception (stages 1 and 2), (2) coping and problem-solving for challenges encountered (stages 3 and 4) and (3) lessons learnt (stages 5 and 6). Each major theme was divided further into common sub-categories (Table 1). The crisis response depended on the student's perception, with minimal differences in the description of the COVID-19 crisis, its impact, and the coping process between females and males, with females being more elaborate in reflecting their feelings.
Theme 1: psychosocial impact & crisis perception (Gibbs 1 & 2) All students completed the description stage of the Gibbs' cycle. 100% described it as a life-changing major crisis; 81% mentioned school suspensions, mosque closures and airport closures; 78% mentioned the terms "pandemic" and "quarantine"; 51% described panic over finding masks and sanitizer, and 22% mentioned the virus's widespread.
Some students described the situation in terms of the effects on their graduation outcomes: During my sixth year in medical school, precisely three months before my graduation, COVID-19 appeared and stopped everything on earth. (P3).
Tuesday, February 25th, 2020, was the day that crashed our routine life, closed the doors in front of us, and faded our dream of graduation. (P13).
While others described the situation as impacting their social life: Self-isolation and quarantine were the toughest, as I have never experienced such an act. (P6) All prayers in mosques were suspended. (P9).
The government issued a partial curfew, and every single airport was shut down. (P22).

AGJSR
Still, others were terrified by the situation: We looked in different pharmacies for "mask boxes already completed". It was quite a sight, all the people looking for masks and sensitizers and looking terrified. (P14) The psychological impact varied according to the timing and available information.
When the student heard about the first confirmed case of COVID-19, the first thing he or she did was deny it. "Social media is full of rumours and speculations". (p16).
I felt depersonalized; it just did not sound real. (P6) AGU announcing a two-week study suspension was received with initial excitement by the majority (81%) of students who wanted time off to study and be with family. Upon the second announcement of study suspension for an indefinite period, students experience uncertainty with worry and anxiety over health, family and graduation (68%), depressive symptoms with feeling sad, poor concentration and poor sleep (35%), and anger triggered by others' irresponsible behaviours (27%).
Two weeks off has now turned into more than a month, and we still don't know when we will go back to Bahrain and university, and this uncertainty is my worst nightmare. (P4).
"Will I lose someone I love if I live in constant stress, anxiety, and fear of not knowing?" Am I going to graduate this year? Will the virus be contained? Or, God forbid, it will keep infecting more and more people till it reaches us? (P7).
I needed an x-ray, but the health centre refused; all non-urgent cases need to go home; it was very stressful. (P22).
Students' anxiety grew in intensity over time; they anticipated the worst-case scenario and developed depressive symptoms that interfered with their functioning. Another student is arguing it's going to be the end of us; we will die before graduation. (P22).
I worry about education more than health (P5).
I started reading about mood disorders, which made me think, "Am I depressed?" (P13).
The experience made me think a thousand times about the people who don't care about others, don't take this virus seriously, and don't care about the elderly in their community, which made me feel furious and unpleased. (P12).
The AGU announcement of a shift to online teaching brought temporary relief. Students affirmed, "We've completed about 1 month with no academic news, and finally, we've been guided to continue the courses online." (P11) "Fortunately, online classes helped students continue their education during quarantine." (P10).
Theme 2: coping with and problem-solving for challenges encountered  The data extrapolated from the Gibbs cycle's evaluation and analysis identified two categories of challenges with which students were coping and problem-solving at various s AGU stages of the crisis: 1) coping with quarantine and lockdown; 2) delayed graduation with the shift to online teaching. The main challenge faced by 78% of students was quarantine, which resulted in social isolation and disruption of education. Keeping faith was the main coping strategy for 68% of students; 70% found it a positive opportunity for spending time with family and friends, studying, self-care and learning new skills with a feeling of gratitude; 46% found reassurance in government precautionary measures; and 41% sought to reach out to others through volunteering or extending help to colleagues.

Sub-category I: coping with the quarantine and lockdown
(1) Faith and destiny I strongly believe that everything happens for a reason "(Quran Verse" and maybe you dislike a thing that is good for you. (P8). " Belief in Allah and destiny." (P2).
(2) Self-care, family and friends Maintaining our health by eating healthy food, doing yoga, and listening to relaxing music is very important. (P31).
To be more stable internally when things are not stable externally. (P30) Although I was feeling a lot of negative emotions, I did many positive things: read books, spend more time with family, talk to friends, and apply for an internship, which I was struggling to find time for. (P9).
(3) Reassurances from the government The GGC health care system controlled the cases from the start with screening programmes, applying the quarantine, providing necessary things for free like medical services, discounts on electricity, delivering apps that worked 24 hours a day, and a daily update on the situation (P36).
The task force assembled by the government to combat this virus assured us that everything is under control and that all residents need to take safety precautions (P33).
I had trust in our healthcare system. (P34).
(4) Reaching out to others The ministry made a link for people to register as volunteers; I was thrilled, and we registered our names right away (P8).
Take further steps for others; help my colleagues who are outside Bahrain by sharing some notes and learning resources. (P11).
Sub-category II: coping with the shift to online teaching and delayed graduation Delayed graduation was a concern for all students, and the shift to online teaching was received as an advantage by 59%. Students believed that distance education and technology incorporation is the need of the hour and change is first in thoughts and then on the ground. Some of our beliefs should change; we should try to improve our distance education; telemedicine is the future. (P28).
While some still had reservations on online teaching and learning Online classes as an alternative are not nearly as fulfilling as the clinical courses. Missing out on the clinical experience is a tremendous disadvantage. (P10).
Theme 3: lessons learnt (Gibbs 5-6) Through the Gibbs' cycle, the majority of students found the reflective exercise a useful therapeutic and educational tool.
Gibb's cycle of reflection help me arrange my thoughts and plans clearly (P20).
The stages of Gibb's reflection have strengthened my practice in this area (P11). 84% of students identified lessons learnt at the personal and community level with a concrete action plan and 20% specified a time frame to execute their plan.
Sub-category I: personal growth Students viewed the pandemic as an opportunity for personal growth, with crisis reframing and resetting priorities, demonstrating a new perspective while realising their limitations and gaining self-confidence, leading to adaptive resilience. Work is a privilege; meeting a deadline is a privilege; being able to go out without feeling scared is a privilege. Being able to travel is a blessing; hugging my family and friends is a blessing. (P9) We learned humans are weak and venerable, and the world will change after this pandemic. (P25) Health is a priority more than education. (P6).
I learned to live one day at a time, to focus more on the present and not worry about the uncertainty of the future, and to appreciate all the little things in life. I would like to face it with more flexibility and resilience. (P9).
This whole situation made me believe in myself more than I used to. It also reminded me of why I became a doctor and dedicated my life to others. (P5) We have to think of this pandemic in another way; God wants us to overcome our conflicts and work together to overcome this problem and live in peace. (P28) Sub-category II: Responsibility towards community.
(1) Student forecast their role as future physicians caring, educating and providing to the community.
I will put all my effort in treating patient, educating my community about disease, signs, symptoms, and prevention. (P14) It is important to take updates from trustworthy and official websites such MOH and WHO. (P4) (2) Students made expedient suggestions to emphasise the importance of collaboration and research advancement to facilitate the eradication of the virus.
The most important thing that I learned from this experience is that we need to stick together and unite, as in unity we can defeat anything. (P29).
Science and scientists should never stop researching and developing throughout their careers, and they should be supported because if we relive the same, we will be prepared. (P3). Maintain trust among organisations and people; provide financial support to research centres; and provide the best treatment and support for all people. (P28).
Encouraging people to get their vaccine and fighting the anti-vaccine campaigns with knowledge and research (P16) Learn from others' experiences and faults and be ready so we don't repeat mistakes. (P30). Figure 1 shows the conceptual framework of the study.

Discussion
Students' descriptions of their COVID-19 experience with emerging themes and sub-themes highlighted the crisis stages with resulting psychological and educational disturbance and students' coping processes leading to adaptive resilience. One of the many crisis definitions in literature describes it as a temporary state of emotional upset and dis-organisation in response to exposure to a sudden threat, impairing the individual's problem-solving abilities with either a negative or positive outcome (Dattilio and Freeman, 2010). In line with this definition, stress and disorganisation can be broadened to include psychological symptoms of anxiety and depression, physiological symptoms of disturbed sleep and poor concentration, and behavioural symptoms of limited problem-solving skills in the initial phase of the crisis (Tempski et al., 2021;Schr€ opfer et al., 2021;Hayat et al., 2021). The concept of collective trauma, defined as "a psychological reaction resulting from a traumatic event affecting an entire society" (Gaur et al., 2020), can be extended to the COVID-19 trauma experienced by our students and the majority of students worldwide, posing a direct and indirect threat to their mental well-being, identity as future physicians, and communities (Gonz alez Ramrez, Martnez Arriaga, Hern andez-Gonzalez, & De la Roca-Chiapas, 2020).Quarantine was the hardest novel experience, depriving students of social and religious connectedness, particularly during the holy month of Ramadan. The preventive guidelines of social distancing, although essential, were opposed to people's natural tendency towards relatedness and closeness during crisis (Bavel et al., 2020). The psychological response to the COVID-19 pandemic can be understood from an individual and environmental perspective. The exposure to the on-going stress of a threatening situation clerk reflections that is surrounded by uncertainty is associated with tremendous anxiety and fear, clouding cognitive flexibility and problem-solving abilities (Dattilio and Freeman, 2010;Gonz alez Ramrez et al., 2020). In COVID-19, fake news and misinformation flooded people on social media, putting their health at risk (Bavel et al., 2020;Al Eid and Arnout, 2020).
According to Erickson (Dattilio and Freeman, 2010), the student's coping process for a crisis demonstrated gradual adaptation, promoting personal growth. In accordance with earlier studies, keeping religious faith (Ela et al., 2021;Rose, 2020), connecting with family and friends, and attending to self-care were vital measures to combat adversity. Moreover, student altruistic qualities were displayed in wanting to volunteer and extend helping hands to colleagues outside Bahrain. Studies examining willingness to participate during COVID-19 showed students' motivation and enthusiasm in caring for non-COVID-19 patients and supporting families of COVID-19 patients (Tempski et al., 2021;Elhessewi et al., 2021;Sani et al., 2020).
Although the impact of COVID-19 on medical education has been unprecedented and challenging (Zepke et al., 2013) for students, faculty and administrations, it has created an opportunity for innovation and adaptation in educational processes. Utama et al. (2020), Sani et al. (2020), andFindyartini et al. (2020) found that technology-based medical education was just as effective as traditional methods and led to good academic results.
Students were relieved to learn of the shift to online instruction and the resetting of exam dates. AGU made rapid adjustments by investing in online platforms, equipment, and support staff to ensure continuity of education. Docherty et al. (2018) say that getting students involved in learning is the key to academic success and better outcomes.
Online facilitated small group discussions with role play, simulated patients when possible, and voice-recorded presentations were used to compensate for limited clinical encounters. Resilience, as defined by the National Research Council (Katsikopoulos, 2020), is "the ability to prepare and plan for, absorb, recover from or more successfully adapt to actual or potential adverse events". The resilience developed by students and institutions represents a dynamic positive adaptation to stress (Smith et al., 2021); hence, it can be viewed as collective resilience to the collective trauma experienced during COVID-19.

Conclusions
The perceptions of the medical students resonate with previously reported ones, symbolising the universal human experience and response to the crisis contributing to personal growth and resilience. Students' reflective action plans provide a framework to build on strengthening crisis preparedness, communications, setting priorities and providing ongoing support.

Limitations
This is a retrospective study of final-year medical students; the experiences of pre-clinical students were not taken as they might have faced similar interruptions but with less immediate impact on graduation. Drawing a parallel between the current crisis and collective trauma represents the author's ambitious bias towards collective resilience.

Recommendations for moving forward
The students are the key stakeholders in their institutions and analysis of their reflections suggests cooperating, learning from mistakes, investing in the "telemedicine of the future" and enhancing communication channels. Furthermore, we can capitalise on current stress management training to incorporate a crisis preparation programme, establish depression and anxiety screening, and provide student group support. Future endeavours are recommended to be directed to gaining further insights of students about uncertain situations and dealing with them and developing the frameworks to implement based on students' perspectives.