The Impact of Transitions Related to COVID-19 on Pharmacy Student Well-being

INTRODUCTION

The well-being of student pharmacists is increasingly a topic of interest in the Academy. A keyword search of the Journal for the term “well-being” identified more than 100 articles published since 2016, with 20 publications in the first few months of 2020 alone. The American Association of Colleges of Pharmacy (AACP) and the Accreditation Council for Pharmacy Education (ACPE) emphasize the importance of student well-being through policy statements and accreditation standards, respectively.^1,2 Likewise, pharmacist associations and stakeholders within the profession have affirmed the importance of well-being among pharmacists and pharmacy students.^3-5

The Centers for Disease Control and Prevention (CDC) defines well-being as “the presence of positive emotions and moods (eg, contentment, happiness), the absence of negative emotions (eg, depression, anxiety), satisfaction with life, fulfillment and positive functioning.”⁶ Research into well-being demonstrates the positive impact of possessing it as well as the negative aspects of lacking it.^7-9 In their evaluation of population level and individual well-being, Gallup categorizes a person’s degree of well-being as thriving, struggling, and suffering using the 11-point Cantril Self-Anchoring Scale.^7,10,11 Gallup uses five domains to conceptualize well-being.⁷ Career/purpose well-being is liking what one does each day. Community well-being captures the extent to which one likes where they live and takes pride in the community. Financial well-being addresses the security of one’s finances. Physical well-being is defined as having good health and enough energy to get things done daily. Finally, social well-being is defined as having supportive relationships and having love in one’s life.

Transition periods are critical periods from a well-being perspective.¹² While pharmacy student research is limited, research across health professions education notes decreases in well-being, or elements thereof, during transition periods and the need for targeted interventions during these periods.^13-16 Our recent work that longitudinally examined the well-being of first professional year (P1) pharmacy students noted significant decreases in multiple well-being domains during the P1 year, especially during the transition semester.¹⁷

The coronavirus disease of 2019 (COVID-19) undoubtedly precipitated a transition period within the Academy as faculty, staff, and students transitioned from in-person to remote teaching and learning in a matter of days in early 2020. A number of peer-reviewed articles were published shortly thereafter emphasizing the real and perceived negative impact of COVID-19 transitions on college student, health care worker, and societal well-being.^18-23 Gallup data for the United States reported 46.4% of US adults thriving in April 2020, the lowest percentage since the Great Recession.²⁴ Having recently published a longitudinal analysis of well-being across the academic year for P1 students, we were not planning to share the well-being data for the current cohort of P1 students.¹⁷ However, the natural experiment inherent in the COVID-19 pandemic presented an opportunity to examine the impact of pandemic-related transitions on student well-being.

METHODS

This study received exempt approval from the East Tennessee State University (ETSU) Institutional Review Board. This study employed a longitudinal design, and the sample consisted of P1 students enrolled in the ETSU Gatton College of Pharmacy during the spring 2020 semester (N=74). As part of a required P1 course, students rated their overall well-being and domain-specific well-being on a weekly basis using a seven-point response scale: 1=extremely poor, 2=poor, 3=somewhat poor, 4=neutral, 5=somewhat good, 6=good, 7=extremely good. Students were familiar with the Gallup well-being domains because they had participated in required curricular and cocurricular sessions during the fall 2019 semester when Gallup’s conceptualization of well-being, the Cantril Self-Anchoring Scale, and the 7-point study response scale were explained. Students had also completed well-being assessments weekly during the fall 2019 semester and developed individual action plans to optimize well-being across the Gallup well-being domains. Individual action plans were evaluated by the course coordinator to confirm student understanding of each well-being domain.

Given the COVID-19 pandemic, the university notified students on Thursday, March 12, 2020, that from Monday March 23 to April 9, 2020, all face-to-face classes would be moved to online classes. Spring break week was March 16-20, 2020. On Friday March 20, 2020, the university announced that spring semester classes would be held online through the remainder of the semester. Prior to moving to remote learning on March 23 (referred to as the “pre-transition” period), students had reported their well-being via audience response software during Monday class sessions. The pre-transition student responses were identifiable. Thereafter (referred to as the “post-transition” period), weekly well-being surveys were administered to first-year students via the institution's learning management system; thus, students’ post-transition reporting of well-being scores was anonymous. Given the overarching emphasis of the course on personal and professional development, well-being assessments were part of students’ participation grades throughout the course.

To elicit well-being perceptions, students were asked to choose one of seven responses to finish the statement, "On a scale from 1 (extremely poor) to 7 (extremely good), over the past 7 days, I would describe my overall well-being as…”. In addition to overall well-being, students completed the same statement for all well-being domains (career, community, financial, physical, and social), for a total of six items weekly. Recognizing the limitations inherent in representing a domain with only one survey item and having invested in previously mentioned efforts to face validate the survey instrument with the students and previous P1 cohorts, we sacrificed methodological rigor to make longitudinal, weekly assessment of well-being feasible in the educational environment. Once the transition to remote learning occurred, each student was given one week to respond to the well-being items. For example, the well-being assessment for March 23, 2020, was open from 9:00 am local time March 23, 2020, through 8:59 am, March 30, 2020. An analysis of response data indicated that a large majority of students responded to the weekly well-being survey on the Monday the survey opened. Only one week of well-being items was open to students at any point in time. Data were not collected during the week of the Martin Luther King, Jr, holiday (January 20, 2020) or during spring break (March 16, 2020).

Given the anonymity of responses during the remote learning period, we were unable to link post-transition responses with pre-transition responses at the individual student level. Likewise, demographic variables could not be linked to post-transition data. Data were analyzed using SPSS Statistics, version 25 (IBM Corp). Multiple imputation techniques were employed to handle missing data. Weekly mean scores were calculated for overall and domain-specific well-being and thereafter used to calculate an aggregate mean pre-transition and post-transition score for each domain. Using the aggregate scores and standard deviations, we calculated the Cohen d_av to determine effect size for wellbeing changes pre- and post-transition.²⁵ The Cohen d_av test uses average standard deviations of repeated measures to calculate the standardized mean difference of an effect in a within-subjects design. The results of a Cohen d_av test are interpreted in the same manner as other Cohen d effect size calculations. As a comparator, we performed the same calculation with the class of 2021 data using spring break as an index point to reflect the timing of COVID-19 in the class of 2023. Paired t tests were used to evaluate differences in mean pre- and post-transition scores across well-being domains. A p<.05 was considered significant for all statistical analyses. To evaluate the cohort using Gallup’s thriving, struggling, and suffering categories, an additional variable was constructed using the weekly overall well-being ratings. On the original 0-10 Cantril scale, the cutoff for thriving was 7, struggling was 4-6.9, and suffering was less than 4. Using these parameters as a guide, student ratings of 1-2 were considered suffering, 3-4 struggling, and 5-7 thriving.

RESULTS

Data were collected for all students in the P1 cohort (N=74). The cohort was 65% female, 70% white, 12% African American, and 10% Asian/Pacific Islander with a mean age of 24 years. Nearly half (48%) had earned a bachelor’s degree or higher upon matriculation. The average weekly response rate pre-transition was 87% (range, 77%-100%) and post-transition was 76% (range, 41%-91%). The weekly mean well-being scores across the spring semester are presented in Figure 1, and the weekly descriptive statistics are provided as Appendix 1. The mean well-being scores pre-transition and post-transition are shown in Table 1 and the results are compared to those obtained from the class of 2021 using spring break as an index point to represent the timing of COVID-19 transitions. Mean well-being scores decreased when comparing pre-transition vs post-transition scores, with effect sizes ranging from d_av=.16 for financial well-being to d_av=.84 for social well-being. Comparatively, for the class of 2021, no significant decreases in well-being domains were noted pre- and post-spring break, and effect sizes ranged from d_av =-.18 for physical well-being to d_av=.09 for social well-being.

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Figure 1.

Doctor of Pharmacy Students’ Scores for Career, Community, Financial, Physical, Social, and Overall Well-being Across the Spring 2020 Semester of the First Professional Year

The pre-transition and post-transition average student responses for each well-being domain and overall well-being are presented in Table 2. Overall, responses shifted towards the somewhat poor/poor/extremely poor end of the response scale post-transition. For example, the range of somewhat poor/poor/extremely poor responses for career well-being post-transition ranged from 3% to 18% of students as compared to a range of 2% to 6% pre-transition. On average, 28% of students reported somewhat poor/poor/extremely poor community well-being post-transition as compared to an average of 6% responding the same across the pre-transition weeks. The percentage of ftudents who reported somewhat poor/poor/extremely poor financial well-being ranged from 12% to 20% pre-transition as compared to a range of 17% to 29% post-transition. Post-transition, 25% to 39% of students reported having somewhat poor/poor/extremely poor physical well-being as compared to 11% to 21% of students who reported this pre-transition. In the first week after COVID-19-related transitions (March 23, 2020), nearly 40% of students reported having somewhat poor/poor/extremely poor social well-being. The minimum percentage of students who reported having somewhat poor/poor/extremely poor social well-being post-transition was 26% on April 27, 2020. Conversely, the percentage of students who reported having somewhat poor/poor/extremely poor social well-being pre-transition ranged from 3% to 7%. Finally, the percent of students who reported having somewhat poor/poor/extremely poor overall well-being post-transition ranged from 9% to 16% as compared to a range of 1% to 7% pre-transition. Pre-transition, one or more students reported poor or extremely poor overall well-being during four of the nine weeks assessed. Poor or extremely poor overall well-being was reported in every week post-transition.

When considering students’ overall well-being from Gallup’s thriving, struggling, suffering perspective, downward trends in student thriving and corresponding increases in students struggling and suffering were noted post-transition (Figure 2). The average percent of students who reported thriving decreased from 81.9% of students pre-transition to 62.8% of students post-transition. The average percent of students who reported struggling increased by 86.1% from pre-transition to post-transition (16.8% vs 31.2%), and the average percent of students who reported suffering post-transition was 351% higher than pre-transition (1.3% vs 6%).

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Figure 2.

Percent of First Professional Year (P1) Students Thriving, Struggling, and Suffering During the Spring 2020 Semester (N=74)

DISCUSSION

Student transitions amid the COVID-19 pandemic were associated with decreases in domain specific and overall well-being in our cohort of P1 students. Likewise, and in alignment with overall US data, the percentage of pharmacy students who reported thriving post-transition plummeted. Our findings demonstrate both the dynamic nature of well-being and the extent to which an unprecedented disruption such as COVID-19 can negatively impact students.

When comparing the class of 2023 to our previous findings involving the class of 2021, notable differences were observed in weekly mean well-being scores during spring semester.¹⁷ The class of 2021 was able to maintain or improve well-being scores across their spring semester and ended on an upswing in well-being scores across all domains. This was not the case for the class of 2023 amid the COVID-19 pandemic. While other mid- to late-semester variables could have influenced the downward trend in wellbeing for the class of 2023, such as falling behind in course work, the same variables would have influenced the class of 2021. While Figure 1 depicts the significant drop in social and community well-being post-transition, anecdotal conversations revealed that students were experiencing loneliness at a level that was difficult to quantify with mean scores. For many students, remote learning and quarantine requirements necessitated social isolation. Also apparent in conversations with students was the extent to which suffering or struggling with social well-being influenced their ability to engage fully in their coursework. Literature affirms the negative consequences of loneliness and social isolation and the relationship between social isolation and cognitive processes.^26,27 The recent American Perspectives Survey found that young people (18-29 years old) were the most likely cohort to report feeling lonely during COVID-19 as compared to older cohorts.²⁸ Our data suggest that pharmacy students are likely similar to other young people in this way.

While the results of this research were somewhat expected, we believe there is a value in sharing them with the Academy. As COVID-19 continues to impact the learning environment, we encourage colleges and schools to assess student well-being and to use their student data to inform interventions to promote well-being. Beginning in fall 2020, we began tracking weekly well-being across the P1, P2, and P3 cohorts. Faculty champions for each cohort reach out to students who report extremely poor, poor, or somewhat poor overall well-being. While this intervention approach has only recently been introduced, students overwhelmingly seem to appreciate faculty reaching out. We are therefore using the weekly well-being assessment described as a proactive early-alert conversation starter with students rather than waiting until students reach out or display downstream consequences of struggling or suffering well-being.

As the Academy prepares for additional semesters impacted by COVID-19, bolstering mental health resources and/or awareness thereof for students may be needed. Moreover, fostering proactive connectedness with a counselor, mentor, or other individual may warrant consideration as opposed to reactively encouraging conversations once students’ social well-being is struggling or suffering. Given that incoming students will have experienced the impact of the pandemic on learning and well-being, they may already be experiencing low social well-being, and/or perceive COVID-19 to be a traumatic event in their lives.²⁹ Trauma-informed resources such as the document developed by Trauma Informed Oregon may need to be developed and/or revised at the college or institutional level.³⁰

Finally, our findings demonstrate the value of face-to-face connectedness. Regardless of whether learning is on-campus or remote, schools should consider how to safely and effectively promote social connectedness among students and hence social well-being while at the same time observing social distancing guidelines, which may be more aptly called “physical distancing” guidelines. Finally, perhaps at no time has it been more important to ensure faculty and staff are equipped to respond to mental health concerns among students and peers.

This study has several limitations. First, the results represent one cohort of pharmacy students at one institution. The extent to which the results are generalizable to other students is unknown. Second, students could have misinterpreted well-being constructs and therefore responded inaccurately. The use of single items to represent well-being domains is also a limitation. Finally, the transition from identifiable well-being responses pre-transition to anonymous responses post-transition could have influenced students' responses.

CONCLUSION

Pharmacy students' domain-specific and overall well-being significantly decreased during COVID-19-related transitions. The percentage of students that reported struggling or suffering significantly increased post-transition. Timely research is warranted to understand and effectively promote student well-being as COVID-19 continues to impact the traditional learning environments of schools and colleges.