This was a retrospective, descriptive, cross-sectional study in which all bachelor-level paramedic students (n = 155) enrolled at Oslo Metropolitan University (OsloMet) were invited to complete an electronic survey in June 2020, five months after the initial outbreak of COVID-19 in Norway in February 2020.
The three-year bachelor program in paramedic science at OsloMet is the largest of four such programs in Norway, with 158 students enrolled in the spring of 2020. The program consists of theoretical training, simulation training, and training in study-related clinical placements. In study-related clinical placements, the students were primarily divided between the prehospital services in the South-Eastern Norway Regional Health Authority. The services consisted of 103 ambulance stations with a total of 214 regular ambulances .
Most of these students had their study-related clinical placements in the ambulance department at Oslo University Hospital (OUH), meaning they were working at the epicenter of the pandemic. The ambulance department at OUH covered a population of 697,010 inhabitants  and consisted of a total of 450 paramedics and emergency medical technicians who carried out 150,000 missions per year . Due to the lack of PPE available in the clinical, half of the second-year class had to reshuffle their study plan so that their study-related clinical placements were postponed for three months. Consequently, 24 out of 48 second-year paramedic students were in study-related clinical placements in OUH (Bjelde, T. Private communication, April 2, 2020).
Because of the shortage of ambulance staff due to high rates of sick leave and quarantine, some paramedic students who attended study-related clinical placements were required to work unsupervised as part of the ambulance service’s professional staff instead of being supervised. The unsupervised clinical placement was accredited their study progression as mandatory study-related clinical placements. This was based on a special exemption for national practice placements sanctioned by the Ministry of Education and Research due to the pandemic . Of the 24 second-year students in study-related clinical placements, 18 students were supervised while six (three second- year and three third-year students) were unsupervised (Bjelde, T. Private communication, April 2, 2020). The remaining 23 second-year students had their study-related clinical placements postponed until the fall of 2020 (Häikö, K. Private communication, June 15, 2021).
In cooperation between the bachelor program in paramedic science and the prehospital services in the South-Eastern Norway Regional Health Authority, it was decided that only students who had acquired theoretical knowledge and implemented simulation skills training in emergency medicine and in trauma and disaster management were allowed to perform paid patient-related healthcare work in the ambulances. In addition, they had to complete at least one module of study-related clinical placement. Consequently, for students to be enrolled as members of the paid working staff in the ambulance service, the requirements were: (1) completion of the first year of the bachelor program in paramedic science, (2) completion of a mandatory skill test in the respective ambulance services to prove their capability, and (3) in hold of a driver’s license. The mandatory skill tests were the same as for every other healthcare worker who seeks employment in the ambulance service. These steps were taken as a necessary precaution to ensure patient safety.
The definition and education of paramedics vary between countries [24, 25], and in this paper we apply the term “paramedic students” only to bachelor students at university level. The program is regulated by the Regulations concerning national guidelines for paramedic education. The regulations state that the aim of the bachelor program in paramedic science is to educate candidates who can promote, maintain and re-establish health and life quality for humans at individual, group, and societal level .
An electronic survey tool developed by the University of Oslo for collecting sensitive data, Nettskjema, was used for data collection. An invitation to participate in the study, together with an information sheet and a link to the self-administered electronic survey, was sent to students’ university email addresses in early June 2020. Reminders were sent to all students repeatedly over a three-week period, and university teachers simultaneously encouraged students to complete the survey. A promotional video of the study was made and presented to students to remind and encourage them to participate.
The collected variables were chosen based on previous research on how the COVID-19 pandemic had affected healthcare workers, such as levels of anxiety, depression and distress , and research related to virus exposure in emergency settings [6, 27].
Characteristics of participants
Data on gender (male, female, other) and age in years were collected.
Exposure to COVID-19
To measure students’ exposure to SARS-CoV-2, we asked participants about their use of PPE, COVID-19 symptoms, and COVID-19 tests. Variables regarding PPE included whether students had experienced insufficient supplies of PPE (yes/no), inadequate use of PPE during aerosol generating procedures (AGPs) (yes/no), and whether they experienced insufficient time to don PPE (yes/no).
Variables of COVID-19 symptoms included typical symptoms of COVID-19 as listed by the WHO  and the Centers for Disease Control and Prevention (CDC)  on May 22, 2020. The symptoms included fever, chills, coughing, shortness of breath, fatigue, body and muscle ache, sore throat, diarrhea, eye infection, headache, skin rashes or discoloration of fingers and toes, and a category for other symptoms. Students indicated whether they had any of these symptoms during the first three months of the pandemic (yes/no). Because it is unclear from the data whether these symptoms occurred simultaneously or not, we focus our report on the proportion of students that did not experience any COVID-19-related symptoms during the first five months after the outbreak of COVID-19 in Norway.
Student self-reported health-related quality of life
The students’ HRQoL was measured using the well-known and validated Euroqol’s EQ-5D-5L instrument in Norwegian translation . The instrument has two parts: a health profile and a visual analog scale (EQvas). The health profile comprises five dimensions of health: mobility, self-care, usual activities, pain and discomfort, and anxiety and depression. Participants rate each dimension on a five-point scale, each point indicating the level of problems experienced (1 = none, 2 = slight, 3 = moderate, 4 = severe, 5 = extreme/unable) .
There are 3,125 possible combinations of responses (i.e., EQ-5D health states) and each response is assigned a value reflecting the population preference for the various health states (EQvalue). This value represents the preferences of the general population, and is presented on a scale where 1 denotes full health and 0 denotes a health state in which the general population on average would state indifference if asked to choose between 10 years of life and immediate death [32, 33].
In the absence of a Norwegian value algorithm for the EQ-5D, we used the EQ-5D-5L crosswalk value set for the UK . The second part of EQ-5D-5L, the visual analog scale (EQvas), is a vertical scale ranging from the endpoints “worst health you can imagine” (= 0) to “best health you can imagine” (= 100) .
Reported HRQoL was compared to Norwegian general population norms for EQ-5D-5L for the same age/sex groups .
Students’ participation in the national response to the COVID-19 pandemic
Descriptions of students’ participation in the national pandemic response included variables grouped as 1) patient-related healthcare work and 2) non-patient-related healthcare work. The variable patient-related healthcare work (yes/no) identified students enrolled in 12 weeks of study-related clinical placements in an ambulance service and students who had other healthcare-related work involving patient contact (such as working in test stations, hospital wards or other healthcare institutions). The variable non-patient-related healthcare work (yes/no) described students who worked at COVID-19 call centers (public telephone service answering questions and giving advice regarding COVID-19 symptoms, testing procedures, quarantine, etc.); logistical work in the ambulance service, hospitals or other places; work at ambulance decontamination stations; and participation in other non-patient pandemic-related activities.
For most analyses we used the computer software platform SPSS, version 26. KH conducted the analysis and AKH checked the data files, SPSS syntax, and outputs for errors. No errors were identified. KR conducted linear regression modelling in the computer program R, version 4.0.4 to compare the results of HRQoL to the Norwegian population.
Descriptive statistics were performed to describe participant characteristics, exposure to COVID-19, HRQoL, and participation in the national response to COVID-19. Results for categorical variables are presented with the number of cases, percentage of the sample, and missing values. Age is reported in terms of mean and standard deviation; minimum and maximum values are not reported due to the risk of identifying individual participants.
Differences in HRQoL between groups were analyzed using independent samples t-tests. Because the number of cases in some groups was small, we conducted sensitivity analyses using the non-parametric Mann Whitney U test. To compare the EQ-5D-5L responses of paramedic students with the Norwegian general population, we made use of data from a general population survey conducted in 2019 and designed to generate population norms for the instrument . Considering the limited age range of the 109 paramedic students, we limited the general population data to the 1,553 respondents aged between 18 and 49 years. EQvalue and EQvas scores from the general population and paramedic student respondents were compared using linear regression modelling, controlling for age (categories for 18–29, 30–39, and 40–49 years), sex, educational level (categories for primary education, secondary education, less than four years of higher education, and at least four years of higher education), and paramedic students’ study progression in years (student seniority). With a base case corresponding to a female general population of respondents aged 18–29 with less than four years of higher education, we used two regression models for each of EQvalue and EQvas: one in which a single parameter indicated paramedic student status, and one in which paramedic students were identified by year of study. Details regarding the setup of these models can be found in “Appendix 1”.