Introduction
As a multi-disciplinary team funded by Clinical Scholars, a national leadership program of the Robert Wood Johnson Foundation (RWJF), we brought together our areas of expertise to empower students in healthcare professional programs or emerging health professionals (EHPs). Our team consists of two medical doctors (endocrinologist and Internal Medicine physician), a pharmacist, a psychologist, and a social worker. Our multi-disciplinary team brought together our students to strengthen their abilities in several areas through training, mentoring, and modeling through a partnership with the University of Hawaii at Manoa John A. Burns School of Medicine Homeless Outreach and Medical Education (H.O.M.E.) project. Due to COVID-19 the H.O.M.E. project was unable to work with patients in person for a period of time. At the same time, the stress the EHPs were experiencing was an opportunity to help empower our students through resiliency education. Thus, our project aimed to focus on empowering our EHP’s to build both resilience in themselves and in the houseless population with whom they work.
This paper’s focus is on one training provided to over seventy-five third-year medical students who took our training entitled “Resilience for Health Providers – Strengthening You to Strengthen Them.” Medical students are at particular risk for high stress and burnout, thus it is essential to help them build skills to strengthen their resilience (Cheung et al., 2021). Research has found that developing programs to support medical students can help them to be overcome some of these challenges (Stoliker et al., 2021).
Resilience Training
The training on building resilience was created by members, Julien-Chinn and Austin Seabury, of the research team) for EHPs in each respective discipline. The training incorporated a parallel learning model that help the students identify and discuss resiliency factors as they apply to the life of a student in a health profession and then apply the same concepts to case examples of patients, specifically those struggling with houselessness. The training utilizes lecture, self-reflection, examination and application to case examples, and opportunities for question and answer.
EHPs are led through 6 protective factors to build their resilience and learn to help those they serve build resilience. These protective factors are: motivation; self-efficacy; appropriate utilization of social support; hope and resilient mindset; initiative-taking, taking charge, and communicating needs; flexibility and creativity in response to challenges. Examples and descriptions are provided for each protective factor. EHPs are then led through exercises to help them implement first the protective factor in their own lives and then in the lives of the houseless population with whom they work.
For example, when we speak to motivation, training participants are asked to think about the reasons that they selected their profession or their why. When providing the training in a synchronous environment, as was the case with this training, we open the floor to allow participants to share their why. In the asynchronous version we provide a pause and ask participants to think about the question and write down their answer or their why. Themes we often hear are: a passion for the work; a desire to help others; that they enjoy the challenge of the work; the ability to use their gifts; and to improve people’s lives. We then speak to why this motivation is important to resilience; such as, helping one to persist when they are tired, or making a tedious task more doable, and even reducing the number of choices that must be made daily. Turning the tables, we then guide participants through why motivation may increase the resilience houseless individual in the case study.
Literature Review
Existing literature supports resilience as a critical aspect influencing medical students’ successes and chances for a successful career. For example, Cheung et al. (2021) emphasizes that the mental health of this group declines during the course of medical school because of the lack of sleep, high levels of stress, and responsibility, indicating that their well-being and resilience may suffer, and they may face higher risks of burnout or failure. Williams et al. (2020) found that poor mental health is one of the common problems for medical students. Under these conditions, activities aimed at enhancing resilience are vital for achieving better outcomes. It helps to be flexible, adaptive to numerous challenges, and integrate into the work of health units (Lin et al., 2019).
The tools to address the problem vary as medical students might benefit from various methods to improve their resilience. For instance, Stoliker et al. (2021) examines the effects of a self-paced online resilience training program to cope with depression symptoms and anxiety. The results prove its effectiveness and positive influence on mental health, with the program helping participants cope with anxiety and depression specifically. The LAVENDER program utilized in the study by Cheung et al. (2021) might also be a powerful method to help would-be medical workers to acquire higher resilience levels. Importantly, the program was well-accepted by students who mentioned enjoying it, with 76% agreeing that LAVENDER-taught skills were useful while 72% would recommend it to others (Cheung et al., 2021).
At the same time, educational establishments should offer wellness interventions to support students. Understanding the difference between wellness and resilience is important here because the former is about being in good mental and physical health while the latter is an outgrowth of wellness in the whole being. Research found that medical students had higher prevalence of burnout in contrast to other courses, which further leads to dropout intention (Rosales-Ricardo et al., 2021). A study on burnout in medical students found that decreased dropout intention was associated with the increased social support satisfaction, adaptive coping, and academic achievement (Alves et al., 2022). Therefore, medical students require consistent support in order to avoid burnout and thoughts about dropping out, and curriculum programs can help achieve this. For instance, Bird et al. (2020) and Wright and Mynett (2019) offer researcher-designed methods to alter existing curriculums to cultivate higher resilience levels in medical students and help them to cope with stress.
Methods
In 2020 a feasibility study was conducted to examine the effectiveness of our resilience training. All trainings were presented virtually due to the COVID-19 pandemic restrictions on in-person learning activities. The feasibility study found that scores improved from pre-test to post-test and the open-ended comments were positive about the impacts of the training. Specifically, the programs allowed participants to cope with environmental challenges, build up their resilience to stress factors, as well as improve mental health overall. Adjustments were made for the final version of the training that mainly involved improving the training for an asynchronous virtual environment that would be used to allow for a wider audience
For this study, conducted in 2021, the training participants completed a pre-test before the training started. A QR code and link were provided to a Qualtrics survey. As part of this pre-test, participants also provided demographic information and responded to the Connor-Davidson resilience scale, a tested and validated scale (CD-RISC-10) (Davidson, 2021). The medical students then received an hour long on-line synchronous version of the resilience training (presented by authors Julien-Chinn and Austin Seabury). At the end of the training participants then took a post-test to measure the efficacy of the training. The pre and post-test consisted of 6 questions, 3 that focused on personal resilience, and 3 that focused on improving the resilience in the patients/clients – particularly those in the houseless population (see Table 1 for full survey). For example, participants responded to “I understand the importance of self-efficacy in resilience” and “I am competent in using strategies that help people who are homeless live healthy lives.” The scale of responses ranged from “not true at all” to “definitely and completely.”
The training evaluation provided information on the efficacy of the training. The CD-RISC-10 provided a base-line resilience score for these participants. As this is part of a larger longitudinal study, participants will be asked to take the CD-RISC-10 at another point in their educational career to determine any change in resilience. Training participants were provided a unique code match their data with future surveys. For this study, only base-line information has been collected and presented.
The CD-RISC-10 measures different aspects of resilience, including flexibility, self-efficacy, the ability to regulate emotion, and cognitive focus/maintaining attention under stress. Overall, the scale is described as a measure of hardiness (Davidson, 2021). The scale measures 10 questions on a 5-point scale, ranging from 0 to 4, the total score is obtained by adding the 10 items together, scores ranging between 0 and 40 (Davidson, 2021). The higher scores indicate higher levels of resilience. Population scores (general population diagnosed with mental health problems) for the CD-RISC-10 are reported as mean scores between 32.1 and 31.8 as reported by Davidson 2021. According to the report by Davidson (2021) the psychometric properties of the scale have been found to apply to a variety of populations, samples, and contexts at it has been tested across diverse groups: “university students, nurses, social workers, physicians, military medical personnel, medical students, missionaries, cricketers” (p. 5).
Findings
A total of 75 medical students enrolled in the 3rd year of a 4-year medical school program participated in the training. Majority of participants identified as Asian (N = 64; 65.98%), about 23% (N = 22) identified as Caucasian, and 11 identified as Native Hawaiian or Pacific Islander. About 55% (N = 40) of the participants identified as female.
In the pre and post-test, participants were asked to respond to a series of 6 questions based on 5-point Likert scale from “not true at all” to “definitely and completely.” Participants were asked to select the answer that best described them. As displayed in Table 1, there was an increase from pre to post-test in each domain measured.
Table 1. Pre and Post-Test
For the base-line Connor-Davidson resilience scale, participants responded to 10 questions to measure their resilience at the point-in-time of the first participation in the training. The reliability measurement for the Connor-Davidson was high (α = 0.90). Seventy-two participants responded to the CD-RISC-10. Participants were asked to provide responses to the questions based on the prompt: “Please indicate how much you agree with the following statements as the apply to you over the past month. If a particular situation has not occurred recently, answer according to how you think you would have felt.” The scale was measured on a 5-point Likert from “not true at all” to “true nearly all the time.” We found that participants scores ranged from 15-40, with the average score being 30.21 (SD = 5.13). Table 2 displays the Mean score and the corresponding percentiles.
Table 2. Connor-Davidson Scores (N = 72)
Discussion
The results of our resilience training were similar to what was found with our feasibility study, where training was effective in improving scores in factor that improve resilience. We saw growth in each area, from personal resilience to building resilience in working with the houseless population. According to Chung et al., 2021, medical students may suffer from mental health decline and acquire high stress levels. Jordan et al. (2020) adds that both females and males suffer from increased burnout levels during their first year of study. Data collected from 172 participants showed that higher perceived stress levels affect their resilience and academic activities (Jordan et al., 2020). Moreover, Oliveira et al. (2017) indicate that problems with health or medicalization (treating human conditions as medical issues) can make negative indicators of resilience more significant. Thus, interventions are needed to help build resilience in medical students. Resilience helps build better coping skills to deal with stress (Lin et al., 2019) and is needed for a successful career (Cheung et al., 2021). Hayat et al. (2021) supports this idea, saying that higher academic resilience leads to increased self-efficacy and enhanced anxiety management. Itis critical to address this problem during medical school to ensure a successful future career. Drawing from the review of literature, it has become clear that resilience training at medical schools has been carried out in Canada, the United States, the United Kingdom, China, Mexico, and several other countries where the educational system will-developed in medical education. While some schools embed the programs into the curriculum, others implement it independently.
This training, designed specifically to help EHPS build their resilience, is needed and timely. We implemented this training during the COVID-19 pandemic, and therefore it was even more encouraging to see that the training could affect improvement in perceived resilience. We were encouraged to see that participants had an improved knowledge of self-efficacy and motivation, and that they felt stronger about being able to make it through.
The CD-RISC allowed for further insight into the resilience of the 3rd year medical students. Our findings, that the average score of the medical students was 30.21, which was slightly lower than the population findings by Davidson (2021). This indicates that this focus on building resilience in this group of students is timely and needed. Unfortunately, we will not be able to determine if the lower score was due to the COVID-19 pandemic but if it was then all students in healthcare professions would benefit from resilience training.
Research specifically with medical students utilizing the CD-RISC-10 has provided additional information of various groups of medical students. In a study of Mexican medical students, Daniel-González et al. (2020) a mean score on the CD-RISC-10 of their medical students was 37.48 while the same score for their psychology students was 35.15. In a study using the CD-RISC-10 of Canadian medical students, researchers found that female medical students had a mean score of 28.84 and male medical students, a mean score of 31.25 (Rahimi et al., 2014). In a study of medical students’ resilience after stressful clinical events, Houpy et al. (2019) found that medical students averaged 28.21 on the CD-RISC-10.
Additionally, a study using the CD-RISC-10 looked at medical students at the University of Saskatchewan, they found that resilience was a partial mediator of the relationship between attachment and the level of perceived stress (Thompson et al., 2018). Specifically, resilience allowed to alter the way in which stress was perceived, thus altering the response to it (Thompson et al. 2018). Examining psychological distress among female medical students at Universities in Malang, Azzahra and Paramita (2019), using the CD-RISC-10, found that “…The higher the level of medical students’ resilience, the lowest the level of students’ psychological distress and vice versa, the lowest the level of medical students’ resilience, the highest the level of students’ psychological distress” (p. 104). For resilience of medical students, it means that they must be supported and guided toward better resilience when the curriculum is dedicated to it. When administering CD-RISC-10 to medical students, it is best to implement the pre-test assessment some time after the studies begin to ensure that the participants get used to the curriculum. Several months will be necessary to implement resilience training while a few weeks will take to determine whether students’ resilience improved as a result of the program.
Conclusion
Resilience is a fundamental role in a medical student’s education to help prevent burnout and anxiety. It is critical to support them by offering training programs because medical students are more likely to burn out and experience negative mental health consequences that their counterparts of other specializations. The findings of programs aimed at strengthening resilience in the target population suggest that students get to build their coping skills and become better at managing stress, especially when programs are embedded into the curriculum. Notably, it is recommended to administer the CD-RISC-10 scale to test students’ resilience before and after the program once the studies at medical schools resume after COVID-19. Since the findings suggest that resilience training can take different forms, it can be adjusted to various educational settings and contexts to fit medical students’ needs and expectations.
References
Azzahra, F., & Paramita, R. W. (2019, March). The Effect of Resilience toward Psychological Distress Among Female Medical Students. In 4th ASEAN Conference on Psychology, Counselling, and Humanities (ACPCH 2018). Atlantis Press.
Bird, A., Tomescu, O., Oyola, S., Houpy, J., Anderson, I., & Pincavage, A. (2020). A curriculum to teach resilience skills to medical students during clinical training.The Journal of Teaching and Learning Resources. Web.
Brown, T., Yu, M., & Etherington, J. (2021). Listening and interpersonal communication skills as predictors of resilience in occupational therapy students: A cross-sectional study.British Journal of Occupational Therapy, 84(1), 42-53. Web.
Cheung, E. O., Kwok, I., Ludwig, A. B., Burton, W., Wang, X., Basti, N., Addington, E. L., Maletich, C., & Moskowitz, J. T. (2021). Development of a positive psychology program (LAVENDER) for preserving medical student well-being: A single-arm pilot study. Global Advances in Health and Medicine, 10.
Daniel-González, L., Cadena, C. H. G., Caycho-Rodriguez, T., & Martinez-GĂłmez, E. (2020). Validation study of the 10-item Connor-Davidson resilience scale among Mexican medical and psychology students. Revista de PsicologĂa y Ciencias del Comportamiento de la Unidad AcadĂ©mica de Ciencias JurĂdicas y Sociales, 11(2), 4-18.
Davidson JRT. Connor-Davidson Resilience Scale (CD-RISC) Manual. Unpublished. 01-01-2021.
Lin, Y.K., Lin, C., Lin, B., & Chen, D. (2019). Medical students’ resilience: A protective role on stress and quality of life in clerkship.BMC Medical Education, 19(473). Web.
Hayat, A., Choupani, H., & Dehsorkhi, H. (2021). The mediating role of students’ academic resilience in the relationship between self-efficacy and test anxiety. Journal of Education and Health Promotion, 10, 297. Web.
Houpy, J. C., Lee, W. W., Woodruff, J. N., & Pincavage, A. T. (2017). Medical student resilience and stressful clinical events during clinical training. Medical Education Online, 22(1), 1320187.
Jordan, R. K., Shah, S. S., Desai, H., Tripi, J., Mitchell, A., & Worth, R. G. (2020). Variation of stress levels, burnout, and resilience throughout the academic year in first-year medical students. PloS One, 15(10), e0240667.
Oliveira, A., Machado, A., &, Aranha, R, (2017). Identification of factors associated with resilience in medical students through a cross-sectional census.BMJ Open, 7, e017189. Web.
Rahimi, B., Baetz, M., Bowen, R., & Balbuena, L. (2014). Resilience, stress, and coping among Canadian medical students. Canadian Medical Education Journal, 5(1), e5.
Stoliker, B. E., Vaughan, A. D., Collins, J., Black, M., & Anderson, G. S. (2021). Building personal resilience following an online resilience training program for BScN students.Western Journal of Nursing Research. Web.
Thompson, G., Wrath, A., Trinder, K., & Adams, G. C. (2018). The roles of attachment and resilience in perceived stress in medical students. Canadian Medical Education Journal, 9(4), e69.
Williams, M. K., Estores, I. M., & Merlo, L. J. (2020). Promoting resilience in medicine: The effects of a mind–body medicine elective to improve medical student well-being.Global Advances in Health and Medicine, 9. Web.
Wright, B., Mynett, J. (2019). Training medical students to manage difficult circumstances – a curriculum for resilience and resourcefulness? BMC Medical Education, 19, 280.
Alves, S. A., Sinval, J., Neto, L. L., MarĂ´co, J., Ferreira, A. G., & Oliveira, P. (2022). Burnout and dropout intention in medical students: The protective role of academic engagement.BMC Medical Education, 22(83). Web.
Rosales-Ricardo, Y., Rizzo-Chunga, F., Mocha-Bonilla, J., & Ferreira, J. P. (2021). Prevalence of burnout syndrome in university students: A systematic review. Revista Salud Mental, 44(2), 91-102.