By: Michelle van den Engh (Biography & Disclosures) and Kiran Veerapen (Biography & Disclosures)
Supportive funding for the project described was provided through an Island Health Seed Grant. The authors have no conflict of interest to declare. Mitigating Potential Bias: Ethical approval to conduct the project described was obtained from the Island Health HREB (Health Research Ethics Board). Recommendations are consistent with current teaching practice patterns.
Life is not about how fast you run or how high you climb, but how well you bounce
-Vivian Komori
What we did before:
Providing health care is a psychologically demanding task at the best of times. Some health care providers burn out, while others not only adapt, but are able to use difficult clinical experiences for transformative growth. Resilience reaches beyond adjustment or recovery. It is a dynamic, transformative trajectory that allows people to thrive on challenges (1,2). In the medical education literature, the conceptual model of a ‘coping reservoir’ has been proposed to illustrate the dynamic processes that can influence potential outcomes from enhanced resilience to distress and burnout (3). Factors that may drain this reservoir include stress, internal conflict and demands on time and energy; positive inputs into the reservoir include psychosocial support, social/healthy activities, mentorship and intellectual stimulation (3). Perceived support from team and faculty members has been associated with a greater likelihood of resilience in medical students, as well as with increased odds of recovery in students exhibiting burnout (4, 5). Furthermore, mentorship and positive role modelling have been cited as general factors associated with a greater likelihood of resilience in medical students and postgraduate trainees (2,6,7).
In our supervisory practice, we aimed to mentor and model positive attitudes, approaches and behaviours following a general sense of what would create a supportive climate for our learners. We wanted, however, to go beyond the general. We asked ourselves:
What are the specific processes occurring during clinical supervision that learners experience as promoting their resilience? What supervisory approaches could we enhance to nurture a positive resilience trajectory in our learners?
What changed our teaching practice:
To trace the effect of past supervision on the development of current ability to respond positively to emotionally challenging situations, we recruited six physicians from family practice and psychiatry who were within their first five years of independent practice. These early career clinicians participated in a semi-structured interview or provided written narrative responses to guiding questions. Through the lens of appreciative inquiry, the focus was on identifying positive, favourable influences as a foundation for further enhancement of those strengths and capabilities that promote resilience. Data was analysed using a phenomenological hermeneutical method for interpreting interview texts (8).
Participants perceived the following features of the supervisory process as contributing positively to resilience:
- Normalisation
Acknowledgment of the inevitability of difficult situations and validation of their emotional responses. Open, honest and genuine discussion of the difficult aspects of the situation. Sharing by the supervisor of having experienced similar situations and responses. Acceptance that we are all humans with limitations trying our best.
- Role modelling
Observing or hearing about strategies supervisors themselves used to process emotionally challenging situations, providing a sense of having ‘tools’ that could be used in a similar situation in future practice.
- Taking an exploratory approach
Feeling a supervisor was listening, responsive and had a vested interest in the learner’s individual experience and needs. Supervisors providing space for the learner to develop their individual approach and promoting learner self-determination.
- Belief in the learner’s capacity
Receiving the message that the supervisor believes in the learner’s ability. Explicit comments from a supervisor communicating belief in the learner’s capacity to later practice independently, as well as more implicit messages through recognition of the learner’s strengths.
- Assurance of backup
Sensing the backup implicit in clinical supervision. Supervisors providing specific coaching at appropriate times, acknowledging their supervisory role and responsibility with difficult parts of care and assuring availability, thus providing learners with a sense of feeling supported and not alone.
- Communicating the big picture
Being reminded of the big picture in their learning trajectory, through placing a learning point within the larger structure of their learning, or simply feeling reassured that learning is a work in progress and it is not necessary to get everything today.
What we do now:
Having gained a deeper understanding of the aspects of clinical supervision experienced by learners as enhancing resilience, we use each supervisory experience to examine the aspects of normalisation, role modelling, taking an exploratory approach, belief in the learner’s capacity, assurance of backup and communicating the big picture that have occurred.
Whereas before we may have responded with: “This is a difficult situation. Have you tried…?” (generally supportive, but not elaborated and more ‘top-down’), we are now more likely to offer remarks such as: “This is a difficult situation. It’s not surprising to feel stressed (normalisation). What is your sense of how you would like to move forward (taking an exploratory approach)? It brings to mind a similar experience I had – I’d be happy to share what I found helpful at the time (role modelling). You don’t have to figure it all out today (communicating the bigger picture). I can see you are putting a lot of thought into working it through (belief in the learner’s capacity). Let me know if you would like to discuss it further (assurance of backup).”
We aspire to use each supervisory encounter as an opportunity to reflect on our process, consider new perspectives, and integrate the totality of the experience to further our ongoing learning and development as supervisors. Through the ‘hidden curriculum’, medical educators are dynamically engaged in a process of often unrealised transmission to trainees of implicit beliefs, attitudes and behaviours (9). How we approach our supervisees will shape how our supervisees will approach their patients. We strive to nurture our clinical supervision process in ways that will nurture resilience in our learners.
How our experience is relevant to teachers in the Faculty of Medicine:
The COVID-19 pandemic has brought unprecedented times. It is a time for adaptation and innovation. It is a time to amplify connection, compassion and care. It is a time for us all to nurture resilience. As we all work together to flatten the COVID-19 curve, we can also work together to steepen the curve of resilience. Positive transformative processes are possible, even at the worst of times. Let us work with our learners to mobilise them.
References:
- Bonnano GA. Uses and abuses of the resilience construct: loss, trauma and health-related adversities. Soc Sci Med. 2012. 74(5):753-756
- Howe A, Smajdor A, Stockl A. Towards an understanding of resilience and its relevance to medical training. Med Educ. 46(4):349-356
- Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 32(1):44-53
- Dyrbye LN, Power DV, Massie FS et al. Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students. Med Educ. 44(10):1016-1026
- Haglund ME, aan het Rot M, Cooper NS et al. Resilience in the third year of medical school: a prospective study of the associations between stressful events occurring during clinical rotations and student well-being. Acad Med. 2009 ; 84(2):258-268
- Winkel AF, Honart AW, Robinso A et al. Thriving in scrubs: a qualitative study of resident resilience. Reprod Health. 2018. 15(1):53
- Kötter T, Fuchs S, Heise M et al. What keeps medical students healthy and well? A systematic review of observation studies on protective factors for health and well-being during medical education. BMC Med Educ. 19(1):94
- Lindseth A, Norberg A. A phenomenological hermeneutical method for researching lived experience. Scand J Caring Sci. 18(2):145-153
- Grofton W, Regehr G. What we don’t know we are teaching: unveiling the hidden curriculum. Clin Orthop Relat Res. 2006. 449:20-27
Resources:
When more support is needed:
- UBC Health and Wellbeing services are available to all UBC students to help navigate challenging times: https://students.ubc.ca/health
- The Physician Health Program provides support, referrals and counselling for BC physicians, resident doctors, medical students and their family members: https://www.physicianhealth.com
- The Province of BC has significantly expanded existing mental health programs and launched new services in the context of the COVID-19 pandemic. A comprehensive list of services for British Columbians, including specific programs for healthcare workers, can be found here: https://www2.gov.bc.ca/gov/content/health/managing-your-health/mental-health-substance-use/virtual-supports-covid-19
- The Government of Canada has launched a portal called Wellness Together Canada, which offers no cost tools and resources for all Canadians to support wellness: https://ca.portal.gs or wellnesstogether.ca
Acknowledgment:
We would like to acknowledge and thank the REDCap (Research Electronic Data Capture) data management system for providing secure data collection and management services for this project.
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