Everyday Resilience: Equipping Faculty With Practical Exercises to Promote Resilience Among Medical Students.

Introduction: Burnout is prevalent in health care. As professionals advocate to increase resilience training as a strategy to reduce burnout, few examples exist of practical resilience programs that equip faculty to help students build and sustain well-being over time. Method: We developed two straightforward, skills-based resilience exercises. Breaking Down Easy taught individuals to identify personal strengths. My Resilience Practice helped individuals identify strategies to cope with daily stressors. We taught these exercises to international faculty in a train-the-trainer workshop format, at two medical education conferences. Faculty applied the exercises, performed pair-share reflections, and discussed opportunities to introduce the exercises in their own institutions. Postsession surveys evaluated the workshop quality and the exercises' ease of use and applicability.
Results: Thirty-five faculty and five students participated across two international conferences. Of participants, 83% (33 of 40) completed postsession surveys. On a 5-point Likert scale, participants rated the workshop on average 4.4 for usefulness, 4.6 for applicability, 4.4 for ease of instruction, 4.5 for clarity, and 4.8 for overall quality. Participants found the exercises to be straightforward to use and planned to use them at their institutions with students, residents, and faculty. Discussion: Participants found our workshop to be relevant and effective and shared their intention to incorporate these materials into their teaching with medical students, residents, and faculty. Implementing effective programs to build resilience is critical to increasing well-being and reducing burnout. This, in turn, may enhance patient safety and improve health system outcomes.

Educational Objectives

By the end of this activity, learners will be able to:

Define resilience and its role as a protective factor against burnout.

Apply two straightforward exercises to promote resilience as a daily practice.

Propose opportunities to teach and promote resilience among medical students.

Introduction

Burnout is prevalent among physicians in training and in practice, with rates of up to 50%[1] and 46%[2] reported respectively. This is a clear signal that our system, and those within it, need help.[3,4] Burnout disproportionately affects health care professionals as compared to the general population, with first line physicians such as family and emergency medicine physicians at greatest risk.[2] Burnout has been associated with reduced self-care, increased mental health concerns, poor professionalism, diminished productivity, ineffective patient care, and decreased patient satisfaction.[5]

Burnout may begin early in medical school, with over half of medical students reporting it.[6] Dyrbye and colleagues have challenged the medical community to pursue more evidence-based approaches to understanding and mitigating burnout in both trainees and practicing physicians.[7] Medical school offers an opportunity for early intervention by providing students with the tools necessary to thrive in a challenging environment. Teaching resilience has been designated a priority area for medical education initiatives.[8]

Resilience connotes inner strength, competence, optimism, flexibility, and the ability to cope effectively when faced with adversity; importantly, resilience can be taught.[9] Teaching resilience to individuals, including effective coping and problem solving, can combat burnout.[10] Higher levels of resilience among medical students have been associated with improved subjective well-being, lower levels of distress, and more positive perceptions of quality of life and the educational environment.[11,12]

Despite calls to bolster resilience training, few examples exist of effective training programs that build resilience and sustain well-being over time.[7] A search of MedEdPORTAL returned recent materials focused on burnout prevention,[13] as well as on well-being and resilience more specifically,[14-17] but these sessions aimed to train medical students and residents rather than the faculty who teach them. One exception was Saeed et al.'s “Building Resilience for Wellness,” a faculty development resource.[18] Like this curriculum, our workshop focused on a faculty audience. Our work expanded on that of Saeed et al[18] by focusing on individual resilience exercises as a way to complement larger system-wide efforts to reform health care and training systems. We offered this workshop as one facet for developing resilience in individuals. Our exercises can complement broader, more comprehensive system-wide improvement strategies to build resilience and prevent burnout, recognizing the multitude of layers associated with resilience development across individuals, institutions, and communities.

In their conceptual review, Howe et al.[9] proposed dimensions of resilience including self-efficacy, self-control, self-care, ability to engage support and help, learning from difficulties, and persistence despite obstacles. The authors also suggested educational approaches to promote these skills including self-directed learning, formative reflection, and strength-identification. The authors noted an ideal learning environment for resilience is one where learners can connect socially with peers and positive role models, and safely reflect on both past successes and challenges.[9] Guided by this conceptual definition of resilience and suggested teaching modalities, author Galina Gheihman developed two exercises de novo called Breaking Down Easy and My Resilience Practice, and situated them within an interactive, self-directed, reflective workshop which also promoted peer-to-peer learning.

Breaking Down Easy was an exercise that helped individuals identify their strengths by reflecting on an ordinary task they take for granted and breaking down the competencies and personal attributes required to complete it. The goal was to illuminate personal strengths and attributes one may tend to discount, as well as to prompt formative reflection on past successes and perseverance. My Resilience Practice was an exercise that helped individuals identify strategies to cope with stressors in daily life, reflect on stress-management techniques that either work for them reliably or may have gone unnoticed in the past, and create a prospective plan to actively and adaptively cope with future stressors and setbacks. This exercise brought attention to self-care and engaging social support during times of challenge, while also promoting real-time, peer-to-peer social support, and role modeling.

The first author (Galina Gheihman) piloted the two exercises in a student-led, 90-minute, discussion-based workshop with first-year medical students at Harvard Medical School. The Journal of General Internal Medicine published the results of that workshop and the two exercises as a Concise Research Report.[19] Student feedback improved the exercises and we adapted the interactive, reflective workshop into a train-the-trainer approach for faculty development.

In this workshop we both taught faculty participants two straightforward, skills-based resilience exercises they can use themselves, and also guided faculty through identifying opportunities to introduce these skills with their learners. Through this train-the-trainer approach, we aimed to reach not only a large audience of faculty, but also enable them to share these resources with medical students and residents at their own institutions.

Methods

Intended Audience and Setting

Our target audience were faculty members with a teaching role and administrators or program coordinators supporting clinical students and trainees (e.g., program administrators). Upon invitation from the conference presenters, we presented our workshop at two international medical conferences in Mount Gambier, Australia, and Hawaii, USA. Each conference invited faculty members with an interest in medical education from multiple international institutions. Conference participants signed up for workshops they desired to attend. Anticipated attendance was 20–30 faculty per workshop. We required no prerequisite faculty training.

We delivered the first workshop during the International Consortium of Longitudinal Integrated Clerkships (CLIC)[20] annual conference in Mount Gambier, Australia in October 2018. Participants included approximately 14 faculty members and five students. The students had an interest in medical education and participated fully and actively in all aspects of the workshop. A student-faculty co-facilitator team (authors Galina Gheihman and Tara A. Singh) delivered the workshop. In developing the workshop, we found that employing a team of two facilitators familiar with the exercises and how to use them was the best strategy. We divided the workshop evenly between the facilitators: one presenter led the introduction and discussion of the first exercise, Breaking Down Easy, and the second presenter led the second exercise, My Resilience Practice. We delivered the second workshop during the Association of Professors of Gynecology and Obstetrics (APGO)[21] annual Faculty Development Seminar conference in Hawaii, USA in January 2019. Participants included approximately 21 faculty members. Here both facilitators were faculty members (Tara A. Singh and Bri Anne McKeon), and again divided the facilitator role between the two exercises.

Workshop Logistics and Summary

In our 90-minute workshop, we introduced the concept of everyday resilience, teaching participants two straightforward, skills-based resilience exercises that individuals could apply to their daily lives. The workshop was skills-based and interactive. Faculty had the opportunity to apply the exercises in real time, followed by facilitated small- and large-group discussion.

We set up the workshop in a large room with participants seated at either one large table or in smaller groups of four to six participants. Participants required a writing utensil, which we made available, and worksheets (Appendix A) were printed beforehand for each participant. We used a projector to display the PowerPoint presentation at the front of the room during the workshop and found it useful to have either a whiteboard or standing easel to make notes during the large-group discussions. It was possible to facilitate this workshop as one individual; however, as two facilitators were present, one facilitator led the discussion and the second facilitator took notes on the whiteboard or easel in a way that was visible to the participants. For facilitation we include the Everyday Resilience presentation slides (Appendix B) and a details Instructor's Guide with speakers notes (Appendix C), which both can be edited and adapted for one's local setting.

The workshop began with introductions, which offered all participants the opportunity to speak. For introductions we asked the audience to think about why they were there, priming them to be intentional in their participation. Next, the facilitators generated a definition of resilience together with the audience. Using this working definition of resilience, the facilitator emphasized that resilience can be taught and that by using the exercises shared in the workshop, participants would learn how to do so. The first facilitator introduced the exercise Breaking Down Easy (Appendix A) and participants completed the exercise on their own. Participants then shared their experiences with a partner, and then with the larger group. The same process was repeated for the second exercise, My Resilience Practice (Appendix A), but during the larger group we compared the two exercises with one another.

Given the train-the-trainer approach to this workshop, in the final section of the workshop we directed a discussion of how faculty participating in this workshop might adapt the two exercises to their own institutions and the trainees with whom they work. We also recommended that participants learn about other well-being resources available at their schools prior to running the workshop so that they would be equipped to refer students to additional resources and support, should this need arise during or after their session. We closed the session by asking each participant to share either one thing they learned or one thing they planned to do differently as a result of the session, reiterating the shared learnings generated during the workshop.

Workshop Evaluation

Participants completed an end-of-workshop survey (Appendix D) to evaluate the workshop quality and their ability to use the two resilience exercises. We first developed the survey for the original pilot workshop with students and modified it to reflect a faculty audience. Participants ranked the usefulness, applicability, ease of instruction, clarity, and overall quality of the session on a Likert scale (1 = lowest, 5 = highest). We queried participants about whether they intended to use the exercises in the future with their trainees and inquired about what barriers to implementation they foresaw. We also asked for suggestions for improvement. The surveys were voluntary and anonymous, completed on paper in real time. We allocated 5 minutes at the end of the workshop specifically for survey completion, to increase the response rate while respecting participants' time and ending within 90 minutes. We recommend allocating this time to prioritize gathering participants' feedback.

Data Analysis

We entered quantitative measures in Excel (Microsoft). We tabulated results from the survey by workshop quality and likelihood of using the exercises again in the future. We performed content analysis on the qualitative data from open responses.[22] We identified and determined the frequencies of themes related to the impact of the workshop on participants and participants' suggestions for workshop improvement.[23] Facilitators also debriefed with one another after each workshop, identifying what went well and what they could improve. No major changes were made between the two workshops at CLIC and APGO.

Results

We compiled and combined our results from both workshops for analysis. A total of 35 faculty and five students participated in our workshop across the two conferences. Of participants, 83% (33 of 40) of participants completed postsession surveys.

We reported mean and standard deviation for Likert scales. On average, participants rated this session at 4.4 (SD = 0.7) for usefulness and 4.6 (SD = 0.5) for applicability at their sites. Participants rated the workshop highly for ease of instruction with 4.4 (SD = 0.7); clarity was rated 4.5 (SD = 0.6); and quality of the session was rated 4.8 (SD = 0.4). In a qualitative content analysis of free responses, 50% (16 of 33) of the participants reported they appreciated having practical exercises to use after the workshop. In terms of elements of the workshop that were most useful, participants reported that they enjoyed the pair-share and group sharing (14 of 33; 42%). In terms of workshop improvement, participants suggested more time for the workshop (2 of 33; 6%); more exercises to take home (4 of 33; 12%); and adding citations to the workshop materials for reference (3 of 33; 9%).

Participants rated the two exercises as easy to use (Breaking Down Easy was rated 4.7 [SD = 0.5]; My Resilience Practice was rated 4.5 [SD = 0.6]) and reported that they were likely to use the exercises at their institutions (4.4 [SD = 0.8] for Breaking Down Easy; 4.5[SD = 0.7] for My Resilience Practice). Participants reported that they would use these exercises with medical students, residents, and other faculty. Participants reported foreseeable barriers to implementation included poor student perception of importance of the subject matter (6 of 33; 18%), lack of administrative support for faculty (2 of 33; 6%), lack of time (9 of 33; 27%), and lack of a safe space and/or comfort with sharing openly with peers (3 of 33; 9%).

Discussion

To address the absence of straightforward resilience building exercises for medical students and trainees, and the lack of faculty development sessions to support teaching of such exercises, we adapted a resilience-building workshop for medical students into a train-the-trainer faculty development intervention. In this reflection- and discussion-based workshop, our goal was to equip faculty with resilience-building exercises and help them plan for introducing these resources to trainees at all levels at their home institutions. We evaluated participants' experiences with workshop quality and the ease of use and applicability of the two exercises, Breaking Down Easy and My Resilience Practice.

Participants found our faculty development workshop to be engaging, relevant, and effective. Participants commended the interactivity, the real time application of the two exercises, and the creation of a safe and open space for discussion. In the workshop we also allowed time for personal reflection on the experience of using the tool and brainstorming about where and how to broadly apply the exercises in participants' own institutions. There are few empirical easy to teach and use resilience exercises available. Our workshop participants reflected on the potential for these exercises to have an impact with students, staff, and faculty at their institutions. We have previously shown that students benefit from using these exercises,[19] and reported here that faculty also appreciated their utility.

We knew from previous work that the exercises we developed were effective for students.[19] We developed this faculty development workshop with a train-the-trainer approach because we believed that training the trainer would allow us to make this resource widely available. With this in mind, we included several important design elements in the workshop: we used the pair-share model to ensure every participant had an opportunity to speak, thereby generating a richer discussion; we prioritized having participants use the exercise in the workshop so they had an opportunity to experience it themselves; and we left time at the end of the workshop to evaluate the workshop, gather feedback, and openly discuss ideas for application and dissemination of the exercise in the participants' own settings. Additionally, we implemented and evaluated the faculty development workshop with two groups of medical educators, including 35 faculty participants and five student participants with a self-identified interest in medical education who attended the conferences. We anticipated that a faculty audience would give us effective feedback about how to modify the workshop and/or where and how they would apply these exercises, given the participants' prior medical education interest and expertise. We also hoped that educators exposed to these exercises would be able to replicate our workshop and disseminate these exercises.

The resilience exercises and the accompanying interactive workshop format we presented were self-explanatory, and faculty can use the exercises with faculty, resident, or student participants at their institutions. Participants commented that they could imagine employing the exercises several times with the same population over a period of time or using the exercises in diverse settings. The exercises were flexible; they were not specific to a time, place, or population, and may be adapted for different audiences. Our participants were primarily medical educators, and they felt they could share the exercises with other groups of participants (e.g., medical students, residents, administrators, staff, and other faculty). Participants were excited to bring these exercises to their settings and proposed several novel ideas and opportunities for their use at the close of the training (e.g., dedicating grand rounds to well-being and deploying the exercises in this setting).

As a result of the two successful workshops at CLIC and APGO, the director of the Harvard Medical School Academy (David A. Hirsh) invited us to share the workshop with faculty locally at Harvard Medical School. We delivered a 60-minute modified version of the workshop (presenting only a single exercise, My Resilience Practice) at an Academy Special Session on Resilience in February 2019. We were subsequently invited by colleagues of one of the facilitators (Tara A. Singh) to share the exercise at one of our affiliated clinical sites, Cambridge Health Alliance (CHA) during a Department of Obstetrics and Gynecology grand rounds focused on well-being. Here we gave a 30-minute modified workshop, again focusing on My Resilience Practice. In both cases, faculty remained the target audience. By adapting the work to audiences of different sizes and sessions of different length, we have continued to demonstrate the applicability and versatility of these exercises for addressing resilience training in medicine.

We recognize that resilience is a complex, dynamic capability that develops over time and includes several dimensions, from self-efficacy and self-control, to the ability to engage and seek support, learn from difficulties, and persist despite obstacles.[9,24] These qualities are crucial for developing clinical leaders capable of embracing the uncertainty and evolving change of our health systems. To create our workshop, we followed the conceptual definition of resilience presented by Howe et al.[9] who suggested modalities for building these skills. Our self-directed, reflective exercises helped participants develop self-awareness, reflect on strengths, and accept personal limitations.[9] The interactive nature of the workshop, and its reliance on pair-sharing and peer-to-peer support, helped build positive personal relationships. Future work can help validate whether these exercises build these specific skills, and whether augmenting components of resilience can strengthen individuals' overall resilience. While there is evidence for building health care professionals' resilience through individual cognitive behavioral therapy or resilience workshops,[25] these efforts should be further augmented by the adoption of organizational-level approaches.[26,27] Workshops focused on individual resilience should not replace, but rather complement, larger system-wide efforts to reform health care and training systems and address the underlying root causes of burnout, isolation, and stress. We encourage faculty to introduce our resilience exercises as one of several resilience-promoting programs addressing individual, community, and institutional factors in parallel.[28,8]

We considered limitations to implementing this resource. An important barrier is lack of time; there is already a paucity of time in the medical curriculum and in faculty's schedules. Faculty leaders must value the domain of well-being to prioritize time in the curriculum, and institutional and administrative support is mandatory. Students' interest in, and recognition of the importance of the subject matter of resilience may be a potential barrier, although students and faculty thus far have enjoyed and recommended the workshop to others. We suggest that generalizability may be limited by participants' ability or willingness to share openly, and we recognize other limitations for people struggling with active mental health disorders. While we hope that the exercises could offer benefits in concert with traditional mental health resources, it also could potentially be a trigger for some people and is not a replacement for health services. We recommend facilitators learn about local resources available to participants prior to running the workshop and provide this information at the close of the workshop.

Limitations of our workshop evaluation included the small sample size, limited scope, and possible self-selection of interested faculty members into this elective workshop. To broaden the generalizability of this work, our target audience included two different populations of educators and we dedicated time within the workshop itself to maximize our evaluation response rate. We recognized that our attendees likely had prior interest in well-being and resilience, and most were medical educators given the nature of the conferences. In future work we seek to assess whether faculty not primed with this interest benefit from our training and will feel equipped to share these resources with students. We would also evaluate whether the exercises are effective for populations beyond students and educators. We also limited our current evaluation scope to the workshop quality and participants' self-report of likelihood to use the exercises in the future. We did not validate the tools as to whether they developed resilience on formal measures of this trait. We also did not follow our attendees longitudinally to see whether they implemented the use of these exercises. Future work should follow participants over time to determine whether these exercises build specific skills associated with resilience, whether this promotes greater overall resilience, and from an implementation perspective, whether and how they use these exercises again in the future.

A future direction is to recruit a cohort of faculty who would be willing to embed this workshop within their programs and follow the outcomes for students and faculty longitudinally. We would be interested in learning if and how participants use these resilience exercises, how frequently they return to them, and whether the training has lasting effects over time. We have not yet conducted an evaluation of its longitudinal impact but coordinating a cohort of faculty committed to implementing it and evaluating outcomes across several schools would be valuable. We are also interested in determining the best time to train faculty in these exercises and when it is best to introduce these exercises in trainees' curricula.

We note that in its original development, this workshop represented one among several efforts at our school to increase students' access to resources for well-being and promote an open dialogue about these critical issues. We strongly believe parallel efforts that address the needs of students, faculty, and staff within an institution can augment efforts to mitigate burnout and nourish a culture of well-being and joy in practice. Although a sole facilitator can deliver the workshop, we encourage faculty to work with a student cofacilitator where possible, who can provide the benefit of near-peer instruction. Team teaching may bolster relationships between students and faculty and among students in different years of training. This approach also supports students interested in well-being and medical education with opportunities to develop their teaching skills. We foresee this workshop as offering one of several touch-points for resilience training throughout the undergraduate curriculum and into the continuum of graduate medical training and continuing medical education.[6,7]

Conclusions

This study demonstrated that our interactive, reflection- and discussion-based faculty development workshop provided tools to train-the-trainer in two previously developed resiliency exercises, Breaking Down Easy and My Resilience Practice. Our participants found the workshop to be useful and the exercises applicable. They appreciated learning straightforward exercises and felt confident about implementing them at their home institutions with a variety of trainees and faculty. By cultivating a growth mindset that resilience can be practiced and built—and providing specific exercises to do so—we hope to assist faculty in preparing students for, and inoculating them against, the stressors they will face in their medical careers. By building resilience, we hope that physicians and medical students can develop increased well-being, reduce burnout, enhance their work and life satisfaction, and contribute to improved patient safety and health systems outcomes.

Everyday Resilience Worksheets.docx

Everyday Resilience Presentation Slides.pptx

Instructor Guide.docx

Session Evaluation Form.docx

All appendices are peer reviewed as integral parts of the Original Publication.