Bouncing Forward: Mental Wealth for All

What is wellbeing and why is it important? The WHO definition reads “Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity. Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community” [1].

There is currently a significant and increasing amount of interest worldwide in how we can best support our learners and faculty, including health professional educators, to maintain and nurture their wellbeing, in challenging circumstances. Does your institution currently assess wellbeing, through an annual survey, focus groups or involvement in strategic discussions? There is also a focus on strengthening an individual’s ability to overcome adversity, manage stress, and thrive in their personal and professional life and in embedding wellbeing into academic and clinical organisational curricula, plans, policies, and practices.

We should be putting people at the heart of what we do! “An individual’s well‐being impacts on their capacity to learn and perform competently. Learner well‐being and supporting their acquisition of skills in self‐care for lifelong practice is therefore core business for educators” [2].

Maslow's theory describing “hierarchy of needs” (see figure) is often portrayed in the shape of a pyramid with the largest, most fundamental needs at the bottom and the need for self-actualization and transcendence at the top [3, 4]. An individuals’ most basic needs must be met before they become motivated to achieve the higher-level needs. The theory states that people are motivated to achieve certain needs and that some of their needs take priority over others. One of our most basic needs is physical survival,this could be in the form of good sleep hygiene, nutrition, all of which can impact our behaviour if not kept in check. Each level needs to be “completed” before we can reach the next level. We work with cultural and interpersonal diversity daily, and we should recognise and address unconscious biases. These biases may include small behavioural cues that signal whether others are valued, whether others are being included or spoken to. Consider the signals you’re sending, your body language, your interaction style, casual comments, and feedback that you deliver. Now look around and consider the environmental signals within your institution, what photos are on your walls, and lastly consider your external signals that may present on your website as images, marketing materials, and which faculty or students are chosen to represent the organisation. Does it suggest all are welcome at this institution? This can really impact the levels of “safety, belonging and esteem” of learners (and faculty).

When considering learners life cycle in parallel to this pyramid, not only are there colliding shapes (!) but there are key life changes and transitions that impact their ability to flourish and self-actualise. A key example are the first few days of university, and therefore the role of a dean of student within faculty is to work with the university to ensure there is a balance in the information shared, enough to support but not overwhelm. Welcome sessions can be led by student societies or supported by student leadership. Key information should be given priority, e.g. academic integrity workshops and the respectful community sessions to encourage student transition and to improve social interaction. In addition, pre-arrival information should be co-designed with student leadership and near peers.

Within the educational context when we consider the learner life cycle, from student recruitment and admission to their learning and then assessment. This then cycles to results and awards/graduation and finally as alumni. During their life cycle, successful progression of learners requires them to be connected, equipped, motivated, and settled.

Why would learners seek support?

• Difficulty in transitioning to university or new country

• Difficulty sustaining academic workload and multiple competing tasks

• Social isolation, social anxiety, loneliness, and victimisation

• Poor cultural assimilation or English ability

• Poor resilience or maladaptive coping mechanisms

• Financial debt or hardship

• Personal life events

• A medical condition or disability

• A psychological predisposition, condition, or disability

• Emotional instability following a physical or psychological trauma

• Substance abuse or addiction

Why do learners not seek support?

• Lack of time

• Lack of confidentiality

• Fear of negative impact on career

• Fear of documentation on record

• Stigma of mental health care

• Not knowing who to go to

• Difficulty accessing services

• Fear of unwanted intervention

• Fear of legal consequences

• “Using services will mean I’m weak”

• Cost

• My problems are not important

• “Nobody will understand”

How would educators recognise learners in distress?

• Marked change in academic performance or attendance

• Persistently late to class or in turning in assessments

• Highly disorganised

• Withdrawn from social situations and communication with others

• Persistent low mood, low motivation, or loss of interest

• Marked change in hygiene and general appearance

• Acute stress, anxiety, or panic attacks

• Unpredictable or irrational thoughts, moods, attitudes, or behaviours

• Being under the influence of drugs or alcohol

• Disorientation, delusional, dissociated thoughts, or behaviours

• Extreme distorted thinking or excessive unwarranted worrying

• Persistent disruptive or volatile physical or verbal behaviour

• Alarming material presented in a student’s written work

The stigma of mental health is prevalent in healthcare students and practitioners. This may result in learners being reluctant to identify as suffering from a mental health condition and from seeking the required support and management. Learners, health science educators, and practitioners may be wary of accessing support due to number of reasons—including those listed above.

To create safe environments for learning and personal growth, we must ensure.

• Barriers to seeking help are removed.

• There is access to role model, e.g. near peer or faculty.

• Confidentiality maintained following disclosure.

• Fears around progression/career concerns are considered and discussed.

• Counselling for all is encouraged.

• Transparency around the benefits of self-care, including the care of others and ensuring safety of patients.

• Help seeking pathways are accessible and visible.

When considering putting strategies into practice to make a difference the institute should monitor policies to promote wellbeing, this can be achieved by finding an existing framework and completing a gaps analysis.

At Bond we created a “Promoting Health and Wellbeing working group” with champions from across the university that included student leaders, professional/administrative staff, faculty, and members of the medical services and human resources. We recognised that many initiatives are fairly siloed across faculties; it was realised that it would be helpful to consider how some of these initiatives can be rolled out across the university (e.g. mentoring programmes/counselling offerings) to the benefit of all. We proposed a review of various faculty-specific initiatives with a view to considering resourcing/embedding of support initiatives across the University? Our suggested priorities are listed below including finalising a Mental Health Strategy complete Bond University Wellbeing Research Project.

• 1. Review and report on the wellbeing and mental health needs of all

  • a. Using “A framework for promoting student mental wellbeing in universities” (Baik and Larcombe [5])

  • b. Plus consider a whole of university Wellbeing Research Project

• 2. Reduce the stigma of mental health

  • a. Part of the Wellbeing Research Project

  • b. Work of the Promoting Wellbeing working group (and individual portfolios)

• 3. Improve education and access to information and promotion of wellbeing within teaching and learning initiatives within the classroom using established framework

  • a. Using “A framework for promoting student mental wellbeing in universities. https://unistudentwellbeing.edu.au” as indicated by the 5 domains (see image)

• 4. Increase the volume and visibility of information, resources, and support available in extracurricular endeavours by promoting internal and external services

  • a. Continue to work with the student society, medical services, and our insurance provider to consider appropriate resources

  • b. Promotion and review of the webpage or create a shared site for all

• 5. Consider a variety of support methods for all

  • a. Listen to the community (research project and the work achieved in other faculties)—sharing is caring

• 6. Highlight support needs at key points in the semester

  • a. Review transition points—is there a student journey or life cycle that could be considered

• 7. Improve communication around support strategies

  • a. Faculty/student training—mental health first aid

• 8. Co-design wellbeing events with staff and students

  • a. Funding and support regular events—key dates

• 9. Establish and promote wellbeing champions

• Training and support for all

A fellow member of the Bond University Collaboration for Research in Understanding Stigma in Healthcare [6] research group and I began the Bond University Mental Health & Wellbeing Project (Bannatyne [7]). Preliminary findings have indicated that during 2020 when reflecting on the impact of COVID-19 on mental health and wellbeing, over half the sample (54.4%) reported a decline in their mental health and wellbeing. 10% of the student population completed the survey with awareness of various support services at Bond University was mixed. Approximately, one-quarter had accessed psychological services. Barriers to accessing University Psychological Services complemented those described earlier, e.g. confidentiality.

Notably, over two-thirds of the sample (66.6%) believed Bond University should be actively trying to reduce mental health stigma within the university community. Ideas suggested included sharing lived experience stories via social media, more visible promotion of mental health statistics and support services, a culture of accountability for student leadership, embracing and supporting mental health week and other wellbeing activities, mental health literacy included as a component of core subjects, peer support programmes, and compulsory mental health first aid training for all educators (Bannatyne  [7]).

Institutions should provide as minimum services such as student counselling service, medical clinic, accessibility & inclusion advisors, security, academic skills centre, first nations support centre, LGBTIQ + services & support, career development centre, and student business centre.

Wherever possible consider the role of student leaders, peers who can state and validate “I’ve been there, I get it!”. Engage learners as stakeholders by having learner representatives as a voice for their peers and promote partnerships in health promotion activities and address misconceptions (bust the myths) and open discussion during distressing events. Consider who are your national learner society representatives, does the learner society have a wellbeing officer?

Now you? As an educator, who would you turn to, where can you go when need support, who supports the supporters? When questioned, faculty stated they sought support from.

• Manager/supervisor

• Executive dean

• Programme director

• Faculty-peer support services

• GP

• Psychiatrist

• Mental health professional

• Clergy member

• Employee assist programme

• Internet sources: discussion forums, social media

The role descriptors of any educator have had to adapt have and the true extent of their academic workload, and daily pressures should not be underestimated. Institutions are responsible for staff wellbeing as it can affect learner wellbeing and, in the healthcare, setting it can impact patient care. Apart from accreditation and legal requirements to look after health and safety of staff, there are cogent reasons why medical schools should actively promote teacher and staff wellbeing. Who supports the supporters?

At Bond, we have supported colleagues by establishing mental health first aid training. This skills based, early intervention training programmes “mobilise and empowers communities by equipping people with the knowledge and confidence to recognise, connect and respond to someone experiencing a mental health problem or mental health crisis. Anyone can have a conversation that may save a life. Everyone should know how” [8]

In April 2020, the Student Support Network was established for faculty across the 23 medical schools in Australia and New Zealand. It was realised as a key initiative as we traversed the unprecedented times of the pandemic to ensure those who supported students were also cared for. The once weekly meetings now occur monthly and allow sharing of best practice and resources. Members highlight that they value this community or practice and are empowered to review difficult or complex situations involving students with advice provided by experienced colleagues in confidential manner [9]

Mentors Across Borders is a dynamic and diverse international community of Leaders in Health Professions Education formed in 2020, united by a shared passion for mentoring and nurturing fellow educators as well as scholarship. This community aims to promote collegial global conversations about important educational topics in a psychologically safe space to interact, share success stories and challenges, and potentially enhance professional identity (BEI [10]).

We have recognised that what learners want and what faculty need is relevant, timely information, in the moment. As educators, you should draw on the expertise of the educational community through membership of organisations such as Australian and New Zealand Association for Health Professional Educators (ANZAHPE), an International Educational Association for Health Professional Educators (AMEE), and the International Association for Medical Science Educators (IAMSE). The publication on redefining scholarship for health profession education [11] emphasises the below resources to support educators:

• Published research

• Engagement with a faculty learning community

• Community of practice

• Engage with colleagues locally

• Professional development workshops and opportunities

• External conference

• Online webinars

• No need for face to face, formation of special interest groups, etc.

• Community can include quality assurance, benchmarking, and peer review

• Evaluation and student satisfaction

Faculty development courses have also been established including an Essential Skills in Medical Education (ESME) course focussing on wellbeing (WESME) (AMEE [12]).

In 2019, colleagues published the medical student wellbeing—a consensus statement from Australia and New Zealand (Kemp et al. [13]) that summarised that we should.

• Design curricula that promote peer support and progressive levels of challenge to students.

• Employ strategies to promote positive outcomes from stress and to help others in need.

• Design assessment tasks to foster wellbeing as well as learning.

• Provide mental health promotion and suicide prevention initiatives. Provide physical health promotion initiatives.

• Ensure safe and health-promoting cultures for learning in on-campus and clinical settings.

• Train staff on student wellbeing and how to manage wellbeing concerns.

The editors of the understanding medical education textbook recognised the need for a learner wellbeing chapter with recommendations for learner support system and approaches that educators could use (Bishop et al. [2]).

The chapter complimented the consensus statement and also suggested the following:

• To care for patients, health professionals must care for themselves, and they need to learn about and develop this capability.

• Programmes and interventions can be categorised as general support to all learners, preventive support in anticipation of challenges, and additional support for learners in need.

• Educators should consider their roles as individual teachers, programme designers, and in creating supportive and safe learning environments that will help learners negotiate future challenges in the clinical workplace.

• Educators should consider professional boundaries in their actions to promote well‐being and welfare. Whilst many educators may draw upon their experiences as clinicians, learners are not their patients.

Future Directions: Building the Future Together

The recent publication by Medical Deans Australia and New Zealand Inc. (Medical Deans) on Inclusive medical education is designed to assist medical schools in their approach to and discussions with prospective and current students with a disability and to identify and consider the adjustments or supports that may be needed for them to commence or continue in a medical programme [14]

In addition, the National Framework, Every doctor every setting; Improving the wellbeing of doctors and medical students is a key enabler of quality patient care and healthier communities. The framework is based on available evidence and advice from doctors, doctors-in-training, medical students, mental health and suicide prevention experts, and other key stakeholders. The overall consideration is that all jurisdictions, settings, services, and stakeholders must be involved to ensure immediate, sustained, and coordinated action (Everymind [15]).

There are predictable times of distress for all of us as we navigate life, and therefore, preventative measures and sharing of a toolbox of skills and resources whilst understanding the “currency of mental wealth” are essential. There are five types of wellbeing described: emotional, physical, social, workplace, and societal wellbeing. Many of us will have a preference—for me, physical activity, weather walking, cycling, or strength training allows me to perform at my best. Emotionally, I am aware of my own requirements and needs to have time out and reconnect. I have a supportive social community with family and friends, in my workplace I have a sense of purpose and drive and thrive during times of challenge. Societal can be difficult when faced with dilemmas outside of our control.

Resilience is often defined as bouncing back from adversity; in reality, no one ever returns to how they were before the event. There is often a required time to reflect and to heal, but more than often there is personal growth; the timelines can vary person to person. Using the narrative, “bouncing forward” gives permission to allow the individual to grow and gain strength from these challenging times. I have gained strength in sharing my own vulnerability and hope this will help others. Brené Brown debunks some myths about vulnerability, the most popular being that vulnerability is a sign of weakness. “When we think of times that we have felt vulnerable or emotionally exposed, we are actually recalling times of great courage; Vulnerability is the birthplace of love, belonging, joy courage, empathy, and creativity” (Brown [16]).