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Stress in healthcare students: are interventions to foster resilience worth a try?

Posted on 9th September 2020 by Germán Báez, Claudia Nadia Panoso, Camila Rosell

Evidence Reviews
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In this blog, Camila, Claudia and Germán, fifth- and sixth-year medical students from Hospital Italiano de Buenos Aires, provide their own summary and thoughts on a newly published Cochrane review: Psychological interventions to foster resilience in healthcare students.

Introduction 

It is quite usual for most healthcare students, such as medical, nursing, psychology and social work students to experience a great deal of stress, mostly related to study, work or both. This specific population may benefit from resilience promotion interventions to prevent development of burnout symptoms or mental ill health.                    

What is resilience? Resilience has been described as a multidimensional and dynamic process in which, despite being subjected to either short or chronic psychological stressors, there is undisturbed mental health during or after adversities, or temporary dysfunction followed by successful recovery. 

We wonder if institutions should promote interventions to foster resilience in order to help healthcare students handle different stressors, including the challenges associated with the current COVID-19 pandemic. 

How can resilience be fostered in healthcare students? 

There is little consensus about when to consider a program as ‘resilience training’, or which main components are necessary. Most interventions with the aim of fostering resilience, whether individual or group‐based, are implemented face‐to‐face. Alternative formats are online or a combination of both. Depending on the underlying resilience concept, resilience interventions target different approaches. These interventions are based on different psychotherapeutic approaches such as cognitive‐behavioural therapy (CBT), acceptance and commitment therapy, mindfulness‐based therapy and problemsolving therapy, among others.  

For instance, from a cognitive behavioural perspective it is believed that it is not the stressor itself, but rather its cognitive response that may lead to stress reactions. Therefore, this approach focuses on challenging an individual’s maladaptive thoughts by exposing them to milder forms of stress and providing coping strategies. Stress inoculation therapy may foster resilience by enhancing factors such as self‐efficacy. Other theories, such as mindfulness‐based therapy is defined by a non-judging self-awareness of the present moment including accompanying mental phenomena; practitioners could then learn how to accept whatever is happening in the present moment. This awareness of the ‘here and now’ may enhance the sensitivity to positive aspects in life and the future. 

What does the evidence say?  

A 2020 Cochrane systematic review analyzed 30 studies (search date up to June 2019) that included 1315 students in order to shed light on some of these questions, comparing psychological interventions to foster resilience, hardiness or post‐traumatic growth to a control condition. The results of this review could indicate that healthcare students may improve their resilience with some of these interventions. We should point out that symptoms of anxiety and stress may be reduced immediately after the treatment, however, it does not appear to reduce depressive symptoms or to improve well‐being. 

We should take into account that there are a limitations in the methods of the studies such as the small number of participants in most studies, and the fact that the findings are limited to certain populations (composed mostly of women from highincome countries such as America, Europe, and Asia), different types of interventions and comparators, and there was uncertain or high risk of bias in selection and blinding in most studies. 

Therefore, the evidence from this review is limited and very uncertain. This means that we currently possess very little confidence that resilience interventions make a difference to the outcomes measured.

The table below provides an abbreviated version of the summary of findings from the review.

Resilience in healthcare students summary of findings from Cochrane review amended table.

Summing up…

There is very low-certainty evidence (meaning that the true effect may differ markedly from the estimated effect) that resilience fostering interventions might be more effective than control interventions for fostering resilience, self‐reported symptoms of anxiety, and stress or stress perception at post‐test. Overall, even if it seems that fostering resilience could be beneficial, none of the studies are robust enough to back it up.  

Personally we have felt some of this stress as we advanced with our medical studies; some of us even started to show some signs of distress (specifically, higher glucose levels than you might expect from a healthy person) despite all of the healthy habits implemented (healthy diet, no alcohol, sleeping at least 7 hours a day, you name it). What made a difference was meditating regularly, and soon our anxiety levels went down and lab results improved as well! However, before dragging everyone into a mindfulness hype, we would want to know if these interventions are actually effective in terms of benefits in mental health. 

Having said that, personally, if you feel like doing some yoga, meditation or mindfulness, and you feel it works for you, then go for it! At least the authors found no evidence of significant adverse events, where it was reported. While we wait for better data on this issue, we might as well sit back and try to relax for a bit. 

References

Kunzler  AM, Helmreich  I, König  J, Chmitorz  A, Wessa  M, Binder  H, Lieb  K. Psychological interventions to foster resilience in healthcare students. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013684. DOI: 10.1002/14651858.CD013684.

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Germán Báez, Claudia Nadia Panoso, Camila Rosell

We are fifth- and sixth-year medical students at the Hospital Italiano de Buenos Aires (IUHI). As healthcare students we get stressed out every now and then, thus we recognize the importance of this subject and enjoy collaborating in a network like S4BE. View more posts from Germán

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