Personal and professional wellness are the foundation of vigilant and safe perioperative practice and patient care. The pandemic’s impact on health care providers’ overall health and well-being are evidenced by increased rates of burnout, depression, substance use, and suicide that threaten the providers’ ability to provide safe and optimal patient care.1 It requires a comprehensive strategy to implement and sustain a positive organizational and learning culture to foster clinician and trainee or learner well-being.
Imagine for a moment that you are a trainee, student, or learner from one of the many perioperative professions entering some phase of care to begin your clinical experience. As a trainee now or when you were a trainee, you are entering a place where your only experience, other than reading about your chosen profession and perhaps shadowing for a few hours, might be a place where you or your family or friends have had a procedure that was filled with many unknowns. Now you are entering a very complex system grounded in science and policy with many professional languages, traditions, and standards of care. As a trainee, you may be concerned about how you will be perceived. You hope to be perfect and realize that in the end perfection and “looking good” is just not possible. You may internalize the following questions: Will your faculty have time or interest to connect what you have learned in the classroom and simulation lab with actual practice? Who will partner with you and how will you be supported for your personal safety and wellness so that you can learn without harming your patient or yourself? Additionally, many first days occur across a health care education program with changing faculty, teams, specialty rotations, and new facilities each with their own learning culture or environment making self-efficacy and confidence even more challenging.
The perioperative period has a culture of its own that is influenced by the organizational culture and subcultures of the professions that have unique languages and customs.2,3 The trainee, student, or learner is seeking a physical and psychological environment with an educational tone that welcomes them and supports their learning, when in fact they may be faced with some preceptors or clinical faculty who will make the learning process very difficult and uncomfortable.4 Medical students who experienced negative faculty role modeling during their training were at higher risk of developing burnout.5 In addition, medical students were at higher risk of depression and burnout if faculty members were perceived to have high demands with little support, did not support student autonomy, and were hostile or harassing. Students who experienced faculty who made education their priority were at lower risk of developing burnout.5 In a recent study, student registered nurse anesthetists (SRNAs) shared that balancing the demands of the rigorous anesthesia and DNP curriculum and their well-being was not appreciated by some clinical faculty, increasing stress and anxiety. The students suggested that a supportive and genuine relationship with certified registered nurse anesthetist clinical site coordinator(s) improved well-being.6
The learning environment or culture has four interactive and overlapping components which are the personal, social, organizational, and physical/ virtual as described in Figure 1.7 When considering these four overlapping and interactive components of the learning environment, it becomes evident that the trainee’s experience and perception of themselves in the learning environment and culture can impact their wellness. The COVID-19 pandemic disrupted the learning environment and interrupted required clinical experiences, as well as how all care is delivered. The pandemic turned the health system on its head, placing clinicians and trainees in the position of changed roles with little clarity of what success looked like and no sign of normalcy returning with surge after surge that increased burnout characterized by high emotional exhaustion, depersonalization, and low sense of personal accomplishment.8 In the 2019 National Academies of Sciences, Engineering and Medicine (NASEM) Taking Action Against Clinician Burnout Consensus Study Report, the Committee found that clinicians who are experiencing burnout, defined as emotional exhaustion, depersonalization, and loss of professional efficacy, are poor teachers and role models who can disrupt the learning environment.8
Much has been said about the trainee taking care of themselves. Indeed, regular exercise with proper diet and sleep are foundational to everyone’s wellness, but is it enough? When you are engaged in rigorous didactic learning that must be linked to skills, techniques, complex communication, and critical thinking of an autonomous health care provider, you may need a bit more to be well.
A trainee’s early perception of themselves and their learning environment are often fixed in their mindset and can be very black and white—be perfect and look good to others or you are a failure.9 The fixed mindset does not support learning or resilience necessary for successful and safe health care practice. Over and over again, throughout an education or training program, the faculty and health care team have opportunities to foster the learning culture that is safe for the learner to move from the fixed to growth mindset.9-11 The growth mindset provides the trainee with a frame of reference; permission if you will, to learn from challenges, feedback, and mistakes.9-11 In an effective learning culture, faculty and students are able to plan for a successful learning day by creating clear, measurable goals to create a timely feedback loop during the clinical day to assess understanding and at the end of the time together. This feedback can identify successes, questions to be answered from the literature and text, and what learning goals are next.5 The student who is resilient and possesses grit is well and confident to seek difficult, challenging learning experiences when the faculty and culture are aligned in a positive learning culture. These students will also know when to ask for help for personal and patient safety.
Fostering a learning culture for trainee or learner wellness uses strategies that promote well-being, empathy, and the learning experience linking the learner, faculty, and culture to create community, eliminate mistreatment, address misperceptions with conversation, continuously improve the learning experience, foster a growth mindset in learners and faculty, and finally mitigate stigma of seeking help (Table 1).5,7,11 Our trainees, no matter their profession, are our future. Investing across our organizations to foster an interprofessional learning culture and environment will pay dividends in attracting and retaining engaged professionals, and will also improve the wellness of our trainees to be vigilant, engaged health care providers focused on patient and provider safety.12 The health care organization has the opportunity to include learners and staff in anonymous surveys to assess organizational culture and learning culture effectiveness, as well as impact on wellness, burnout, and learning.7,12 Beyond the clinical site, social activities arranged outside of didactic and clinical time allow students to connect with each other to improve the education experience.6 Wellness days during the education program promote work-life balance.6 Clinical faculty and perioperative team members have an opportunity to connect with students to foster them into their professional role through inclusion in team conversations and communications, education and quality improvement activities, birthday and other celebrations, and social gatherings outside of the clinical site. Being part of a community which genuinely connects with the student as a person will provide the students with a safe place to learn and grow to be well.
Table 1: Learning Culture8
Educating and mentoring our trainees, students, and learners in a healthy and well learning environment is a complex and critical issue.8 It demands our attention and commitment to monitor our students, culture, metrics, and ourselves for wellness linked with safety and, most of all, to ask our trainees, are you OK? Then we should continue to support the future of health care, our learners, for continued wellness or guide the learner to resources to gain wellness for their own and patient’s safety.13
- Health Policy Institute of Ohio. A call to action. Improving clinician well-being and patient care and safety. 2020.
- Allen MP, Johnson RE, McClave EZ, Alvarado-Little W. Language, interpretation, and translation: a clarification and reference checklist in service of health literacy and cultural respect. National Academy of Medicine. February 18, 2020 https://nam.edu/language-interpretation-and-translation-a-clarification-and-reference-checklist-in-service-of-health-literacy-and-cultural-respect/ Accessed November 20, 2021.
- Raksamani, K., Stalmeijer, R.E. How postgraduate trainees from different health professions experience the learning climate within an operating theater: a mixed-methods study. BMC Med Educ. 2019;19:1–11.
- McKimm J, Nishigori H. The implications of culture in the education and practice of healthcare professionals. The Asia-Pacific Scholar. 2019;4:1–2.
- Dyrbye LN, Satele D, West CP. Association of characteristics of the learning environment and US medical student burnout, empathy, and career regret. JAMA Netw Open. 2021;4:e2119110.
- Mesisca J, Mainwaring J. Stress, anxiety, and well-being in nurse anesthesia doctoral students. AANA Journal. 2021;89:396–402.
- Gruppen L, Irby D, Durning S, Maggio L. Interventions designed to improve the learning environment in the health professions: a scoping review. MedEdPublish. 2018;7:1–32.
- National Academies of Sciences, Engineering, and Medicine. Taking action against clinician burnout: a systems approach to professional well-being. The National Academies Press. 2019.
- Bartlet AD, Um IS, Luca EJ, et al. Measuring and assessing the competencies of preceptors in health professions: a systematic scoping review. BMC Medical Education. 2020; 20:165.
- Dweck C. Mindset: The new psychology of Success. Ballantine Books. 2007.
- Theard MA, Marr MC, Harrison R. The growth mindset for changing medical education culture. EClinicalMedicine. 2021; 37:100972
- Dyrbye LN, Lipscomb W, Thibault G. Redesigning the learning environment to promote learner well-being and professional development. Acad Med. 2020;95:674–678.
- Huang J, Brenner A. Our own safety. APSF Newsletter. 2019;33:82–83.