Using Reflective Writing to Explore Resident Resilience during Global Health Electives

ABSTRACT.

Pediatric residents participating in global health electives (GHEs) report an improved knowledge of medicine and health disparities. However, GHEs may pose challenges that include cost, personal safety, or individual mental health issues. The objective of this study was to describe the use of guided reflections to understand resident resilience during GHEs. Forty-five residents enrolled in two pediatric training programs were asked to respond in writing to weekly prompts during a GHE and to complete a post-trip essay. Analysis of the reflections and essays, including an inductive thematic analysis, was completed. Two coders performed a second analysis to support classification of themes within the Flinders Student Resilience (FSR) framework. Four themes emerged from the initial analysis: 1) benefits, 2) stresses and challenges, 3) career development, and 4) high-value care. Analysis using the FSR framework revealed the following themes: acknowledgment of personal limitations, importance of relationships in coping throughout the GHE, and discernment of career focus. Reflective writing provided insight into how residents mitigate GHE challenges and develop resilience. Despite statements of initial distress, residents focused on their personal benefits and growth during the GHE. The FSR framework revealed the residents’ robust self-awareness of limitations and that strong relationships on the ground and at home were associated with perceived benefits and growth. Programs should consider helping residents to identify healthy coping practices that can promote personal resilience during GHEs as part of pre-departure preparation and debriefing, as well as providing for supportive communities during the GHE.

INTRODUCTION

More than 5 million children younger than 5 years old died in 2018, and another 200 million are at risk for developmental delay. The majority of these children were from low- and middle-income countries.¹ These concerns, along with migration, natural disasters, globalization, and the recent coronavirus pandemic have strengthened the case for global health (GH) as an important area of education for medical trainees.^2–4 GH education has been associated with improved diagnostic and communication skills, cultural humility, public health knowledge, high-value care, and choosing primary care careers among trainees.^5–11 Despite development of best practices in GH^2,3,5 and 73% of pediatric residency programs having GH education programs, there remains great variability in the content and quality of these programs.^2,3

One challenge in providing and sustaining high-quality GH education is supporting the physical and mental health of trainees during global health electives (GHEs).^6–10 Mental health challenges during GHEs may include anxiety, depression, culture shock, and the potential for moral distress and ethical injury.^7–12 This is often related to higher rates of patient mortality and medical complexity, or even the trainees’ awareness of the potential negative impact of their GHEs on the local community.^7,10–16 Pre-departure training^17,18 that includes a wellness curriculum¹⁹ before GHEs and debriefing¹⁵ after GHEs has shown promise in supporting the needs of trainees.⁵ However, factors associated with trainee resilience during GHEs have not been well studied.^5,8 Understanding these factors may provide further insight in assisting trainees in mitigating these challenges.

Resilience is defined as “a dynamic process wherein individuals display positive adaptation despite the experience of significant adversity or trauma.”²⁰ Greater resilience in medical trainees has been associated with greater self-compassion and less burnout, but has not been studied during GH training experiences.^20–24 Reflective writing has been shown to have an ameliorative impact on stress and also supports the development of problem-solving capabilities, compassion, and cultural humility.^21,25,26 In addition, it has been associated with the promotion of resilience during other medical training experiences.^21,25–28 In GHEs, post-trip reflective writing has been used to study educational competencies and clinical knowledge gains, but has not been used to study resilience or wellness during GHEs.^9,26,27

This qualitative study is the first to explore factors associated with resident resilience during GHEs. The Flinders Student Resilience (FSR) framework is an established framework used previously to identify more completely trainee resilience factors (including but not limited to self-compassion, mindfulness, engagement in social support, and self-efficacy) through reflective writing during difficult training experiences, including those in underserved and rural locations.^21,29 Using the FSR framework as an established conceptual framework to analyze reflective writing for medical trainees in underserved settings, we examined factors associated with resident resilience and wellness. In addition, we used the FSR framework to understand more fully how to help residents mitigate challenges and optimize the educational and professional benefits of GHEs.

METHODS

Context.

Cincinnati Children’s Hospital Medical Center’s and the University of Wisconsin’s pediatric residency training programs have established GH pathways/tracks, founded in 2009 and 2010, respectively. Residents enter these volunteer pathways/tracks as interns and participate in a competency-based curriculum including GHEs. Residents from both programs are required to complete pre-departure training and post-trip debriefing. University of Wisconsin residents have implemented post-trip reflections since 2010, whereas the Cincinnati Children’s Hospital Medical Center implemented this practice in 2015. GHEs across both institutions are conducted at sites with partnership agreements.

Reflection prompts.

Reflection prompts were developed by a pediatric resident and two of the authors using an iterative process that involved physicians from the Midwest Consortium of Global Child Health Educators, including a qualitative research expert. The prompts were designed to encourage progressively deeper reflections each week of the GHE. The first prompt encouraged reflections on the initial impressions of the host site and culture. Subsequent prompts led residents to reflect on the challenges experienced within their medical work and within the host culture. The final prompt encouraged reflection on departure from the host site as well other challenges or joys, including perceived challenges upon returning home. The post-trip essay, completed within 2 to 4 weeks after the GHE, was designed as a summative reflection of the GHE, including its impact on career decisions and the resident’s future approach to health care in the United States. The prompts were piloted for 2 years prior to the beginning of the study (Supplemental Table 1).

Data analysis.

This study was approved by both institutions’ institutional review boards. All residents participating in GHEs in 2016 through 2018 were approached. Those who chose to participate completed the consent process. Resident responses to the reflective prompts were de-identified and entered into a secure database.

Inductive analysis: Identifying general themes.

Four authors trained in qualitative analysis used an inductive approach based on grounded theory through a constant comparison method initially to code reflections during the GHE and the post-trip essays. The codes were created de novo, then were compared over several iterations until agreement was reached regarding the final code list. The code list was used independently by four coders/authors who came together periodically to compare coding of the reflections completed during the GHEs. When the reflections were coded, the researchers met and identified the major themes. Last, post-trip essays were reviewed independently by the same four authors using deductive qualitative analysis, with particular attention to the previously identified themes.

Deductive analysis: Using a resilience framework to identify themes.

A deductive analysis was then completed using the FSR framework to describe resident resilience further. The FSR framework was used originally to describe characteristics and experiences associated with resilience in medical students participating in domestic longitudinal rural/underserved clerkships in Australia.²¹ Our team chose this framework for analysis because it was designed to study trainee resilience in resource-constrained medical training settings.²¹ The FSR framework has three core components: Journey Within, Safe Haven, and Staying the Course. Journey Within explores trainees’ capacity for personal transformation through the following factors associated with resilience: acknowledgment of limitations, self-awareness, self-compassion, mindfulness, gratitude, and optimism.^21,22,29 Safe Haven explores trainees’ coping through the following resilience factors: engagement of support through social networks and finding familiarity.^21,22,29 Staying the Course explores how, with guidance, trainees can transform their identities as young physicians by increasing self-efficacy, learning from difficulties, and developing tenacity.^21,22,29 The iteratively derived prompts were found to match the FSR framework core components, and therefore the FSR framework was selected as the theoretical framework for the deductive analysis. Two coders (A. R. and L. S.) completed this deductive analysis using the consensus method described earlier.

RESULTS

From 2016 through 2018, 45 GHE participants (37 women and 8 men) traveled to 11 sites: Malawi (n = 14), Dominican Republic (n = 8), Cameroon (n = 3), Guatemala (n = 1), Cambodia/Vietnam (n = 3), Ethiopia (n = 1), Ecuador (n = 2), Indian Health Service (n = 5), and Uganda (n = 5). Four of the participating residents returned to a site for a second GHE.

Inductive analysis: Identifying general themes.

Four major themes emerged from the initial analysis: stresses and challenges, personal benefits, career development, and high-value care. All participants reported stresses and challenges (Supplemental Table 2) which included the following subthemes: lack of resources, lack of social support/connection on the field and upon reentry to the US, cultural barriers (e.g. language, lack of purpose), and experience of negative emotions/trauma (e.g. exposure to death) as illustrated in the following quotes.

The residents, while very friendly, appear burdened by our presence … .

I felt exhausted and drained from the culture shock, the amount of death we had experienced, and from coming to the realization that I would not be able to provide some of the care that I would want to due to the limitation in resources.

Notably while the residents’ reflections often described stresses/challenges, these were followed by contrasting positive statements. This was also reflected in the overarching positive themes in post-trip essays, for all but two residents (Supplemental Table 2: 5A--B). All 45 respondents reported a personal benefit from the GHE (Supplemental Tables 3--5) which is further described below.

Deductive analysis: Using a resilience framework to identify themes.

Journey within: Self-awareness, optimism and gratitude to promote trainee resilience.

All but two residents indicated hopefulness or maintenance of optimism in the midst of challenges or when describing disturbing experiences. Thirty-one participants indicated using challenges as an opportunity to acknowledge personal limitations and to practice self-compassion/self-care (Supplemental Table 3):

[Long list of negatives and challenges]. Just because you can’t change the future for every child does not mean you shouldn’t do everything in your power for the one you might be able to positively impact. Maybe this experience isn’t to change this place, but rather to change us, so that next time, for the next patient, we can be exactly what they need.

Other themes of self-awareness were noted in the reflections from week 4 and in the post-trip essays, where the trainees’ recognition of their personal limitations in addressing challenging patient encounters tended to grow into more complex thoughts (Supplemental Table 3):

I have also learned a great deal about myself as a person, living independently in a new country, dealing with work and personal life stresses. I have grown as a physician, both my brain and my heart.

Self-compassion has been shown in other studies to be protective from burnout. Thirty-two residents had at least one quote indicating self-compassion.^23,24 In addition, all but two trainees described optimism, and although a few had overall negative post-trip perspectives, even these residents tended to focus on positive gleanings (Supplemental Table 2):

I am not as much of a global health person as I expected …. I think that I am going to focus my career away from global health and back toward research. I can continue doing research … that will benefit people in places like Malawi.

Residents described many challenges as opportunities to practice compassion and empathy for patients, families, and fellow health-care providers. For example, some residents described admiration for hosts who practiced medicine in challenging contexts (Supplemental Table 3):

And, turns out, the peds residents here get even less training than we do in these situations [codes], so apparently I have something to teach them. But mostly, they teach me. It is just amazing how they practice medicine with so little resources … every day it blows my mind.

This compassion moved several residents to cite a motivation toward personal/professional advocacy for health equity in their post-trip essays (Supplemental Tables 5, 8A–8C). In addition, residents expressed new-found gratitude toward the resources and education they experienced at home (Supplemental Tables 3, 4A–4D):

Seeing children survive diseases that Malawian children died from made me incredibly grateful to have all the support and resources that we are privy to … .

Last, the responses from 14 residents revealed protective factors that are known to counteract burnout and reminded these trainees of the reasons they pursued medicine initially^23,29 (Supplemental Table 3):

I feel more grounded as a physician and was reminded of some of the reasons why I chose medicine in the first place.

Safe haven: Fostering and sustaining social networks to facilitate trainee resilience.

Residents positively referenced sharing GH experiences with both local residents and partner residents from their home institution (Supplemental Tables 4, 1A–1F). Residents discussed the importance of having peers from their own culture to process and debrief challenges, navigate cultural differences, stay safe, and help each other master GH best practices (Supplemental Table 4, 1D):

After a very traumatic code resulting in a death, I was walking home with [one of their chiefs], and we were both so upset… . That night talking with her… was very helpful.

In addition, references to wellness or self-care activities involved notable interactions with resident companions (Supplemental Tables 4, 1E and 1F).

Having North American mentors on the ground was associated with positive reflections in processing challenges and in helping to find familiar touchstones from the United States. These mentors were also helpful to mitigate culture shock. This was associated with descriptions of empathy and compassion for hosts (Supplemental Table 3A–3E), in contrast to identifying cultural barriers (Supplemental Tables 2, 3A–H):

I took the opportunity to talk to [U.S. fellow] who had been here before and gave me good advice. I started making more of a concerted effort to strike up conversation with the nurses … . I found I really had to get good buy-in from the nurses by understanding and taking an interest in the culture … . I think I have developed a good relationship with most now … .

One exception involved a visiting faculty who was perceived as very critical of a local host resident (Supplemental Table 2):

This particular physician … volunteered at [the GHE hospital] for the past 10 years… . he rounds … with the residents (like us) and also gives lectures. Rather than working to help “build up” the residents, though, he spends the majority of each afternoon tearing them down … . To me, this physician appears to have little regard or appreciation for the work that the physicians and residents are doing.

The resident reflected this experience back to empathy for the hosts and GH best practices in listening to host perspectives, and pointed out the inequitable treatment by a fellow visitor.

Host faculty also played roles as cultural brokers and mentors by helping residents to thrive while processing challenging situations. Host faculty also facilitated interactions between local and visiting residents while facilitating transformative professional experiences during teaching and scholarly projects (Supplemental Tables 4, 2C and 2D, 4A–4G, and 5A–5E). The lasting impressions made about host trainees were mixed throughout the GHE. Of the 21 references to host trainees, 19 were positive. Although two of the reflections contained negative or skeptical themes about host trainees in the residents’ initial weeks, these residents eventually reflected that building relationships with the host trainees became one of the major positive attributes of their experience (Supplemental Table 4):

The [intensive care unit] nursing staff at [the hospital] is incredible. They are dedicated, efficient, knowledgeable, and personable … dedicated residents, a great nursing staff, and wonderfully skilled surgeons and [Dr P]. I could not ask for better experience.

Some residents described solidarity in processing difficult experiences with host trainees (Supplemental Tables 4, 1F, and 3A–3C). There were also examples of perceived mutual learning and benefit when some residents positively described taking on a teaching or mutual learning role with host trainees (Supplemental Table 5):

I had the unique opportunity to teach Pediatric Advanced Life Support …alongside [U.S.] leadership … . I selfishly expected to impart a lot of new, advanced knowledge to the group; however, I was very pleasantly surprised to find them receptive, engaged, kind, willing to learn, and already knowledgeable about the medicine itself … great example that learning goes both ways sometimes.

Teaching [cardiopulmonary resuscitation] and helping … lead a morning report … were definitely the biggest joys.

In addition, numerous residents described positive connections to host hospitality (Supplemental Table 4A–4C). In contrast, one resident who had negative reflections overall described a lack of connection with peers and hosts (despite being at a site with other peers from the United States), and another resident had a negative experience with nursing staff (Supplemental Tables 2A–2C and 3A–3H). Last, residents returning to the same site referenced continuation of relationships, more autonomy, as well as participation in clinical and teaching roles earlier in the GHE with less “stress” than during the first experience (Supplemental Table 4):

[Returning] … allowed me to really get my feet under me early. Instead of fighting for weeks to figure out … . It allowed me to get right down to work.

Staying the course: Guidance from near and far promotes professional development and trainee resilience.

Residents described gains in confidence in the identification of sick patients, the performance of procedures, creative problem solving, clinical team leadership, and second-language proficiency (Supplemental Table 5):

… forcing me to see the big picture regarding evaluation of sick vs. not sick, priorities … recognizing improvement vs. deterioration, etc.

Hands on experience … list of procedures].

… utilizing creative/dogged problem solving.

Most residents felt their physical exam skills improved as a result of the limited access to tests and imaging, and stated that a great deal can be learned from the physical exams of patients (Supplemental Table 5):

… I used to think that the labs and imaging available to us in the United States at the snap of our fingers was a great luxury that was revolutionizing the course of health care. Well, I do think it is altering the course of health care, but not exactly in a positive light.

All residents stated their GHE impacted their career focus, and all but two stated intentions to have GH be a component of their career going forward (Supplemental Tables 2, 5A, and 5B). Several residents discussed a future quality improvement or scholarly GH project, and two committed to medical education in GH (Supplemental Table 5):

… I feel like if I can be helpful with a project that Dr T wants to be done … I will be contributing something while I am here … helps give me more of a purpose, I think.

I get to teach—something I never thought I would be very interested in, or good at—but I have realized it’s become part of my work, and I love it.

In addition, 11 residents described how their GHE impacted their choice of fellowship, and many expressed a desire to commit to the same site/country in the future (Supplemental Table 5):

My initial rotation in Malawi is what solidified my decision to pursue a career in pediatric critical care … .

Of the two residents who did not intend to continue GH, one committed to GH research. The other resident initially said they would never do a GHE again, and then at the end of the post-trip essay re-considered future GH work (Supplemental Tables 2, 5A, and 5B).

Fourteen residents referenced teaching local trainees as a positive aspect of the GHE, and described increased confidence in these skills upon reentry to U.S. practice. Teaching a formal course or having a research or quality improvement project was associated with a sense of purpose even when other experiences were overwhelming (Supplemental Tables 5, 4A–4G, and 5A–5E).

Residents gave numerous examples of how their GHE changed their cultural awareness. Perceptions of cultural barriers and difficult patient/family encounters during patient care (Supplemental Tables 2, 3A–3H) progressed to residents having compassion for the patients and gratitude for their resources and training at their home institutions (Supplemental Tables 3, 4A–4D). Many described a commitment to sustainable, ethical GH practices, including long-term partnerships and deferring to host preferences and norms (Supplemental Tables 5, 6A and 6B, and 8A–8C). Similarly, many reported the GHE changed their perspective in caring for multicultural families in the United States (Supplemental Tables 5, 7A and 7B):

It takes a lot of time to develop a relationship … I realized what a difference a consistent staff presence could make for the babies in morbidity and mortality … .

Recognizing my lack of cultural connection means I will take the extra time to communicate … and prevent misunderstandings … to provide high-value care.

Last, 10 residents described a personal and professional commitment to health equity and social justice, and even acknowledged the potential negative impact of their own GHE (Supplemental Tables 2, 3C and 3D, 5, and 6A). One resident also noted the lasting effects of colonialism in GH (Supplemental Tables 5, 8C). They described how their GHE not only highlighted disparities for them at the GHE site, but also health disparities at home. Many of these residents identified action steps toward career commitments working for a more equitable system for all children (Supplemental Table 5):

It has also shown me that global health is not a separate entity that you can choose to “do” or “not do.” It has strengthened my belief that economy, culture, religion, etc., are fundamentally intertwined in the practice of medicine.

DISCUSSION

This is the first study to evaluate factors associated with residents’ resilience during GHEs. Our results show that guided reflective writing provided insight into the way residents mitigated challenges and displayed resilience during GHEs. Although pediatric residents have challenging experiences on GHEs,^8,11,13–18 our findings suggest these residents displayed features associated with resilience such as self-compassion, mindfulness, engaging a network of supportive relationships, and developing self-efficacy.^23,24,29 This is similar to what has been observed in other stressful medical training experiences.^21–24,29 After GHEs, residents showed additional factors associated with resilience, including increased confidence in clinical and leadership skills as well as a renewed sense of professional purpose, with a desire to incorporate care of underserved populations into their future careers.^21,24,29

Our initial inductive analysis highlights previously described adversity during GHEs, including concerns of safety, health, ethical practices, and loneliness.^5,8,17 However, our deductive analysis using the FSR framework revealed that statements describing challenges (Supplemental Table 2) were often followed by positive statements revealing self-awareness. For example, in Supplemental Table 3 (1A), a resident described using self-compassion, gratitude, and a social network to navigate numerous resource constraints and ethical challenges. All these factors have been described previously in other resilience studies, which in some cases were protective against burnout and depression.^21–25 Therefore, wellness activities, which promote self-compassion and mindfulness (including reflective writing), may be helpful to incorporate not only into pre-departure training,¹⁹ but also during and after GHEs. These practices may optimize the trainee’s learning and growth while participating in a GHE.^17–19,23

Although reflective writing is already a part of many programs’ debriefing practices, the use of reflective writing during GHEs to highlight individual resident’s resilience factors and their internal journeys has not been studied. Our study reveals that although post-trip essays and week 4 reflections exhibited negative statements, they were often followed by positive statement patterns (Supplemental Tables 3, 1C and 3D; ⁵, 1B and 6A). These findings suggest that incorporating resident reflective writing into post-trip debriefing could be helpful to faculty when counseling residents. The faculty could highlight the resilience factors noted in the reflective writing and use this information to assist residents in transitioning back to their home institution after the completion of their GHE.^8,21,23 The use of reflective practice as a wellness activity during GHEs may also help educators better understand resident experiences and enrich the quality of debriefing after a GHE. Further studies are needed to expand the understanding of what education or personal factors impact residents’ resilience factors during a GHE. Future studies could look for any associations between innate coping factors or pre-departure training content, or the act of reflective writing with development of resilience.^{5,17,19,21,25}

Previous resilience studies have reported that strong social networks of peers or supportive faculty were protective against burnout, depression, stress, and fatigue. However, this has not been studied previously in GHEs.^21–23,29 Our study reveals this is also true in the context of a GHE. We saw numerous examples of the power of social networks in enriching GHEs, including debriefing difficult situations, navigating cross-cultural communication, and having fun during downtime (Supplemental Table 4). In addition, in Supplemental Table 5, similar to the initial FSR framework study, participants described the importance of proximal guidance either from mentors or peers in their professional growth.^21,25 With these results in mind, residents should be made aware prior to departure who is available onsite and at home, so when situations become difficult, they know where to turn.^5,19,21 The multiple examples of processing challenges with peers or faculty on-the-ground (Supplemental Tables 4, 1–3) may indicate that incorporating peer debriefing exercises into pre-departure training could be helpful. Likewise, sending residents in pairs or groups may promote coping and may even foster greater resilience. There may also be benefits to post-GHE debriefing sessions in small groups.^18,30 Last, repeat electives at the same partner institution and/or staying at the site longer may foster the development of enhanced relationships and trust with host colleagues.^3,5

Residents reported that engagement in teaching or projects provided a sense of purpose and was protective against challenges, suggesting that locally owned projects in which residents participate may provide a more enriching GHE experience overall.^2,31 Notably, with every project or formal course mentioned, there was a mention of a mentor at the host site and, in several cases, supportive host peers (Supplemental Table 5).³¹ This further underlines the importance of relationships, particularly in institutional, bidirectional partnerships that foster resilience, learning, and sustainability during ethical GH practices.^3,7,32,33

This study has several limitations. It was limited to two pediatric/medicine–pediatric residency programs in the Midwest. Future studies could focus on the use of reflective practice and resident resilience in a wider cross section of programs and specialties using mixed methodology to analyze resident resilience on GHEs further. Our study is also limited in that it only tells one side of the GHE experience; future studies should focus on incorporating host partner perspectives into reflective practice and debriefing.^2,3,32 In addition, prompts could be expanded to give residents the opportunity to reflect on inequitable power dynamics and the potential negative impact of GHEs on local communities. Comparing and evaluating reflective practice to other interventions including pre-departure training curriculum,¹⁷ wellness curriculum,¹⁹ peer debriefing,³⁰ and inventories of key debriefing quality indicators are needed to determine best practices in fostering resilience during GHEs. Greater analysis and triangulation with focus groups and quantitative surveys would provide richer data regarding the value of reflective writing in GH specifically with regard to resilience.

CONCLUSION

Similar to studies about resilience in other medical contexts, residents on GHEs exhibited factors associated with resilience and professional growth. This was particularly true when they were able to practice self-compassion and find relational support in peer networks, faculty, or host mentors. Our findings show the utility of implementing reflective writing in academic GH programs/tracks to understand chosen wellness activities/strategies that build individualized resilience in residents. Future studies should focus on tools to assist trainees in awareness and promotion of personal resilience. This may include reflective writing practices and wellness curricula as part of pre-departure training and/or the incorporation of reflective writing into post-elective debriefing.^{17,19,21,23,25} Last, the results reveal the potential of GHEs as a transformative experience for pediatric residents in building confidence, discerning career focus, and instilling a heart of equity for children around the world.