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Wellness programs for healthcare graduate students: a literature review with recommendations for nurse anesthesia programs
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WELLNESS PROGRAMS FOR HEALTHCARE GRADUATE STUDENTS
Wellness Programs for Healthcare Graduate Students: A Literature Review with Recommendations
for Nurse Anesthesia Programs
by
Sara Kent, RN, BSN, CCRN
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2021
WELLNESS PROGRAMS FOR HEALTH ii
Acknowledgements
I wish to thank the following individuals for their mentorship and assistance with this project,
and their unwavering support for SRNA wellness during a pandemic:
Charles Griffis, PhD, CRNA; Elizabeth Bamgbose, PhD, CRNA; Teresa Norris, EdD, CRNA
WELLNESS PROGRAMS FOR HEALTH iii
Table of Contents
Acknowledgements ......................................................................................................................... ii
List of Figures ................................................................................................................................ iv
Abstract ............................................................................................................................................v
Chapter 1 ..........................................................................................................................................1
Introduction ......................................................................................................................................1
Research Question .......................................................................................................................2
Specific Aims ...............................................................................................................................2
Operational Definitions ................................................................................................................2
Background and Significance ..........................................................................................................3
History of the Modern Concept of Wellness ...............................................................................4
The Psychology of Stress and Coping and Mental Health Considerations .................................7
Maladaptive Coping .....................................................................................................................9
Specific Wellness Concerns for Student Registered Nurse Anesthetists ...................................10
Chapter 2 ........................................................................................................................................12
Methods......................................................................................................................................12
Chapter 3 ........................................................................................................................................14
Literature Review ...........................................................................................................................14
History and Status of the Graduate Student Wellness Movement .............................................14
Psychology, Stress, and Coping Related to Wellness ................................................................15
Studies of Wellness, Stress and Coping in Graduate Students ..................................................17
Evaluations of Wellness in Nurse Anesthesia Educational Programs .......................................22
Chapter 4 ........................................................................................................................................27
Results ........................................................................................................................................27
Recommendations .....................................................................................................................29
Chapter 5 ........................................................................................................................................31
Discussion ..................................................................................................................................31
Conclusion .................................................................................................................................34
References ......................................................................................................................................36
WELLNESS PROGRAMS FOR HEALTH iv
List of Figures
Figure 1 ......................................................................................................................................... 44
Figure 2 ......................................................................................................................................... 45
WELLNESS PROGRAMS FOR HEALTH v
Abstract
Student Registered Nurse Anesthetists (SRNAs) are exposed to extreme levels of stress,
and are at an increased risk of burnout, depression, and suicidal ideation. This investigation
reviewed current literature on graduate student wellness initiatives, stress, and coping
psychology, in order to recommend improvements to the existing wellness efforts in nurse
anesthesia training programs. Sixty- eight articles were evaluated and after a quality assessment
utilizing the (2005) Health Evidence Quality Assessment Tool (HEQAT), eighteen articles were
selected for review. After an analysis of the literature a series of recommendations were formed,
which include (1) ensuring SRNA wellness programs have a clear policy and procedural
pathway for students who feel at risk, (2) provision of training for program directors and key
faculty in the early recognition of students at risk, and effective intervention strategies, and (3) a
suggestion for the Council on Accreditation of Nurse Anesthesia Educational Programs to revise
and update the recommended curriculum components regarding wellness initiatives in programs
of nurse anesthesia training. Future research is urgently needed to investigate the current status
of wellness in SRNAs, the effectiveness of the current wellness initiatives currently
implemented, and how these might be improved.
Keywords: wellness movement, wellness history, stress, coping, stress appraisal, wellness
programs health profession, and medical education wellness, graduate medical education, higher
education, student registered nurse anesthetist, certified registered nurse anesthetist
WELLNESS PROGRAMS FOR HEALTH 1
Chapter 1
Introduction
Student Registered Nurse Anesthetists (SRNAs) face tremendous stress during the most
rigorous training program undertaken by advanced practice registered nurses (APRNs),
comprised of thousands of hours of intense didactic coursework and extensive and challenging
clinical training (Council on Accreditation for Nurse Anesthesia Educational Programs, 2019).
Sources of SRNA stress while completing this advanced degree in preparation to become a
Certified Registered Nurse Anesthetist (CRNA) can include but are not limited to: leaving a job
as a critical care registered nurse, moving away from home for education and training, beginning
graduate school, decreasing income, and adapting to the rigors of graduate education (Chipas et
al., 2012). While eustress, defined as a beneficial, manageable stress, is an ideal state to achieve
lasting learning experiences, excessive or high levels of stress can cause cognitive overload, and
a surge of negative outcomes (Chipas et al., 2012; O’Sullivan, 2011). For example, Chipas
(2012) reported as many as 47.3% of SRNAs self-reported perceived depression and 21.2% self-
reported suicidal ideation.
Student Registered Nurse Anesthetists (SRNAs) are a vulnerable student population at
risk for negative outcomes (Bozimowski et al., 2014; Chipas et al., 2012). Careful consideration
of the current facts—graduate students in all settings are experiencing depression, and
committing suicide at an elevated rate over the general population; all graduate students are
under more stress than ever due to current events such as the 2019 novel coronavirus pandemic
(COVID-19); and there is no standard approach to wellness training across all the national
SRNA programs—seems to reveal a gap in knowledge of how best to manage wellness
initiatives and a lack of studies linking wellness initiatives with student outcomes (Chipas et al.,
WELLNESS PROGRAMS FOR HEALTH 2
2012; Council on Accreditation, 2019; Garcia-Williams et al., 2019; Griffin et al., 2017; Wang et
al., 2020). This investigation seeks to address these gaps by exploring the literature on graduate
student wellness initiatives and interventions, the psychology of stress and coping, and wellness
challenges specific to SRNAs.
Research Question
What is the importance of, and what are the possible improvements for wellness initiatives in
nurse anesthesia graduate programs?
Specific Aims
1. Explore current literature on the history and utility of the wellness movement in graduate
healthcare programs.
2. Explore wellness initiatives utilized to improve graduate student outcomes.
3. Describe wellness issues and challenges facing SRNAs documented in the literature.
4. Formulate universal recommendations to improve wellness initiatives in nurse anesthesia
graduate programs based upon a review of the current literature.
Operational Definitions
Throughout this literature review the words “wellness,” “burnout,” “stress,” “eustress,”
“distress,” “coping,” “maladaptive coping,” and “adaptive coping” will be utilized and defined.
The World Health Organization (WHO) defines wellness as the optimal state of health with
complete physical, mental, social well-being, and not merely the absence of disease (WHO,
2006). For the purpose of this paper, the term “burnout” is operationally defined as a “syndrome
conceptualized as resulting from chronic workplace stress that has not been successfully
managed,” (WHO, 2019). The term “stress” is defined as a person’s perception that the
WELLNESS PROGRAMS FOR HEALTH 3
environment is taxing personal resources and compromising personal wellness (Berjot & Gillet,
2011; Lazarus & Folkman, 1984). While stress may be helpful to learning, and provide
motivation to achieve life goals, which is defined as “eustress,” excessive stress may be
detrimental to the human host and is defined as “distress” (American Psychological Association,
2020; Chipas et al., 2012). The term “coping” as used in this paper is defined as the human
response to internal and external stressors and the ability to overcome, decrease or endure stress
(Berjot & Gillet, 2011; Lazarus & Folkman, 1984). The term “adaptive coping” is defined as a
host positively responding to a stressor in a way that will reduce stress; “maladaptive coping” is
defined as a host’s response to stress involving repressive coping mechanisms (e.g. alcohol and
drugs) that will lead to an overall increase in stress, and may result in damage or death (El-
Ghoroury et al., 2012; Lazarus & Folkman, 1984).
Background and Significance
Graduate healthcare education creates an opportunity for career advancement, and an
opportunity for new stress-inducing life changes; stress can manifest as physical, emotional, and
mental reactions to change (Chipas et al., 2012; Griffin et al., 2017). Medical professional school
stressors can be classified as academic, clinical and external (Chipas et al., 2012; Jennings &
Slavin, 2015; Sharp & Burkart, 2017; Wolfe et al., 2019). Academic stress can be defined as the
anxiety and discomfort experienced during the learning process, especially during challenging
graduate education programs (Chipas et al., 2012; Griffin et al., 2017). Clinical stressors
associated with medical professional training include multiple factors associated with clinical
training environments such as increased cognitive load and workload, lack of control, imbalance
between effort and reward, fairness, community factors, and differences in values (Jennings &
Slavin, 2015). Graduate medical learners may experience additional stress, as clinical instructors
WELLNESS PROGRAMS FOR HEALTH 4
may not receive formalized training in education (Chipas et al., 2012). External stressors
associated with medical professional training include personal and family traits and
responsibilities that students arrive with including social and financial strain. This external stress
also includes such considerations as a history of mental illness or depression (Chipas et al.,
2012).
College students, compared to the general population, exhibit a higher prevalence of
depression, and the incidence of depression and psychological distress are commonly associated
with suicidality (Davis et al., 2020). Depression is a mood alteration often accompanied by
feelings of sadness and marked by anhedonia—a loss of interest in activities (Loas, et al., 2019).
Suicidality includes behaviors of suicidal ideation, planning, and attempts (Davis et al., 2020). A
thorough literature search revealed few studies have explored the relationship between self-
perceived stress, depression, and suicidality, and even fewer studies have explored this
relationship in graduate medical education for physicians and APRNs. In a 2016 meta-analysis,
the prevalence of medical school suicidality was reported at 11.1% (Rotenstein, et al., 2016;
Loas et al., 2019); wellness programs and initiatives are aimed at preventing the negative effects
of stresses associated with graduate training.
History of the Modern Concept of Wellness
Hippocrates (460-370 BC) may be considered as an initial trailblazer in the wellness
movement as he is reported to be the first medical provider to prescribe exercise to his patients
suffering from tuberculosis (Tipton, 2014). The wellness movement has evolved into the modern
day, but Hippocrates’ exercise prescription was echoed in an eight-year prospective study in
1989 of 10,224 men and 3,120 women that found an association of decreased all-cause mortality
WELLNESS PROGRAMS FOR HEALTH 5
in participants with higher stratified levels of physical fitness. The study also found a lowered
incidence of cardiovascular disease and cancer in the participants with higher physical fitness
quintiles (Blair et al., 1989). In 2007, the American College of Sports Medicine, endorsed by the
American Medical Association and the Office of the Surgeon General, urged healthcare
providers to encourage patients to complete 150 minutes of exercise per week to reduce the
impact of chronic disease as an initiative called Exercise is Medicine (EIM) (Tipton, 2014). The
EIM initiative is reported to have had a positive effect by ameliorating the impact of Type II
diabetes on cardiovascular mortality, decreasing the pain of osteoarthritis, improving cognition
of people suffering from dementia, and reducing the risk of cancer mortality (Garber et al., 2011;
Physical Activity Guidelines Advisory Committee, 2018). A 2009 meta-analysis of 58
randomized trials reported Grade A evidence for reduced depression scores after treatment with
exercise (Rethorst et al., 2009). Modern approaches to wellness, like EIM, not only improve the
health of people with chronic disease, but also improve the overall physical function, brain
health, and weight status of people in the absence of chronic disease (Rethorst et al., 2009;
Garber et al., 2011).
In 1976, Dr. Bill Hettler introduced and operationalized what he described as six
dimensions of wellness: occupational, physical, social, intellectual, spiritual, and emotional. As
co-founder of the National Wellness Institute (NWI), this holistic approach marks the beginning
of the era of modern wellness (Hettler, 1976). In recent years, the NWI has expanded to include a
multicultural competency committee for underserved and underrepresented populations. The
AANA adopted this theoretical framework as its foundational support for both CRNA and
SRNA wellness (Griffin et al., 2017).
WELLNESS PROGRAMS FOR HEALTH 6
Wellness initiatives are found in over half of the United States college and university
graduate educational programs (Amaya et al., 2019). These programs aim to improve the
emotional and cognitive lives and abilities of students by providing education about the facility
of wellness activities and actions such as exercise, meditation, adequate sleep and others to
enhance the quality of life and prevent harmful behaviors (Finley, 2016; Stillwell et al., 2017;
Wolfe et al., 2019). Higher education wellness programs typically use numerous approaches
including creation of a safe environment, faculty buy-in, development of wellness education,
identification of mentors, social integration, and community engagement (Finley, 2016; Stillwell
et al., 2017; Wolfe et al., 2019). At Case Western Reserve University, the wellness program is
based upon the Wellness Council of America (WELCOA) and their seven benchmarks of
success including: faculty support, creation of a unified wellness collaboration, collection of
wellness data and metrics, measuring and evaluating program outcomes, creating an annual
operating wellness plan, and creating a supportive, health-promoting environment for both
faculty and students. University campuses that adopt wellness strategies similar to WELCOA
report improvement in students’ lives and wellbeing (Amaya et al., 2019). Education-based
initiatives focused on increasing student resiliency and stress-coping skills have not only shown
increased educational achievements, but also a decrease in risky health behaviors (Pascoe et al.,
2020). The University of Utah became 100% tobacco free in 2018 by promoting stress
management training, enhanced tobacco cessation, and mindfulness-based stress reduction
strategies (Amaya et al., 2019). Wake Forest University purchased gym memberships for their
neurosurgical residents and hosted a weekly exercise program that reported increased comradery,
grit, leadership, and research productivity (Wolfe et al., 2019).
WELLNESS PROGRAMS FOR HEALTH 7
The AANA’s embrace of wellness initiatives stemmed from members reporting burnout,
depression, substance use disorder (SUD), and suicide (Stone et al., 2016). In 1984, the AANA
identified six components of wellness that CRNAs and SRNAs should strive for, including the
following life domains: physical, intellectual, social, emotional, spiritual and occupational
(Quinlan, 2009; Stone et al., 2016). In 2004, the AANA established the Health and Wellness
Initiative to support the personal and professional well-being for both CRNAs and SRNAs
(Griffin et al., 2017).
Despite studies showing that learning stress reduction techniques and coping strategies
may improve depression, anxiety, and burnout in selected populations, there is a limited body of
research on wellness promotion and education (Jennings & Slavin, 2015; Sharp & Burkart, 2017;
Stillwell et al., 2017; Wolfe et al., 2019). Student Registered Nurse Anesthetist wellness studies
report an association between perceived wellness and perceived self-efficacy scores and a need
for future research on curriculum strategies to improve positive coping behaviors and reduce
maladaptive responses to increased stressors (Chipas & McKenna, 2011; Chipas et al., 2012;
Griffin et al., 2017).
The Psychology of Stress and Coping and Mental Health Considerations
Stress can be defined as an environmental demand or challenge to the human host. The
host appraises and evaluates the nature and magnitude of the demand in order to determine a
response (Berjot & Gillet, 2011; Lazarus & Folkman, 1984). This process is influenced by
internal factors such as emotional intelligence, cognitive ability and problem-solving
experiences. External factors such as social support and educational program resources also help
determine responses, which can be adaptive; the affected person copes successfully and moves in
WELLNESS PROGRAMS FOR HEALTH 8
a more positive direction to learn and excel (Berjot & Gillet; Lazarus & Folkman, 1984). Stress
responses may also present with negative or maladaptive symptoms, where harmful behaviors
may result in damage (El-Ghoroury et al., 2012). Maladaptive stress responses can include the
misuse of alcohol or other drugs, giving up trying to deal with stress, loss of reality testing—
refusal of belief that maladaptive responses are having a negative effect on life—
gossiping/venting, self-criticism, abandoning positive coping efforts, and expressing negative
feelings (El-Ghoroury et al., 2012; Garcia-Williams et al., 2019).
An important mediating factor in the psychology of stress and coping is the presence of
mental health disorders such as depression. In a 2019 study of 301 graduate students, Garcia-
Williams et al. found the average scores on a depression instrument indicated mild to moderate
depression, and the majority of graduate students reported feeling nervous with frequent
worrying (Garcia-Williams et al, 2019). Disorders such as anxiety and depression may
negatively influence coping behaviors, and may cause negative student outcomes (Bozimowski
et al., 2014; Davis et al., 2020; El-Ghoroury et al., 2012; Garcia-Williams et al., 2014; Loas et
al., 2019; Pascoe et al., 2020; Wang et al., 2020). Indeed, studies have demonstrated anxiety,
stress, and depression are inter-related, often with a stressful event (such as entering graduate
education) triggering the onset of depression (Lewinsohn et al., 1999). Pascoe et al. (2020)
reported students with higher anxiety and depression scores demonstrated lower academic
outcomes compared to their peers. Additionally, higher self-reported depression scores were also
associated with increased difficulty in concentration, increased difficulty in maintaining close
peer relationships, and increased difficulty in employment outcomes (Pascoe et al., 2020).
WELLNESS PROGRAMS FOR HEALTH 9
Lack of diversity in higher education is also a source of stress for many minority graduate
students, with multiple studies reporting higher perceived stress levels in minority graduate
students (Chipas et al., 2012; Davis et al., 2020; El-Ghoroury et al., 2012; Finley, 2016; Frick et
al., 2019; Kilburn et al., 2019; West et al., 2011). Suicidal behaviors and thoughts are four times
higher in lesbian, gay, and transgendered college students compared to heterosexual colleagues
(Frick et al., 2019) African American, Hispanic and Latino and Asian American college students
are also at an increased risk of suicidal thoughts and behaviors compared to white colleagues
(Frick et al., 2019). In 2017, the AANA reported that 90% of the 52,000 CRNAs practicing in
the United States identify as white. Kilburn et al. (2019) conducted a 12-month study
implementing a two-tiered approach to increase nurse anesthesia program admission to students
of color. The authors define people of color as a term for a nonwhite student and support its use
as a more inclusive term compared to “nonwhite,” “diverse,” and “minority.” Recruitment
strategies included information sessions at colleges and workplaces, online information sessions,
partnerships, inclusive marketing, targeted recruiting, and institutional support. Results from this
study showed an 87.5% increase in nurse anesthesia applications from candidates of color and an
increased acceptance of students of color from 6% to 24% (Kilburn et al., 2019).
Maladaptive Coping
Maladaptive coping behaviors in graduate school populations, like overuse of alcohol and
other drugs, can develop into SUD and are associated with suicidality (Davis et al., 2020; Garcia-
Williams et al., 2014; Pascoe et al., 2020). Increased alcohol use and abuse is associated with
ineffective coping strategies, higher perceived stress, and strained familial relationships (Pascoe
et al., 2020). Suicide was shown to be associated with substance abuse behaviors in a surveyed
population of 2857 undergraduate university students; more studies are needed to connect stress,
WELLNESS PROGRAMS FOR HEALTH 10
suicide, and the prevalence of substance abuse behaviors in graduate students (Barrios et al.,
2000). Few studies exist investigating the association of prescription opioid misuse with suicide
in graduate student populations (Davis et al., 2020; Garcia-Williams et al., 2014).
Specific Wellness Concerns for Student Registered Nurse Anesthetists
Student Registered Nurse Anesthetists are a population struggling not only with stressors
and challenges common to all graduate training, but they also must cope with factors specific to
Advanced Practice Registered Nurse (APRN) training (Bozimowski et al., 2014; Chipas et al.,
2012; Griffin et al., 2017). All SRNAs come to training with years of experience as seasoned
critical care nurse professionals and must cope with the loss of status and influence consistent
with assuming the role of a beginning student in a new specialty. Upon entering training, SRNAs
must give up the financial security of full-time employment and assume the prodigious debt of
modern graduate education, which may persist well beyond graduation. Student Registered
Nurse Anesthetists may also face the social isolation of attending training programs distant from
home, friends, and family. The SRNA didactic curriculum includes 24-51 months of intense
doctoral coursework including advanced anesthesiology, pathophysiology, anatomy and
physiology, pharmacology, leadership, healthcare policy, healthcare informatics and technology,
and epidemiology (AANA, 2019; Council on Accreditation of Nurse Anesthesia Educational
Programs, 2019). The clinical training component of SRNA education, which may overlap part
of the didactic curriculum, includes two years of learning in a consistently high stakes
atmosphere, executing knowledge, responsibility, and rigor in practice on vulnerable patients
(Conner, 2015). On average SRNAs complete 9,369 hours of training including nursing
experience prior to enrollment and clinical training during their enrollment (AANA, 2019). High
stress levels and immediate access to potent and dangerously addictive drugs provide
WELLNESS PROGRAMS FOR HEALTH 11
opportunities for SRNAs to become involved with SUD (Bozimowski et al., 2014). Student
Registered Nurse Anesthetists may also be affected by burnout, a syndrome Maslach and Leiter
(2007) described as exhaustion and depersonalization related to work-place stress, which can be
brought on by working with others in challenging situations. The clinical training environment,
in which SRNAs spend extremely long hours, are the lowest status team members, and perform
high stakes procedures on human patients while being supervised by practitioners with limited
training in supportive educational practices, can contribute to burnout in SRNAs.
The intense pace of time requirements of training impedes the use of positive coping
mechanisms such as exercise, meditation, and engaging in fun activities (Chipas et al., 2012).
Thus, it is likely that SRNAs continue to suffer from elevated rates of SUD, depression and
suicidal ideation even though the Council on Accreditation for Nurse Anesthesia Educational
Programs (COA) requires wellness teaching and initiatives as a component of accreditation
(Bozimowski et al., 2014; Chipas et al., 2012).
WELLNESS PROGRAMS FOR HEALTH 12
Chapter 2
Methods
This investigation consisted of an integrative review of relevant literature, analysis of
findings and synthesis of recommendations for the improvement of wellness approaches. The
following data bases were accessed: PubMed, PsychInfo, CINAHL Complete, Web of Science,
MBASE, Cochrane Library, Google Scholar, and Google utilizing these keywords: wellness
movement, wellness history, stress, coping, stress appraisal, wellness programs health
profession, and medical education wellness.
The criteria for articles to be included in the review are as follows: published in the last
15 years (exceptions for classic and seminal sources), peer-reviewed, published in the English
language, and relevance to the specific aims of the project, including stress, coping, and wellness
initiatives in graduate student populations. Articles were evaluated utilizing the (2005) Health
Evidence Quality Assessment Tool (HEQAT) to assure adequate quality of the data (Dobbins,
2005). The HEQAT consists of ten questions addressing the critical appraisal of: the research
question, inclusion and exclusion criteria, search strategy, search dates, level of evidence,
methodological quality, results, analysis, appropriateness of analysis methods, and interpretation
(Dobbins, 2005). Seminal studies were included in the literature search and snowballing and
reverse snowballing techniques of supportive articles were utilized to select the final articles.
Due to the limited literature of level one evidence, inclusion of level three observational case
studies and review articles were included in the literature search. Research on the target
population in key areas related to this investigation, included the psychology of stress; history of
the modern wellness movement in graduate education; and wellness initiatives in educational
programs of nurse anesthesia. Please see Figure 1 for the Prisma Diagram outlining the search
WELLNESS PROGRAMS FOR HEALTH 13
process and article selection. This Prisma Diagram shows the selection process of 12 studies, one
systematic review article, and five review articles included in this integrative review.
WELLNESS PROGRAMS FOR HEALTH 14
Chapter 3
Literature Review
History and Status of the Graduate Student Wellness Movement
Tipton (2014) published a historical review article discussing the origins of the wellness
movement on a continuum from antiquity to the modern exercise recommendations. Tipton
described the first prescription of exercise as a beneficial practice originating from Hippocrates
(460-370 B.C.) in advice to his patients. The author reviewed literature from Susrata (600 B.C.),
the first physician to prescribe exercise as medicine and best known for regarding diabetes as a
curable disease through exercise and diet modification. This historical review of the notion that
exercise is medicine supports the data collected for the global EIM initiative that recommends
weekly exercise expenditure of at least 150 minutes to optimize health and wellness.
Finley (2016) conducted 15 focus groups across nine liberal arts colleges utilizing a
Bringing Theory to Practice (BToP) Well-Being Initiative to better understand and improve the
wellness of underserved, low-income, minority, first-generation, and transfer students. In the
review article, 15 focus groups were conducted at 9 liberal arts colleges to survey 100 students
with recommendations for future improved wellness programs. Recommendations included
connected learning experiences with the community and a commitment from faculty to embrace
student wellness promotion and self-empowerment. Participants reported greater sense of
community and engagement with faculty members, and 57% of participants reported the project
as creating a positive impact on wellness. Finley also recommends that future wellness programs
acknowledge the heterogeneity of student populations, utilize diversity workshops to combat
micro-aggressions, and connect the wellness program to the core values of the institution for
maximal student well-being and engagement.
WELLNESS PROGRAMS FOR HEALTH 15
Psychology, Stress, and Coping Related to Wellness
Maslach and Leiter (2007) provide an overview of the causes, control and prevention of
burnout in their review article of the phenomenon. The authors describe six contributors to
workplace burnout: workload, control, effort and reward balance, community, equality, and
ethics. The role of each contributing factor is gleaned from existing cross-sectional, longitudinal
research studies assessing survey measures of depression and burnout amongst a large population
of psychiatrists. The authors’ review utilized the validated tool, the Maslach Burnout Inventory,
assessed three dimensions of burnout—exhaustion, cynicism, and inefficacy—and found a link
between depression and burnout. Additionally, the authors identified the antithesis of ‘burnout’
to be ‘engagement.’
Berjot and Gillet (2011) authored a review article on stigmatization, discrimination, and
identity threats, with a specific focus on how people perform stress and coping appraisals. The
authors utilized the Lazarus and Folkman Transactional Model of Stress and Coping as a
theoretical framework (Berjot & Gillet, 2011; Lazarus et al., 1984). Stigma was defined as a
visible or invisible and a controllable or uncontrollable human characteristic, which can include,
but is not limited to: race, religion, physical appearance, mental illness, and sexual identity.
Utilizing the Transactional Model of Stress and Coping, the authors reasoned the responses to
such characteristics were shaped by attributes of the stigmatized person and included personal
attributes like motivation, optimism, stigma consciousness, and coping responses. Berjot and
Gillet adapted the Lazarus and Folkman model to determine the role of internal and external
factors and the implications they can have on a host (Berjot & Gillet; Lazarus & Folkman).
When a human host encounters an internal or external stressor, the host will make a coping
appraisal utilizing working coping resources to construct a coping response—deciding that a
WELLNESS PROGRAMS FOR HEALTH 16
stressor is a threat, loss, or an opportunity and challenge. Berjot and Gillet suggest that this
challenge appraisal offers an opportunity to reduce stress and improve performance (2011).
Howard et al. (2017) investigated the link between stress, coping, and health. The authors
studied the autonomic responses of a sample of 86 females to find that repressive coping to acute
and chronic stress may be associated with an increased cardiovascular risk. The authors
identified a repressive coper, or repressor, as a person who is more likely to self-report fewer
negative emotions. Howard et al. studied the blood pressure and cardiac output of the sample
population. They found the more repressed females, although appearing less stressed, developed
elevated physiologic responses to novel stressors. During each phase of exposure to a novel
stressor, repressive coping correlated with elevated systolic blood pressure (p < 0.03) (Howard et
al.).
More recently, Wang and colleagues (2020) conducted a cross-sectional survey of 2,031
Texas A&M University undergraduate and graduate students with the validated major depressive
disorder (MDD) section of the Patient Health Questionaire-9 (PHQ-9) to assess depression, the
validated General Anxiety Disorder-7 (GAD-7) to assess anxiety, and open-ended questions
about stress and coping related to the impact from COVID-19 pandemic. Moderate to severe
depression levels were self-reported in 48% of participants and 38% of participants experienced
moderate to severe anxiety. Suicidal thoughts were reported in 18% of participants. (Wang et
al.). Stress and anxiety levels increased during the pandemic for 71% of participants, and over
97% of participants expressed belief that fellow classmates were experiencing increased stress
and anxiety due to COVID-19. Friends and family were the most prevalent source of coping
mechanism (67%), followed by support from technology and mobile apps (32%) and utilization
WELLNESS PROGRAMS FOR HEALTH 17
of mental health services (14%). Maladaptive coping mechanisms of distraction, excessive
alcohol intake, and isolation were reported by 10% of students. Adaptive coping mechanisms
included physical activity (39%) and relaxing activities (37%) included gardening, meditation,
hobbies, time with pets, reading, writing, playing instruments, creative activities, and spiritual
and religious practices. The largest reported barrier to mental healthcare access was financial
(70%), followed by social stigma (58%), and lack of available resources and appointments (48%)
(Wang et al.).
Studies of Wellness, Stress and Coping in Graduate Students
West et al. (2011) surveyed a national sample of 7743 United States internal medicine
residents and 8571 international medical graduates from the 2008-2009 Internal Medicine In-
Training Examination and compared demographics, educational debts, medical knowledge, and
burnout. Quality of life assessment was conducted via a validated linear analogue self-
assessment tool, and 2-individual items from the Maslach Burnout Inventory were utilized to
assess burnout, depersonalization, and emotional exhaustion. Quality of life was self-reported,
“as bad as it could possibly be” or, “somewhat bad” in 14.8% of internal medicine respondents.
United States medical graduates, women, and first and second year residents were more likely to
self-report work-life balance dissatisfaction. Quality of life and work-life balance satisfaction
scores were lower with the presence of education debt, increasing as the highest levels of student
loan debt exceeding $200,000. Burnout associated with higher levels of debt was statistically
significant in United States residents. A low quality of life assessment, emotional exhaustion,
and student debt burden associated with lower Internal Medicine In-Training Examination scores
was statistically significant (West et al.).
WELLNESS PROGRAMS FOR HEALTH 18
El-Ghoroury et al. (2012) identified sources of stress, coping strategies, and the leading
barriers to graduate students utilizing wellness strategies and activities by surveying 387
graduate psychology students through random selection from 39 different states, the District of
Columbia, and Puerto Rico. Survey results identified the most important barriers to utilizing
wellness strategies and activities as the combined lack of money and time. Self-reported stressors
also included anxiety and a poor work-school life balance. Additionally, the authors reported a
higher incidence of discrimination as a stressor for minority students compared to their non-
minority colleagues, with 8.3% of white survey respondents self-reporting functionality
disruption from discrimination and 24.3% of racial and ethnic minority students self-reporting
moderate, significant, or severe functionality disruption from discrimination (El-Ghoroury et al.).
Jennings and Slavin (2015) wrote a review of principles aimed to optimize medical
resident wellness during their training. The authors commented on the Accreditation Council for
Graduate Medical Education Clinical Learning Environment Review Program, which requires
institutions to educate residents about burnout, perform annual burnout assessments, and
implement a program to increase resident wellness and engagement. The authors suggest medical
trainees need educational programs to improve coping skills and resiliency. Suggested topics
include perceptive distortions like imposter syndrome and fixation on negative evaluations in the
clinical and academic environment.
In a 2017 cross-sectional, randomized and stratified survey of 306 male and female
medical students in Saudi Arabia, Almojali et al. found a loss of sleep quality and quantity was
associated with increased inattention, higher stress, lower examination scores and decreased
learning ability (Almojali et al., 2017). The authors utilized the validated Pittsburg Sleep Quality
WELLNESS PROGRAMS FOR HEALTH 19
Index to assess sleep quality and the Kessler Psychological Distress Scale (KPDS) to assess
medical learner stress levels. Poor sleep quality was present in 76% of the medical students, and
high stress levels were present in 53%. Researchers documented a statistically significant (p <
0.001) association between poorer sleep quality and higher stress levels. Students who self-
reported less stress were less likely to self-report poor sleep quality, and these results were also
statistically significant (p < 0.001). Medical learners with lower grade point averages were four
times more likely to self-report poor sleep quality (p < 0.03) (Almojali et al.). Researchers
achieved a confidence interval of 95% with a 5% margin of error given the large sample size.
Sharp and Burkart (2017) reviewed medical trainee wellness from business perspectives,
wellness promotion and burnout prevention strategies, both program and individual trainee
wellness strategies, and wellness initiatives to improve the quality of life of medical trainees. The
researchers proposed revisions to the Accreditation Council for Graduate Medical Education
Common Program Requirements to improve medical trainee wellness and reduce burnout
(2017). The authors provided a framework for wellness program development that illustrated the
principles expounded in the article (see Figure 2). Wellness is defined as thriving and meeting
challenges with personal and professional success. To improve medical trainee wellness,
recommendations included creation of a supportive institutional environment and management
style, implementation of a wellness committee, assessment of trainee wellness and burnout
needs, institution of specific interventions including small group training in stress management,
self-care, communication, and mindfulness, and consistent reassessment of medical trainee
wellness and burnout.
WELLNESS PROGRAMS FOR HEALTH 20
In 2017, Stillwell et al. conducted a systematic review of existing evidence on the
practice of self-care interventions and their effect on perceived stress levels on graduate nursing
students. The goal of this study was to critically appraise the current literature in order to provide
an evidence-based recommendation for wellness promoting activities to graduate nursing
students. Due to the gap in literature of wellness studies on the population of interest, inclusion
criteria comprised studies of graduate students in other professions, including speech-language
pathology, mental health counseling, medical students, physical therapy, and psychology.
Researchers examined eight wellness promotion activities that included stress management
courses, mind-body-stress-reduction (MBSR) programs, yoga, mindfulness, breath work, and
meditation. After reviewing 5,108 articles, eight studies with wellness promotion interventions
were selected and all studies resulted in decreased perceived stress levels post-intervention,
utilizing the validated Perceived Stress Scale (Stillwell et al.). Evaluation of the evidence
included statistical analysis, review of attrition, results, and applicability. Stillwell et al.
recommended implementation of a graduate nursing wellness curriculum with a didactic
element, a weekly MBSR activity by a trained MBSR professional, and a homework assignment
to reinforce the learning. These recommendations were based on the integrative review of
existing literature.
Wolfe et al. (2019) utilized a systematic voluntary sample to survey established wellness
programs in United States neurosurgical residency training departments. The survey was sent to
all 116 doctor of medicine (MD) and doctor of osteopathic medicine (DO) neurosurgical
residency programs, of which seven programs participated. Program directors were asked why
the wellness program was implemented, which part of the program is perceived as the most
important, and if the department thinks the program is effective in promoting wellness. The
WELLNESS PROGRAMS FOR HEALTH 21
wellness program components were diverse across the seven university hospital programs and
consisted of: team workout sessions, gym memberships, team workout clothes, scheduled group
events like 5K runs, annual softball tournaments, non-fitness team building exercises, mind-body
wellness (yoga, Tai-Chi), healthy food at conferences, actigraphy (Fitbit), regular lectures on
wellness, body composition testing, scheduled primary care provider appointments, blood work,
spouse support initiative, leadership curriculum, museum tours, escape room events, rafting and
camping, and a group pheasant hunt. The authors compared the annual cost of each wellness
program, the length of time the wellness programs had been offered, and the attendance rate of
both trainees and faculty members. Annual cost of each wellness program ranged from $3,360 to
$15,000. All survey respondents reported the wellness programs had been available for at least
one year, and three of the seven residency programs were implemented over two years prior. The
majority of residency wellness programs reported greater than 50% resident attendance to
wellness events, but less than 25% of faculty attendance to wellness events. While Tufts Medical
Center, Wake Forest University, Vanderbilt University, and the University of Minnesota did not
report specific objective data to support their wellness program, efforts to support and measure
resident wellness were ongoing. Resident survey respondents at the University of Florida self-
reported less stress, improved conflict resolution, and increased motivation from the wellness
program initiatives. At Louisiana State University, 79% of residents reported the wellness
program improved their neurosurgical training. The Medical University of South Carolina
residents self-reported improved physical fitness, sleep, and a reduction in anxiety and
depression scores after implementation.
Frick et al. (2019) utilized a three-month pilot study assessing the feasibility of a
universal suicide-screening program in an undergraduate and graduate student healthcare center
WELLNESS PROGRAMS FOR HEALTH 22
to increase awareness and promote positive changes in their student population. A population of
1,607 students were examined during primary care visits via the Annual Suicide Behaviors
Questionnaire over a period of one semester. Five advanced practice nurses, six registered
nurses, and one registered dietician received one and one-half hours of clinical simulation
training with pre-test and post-test survey assessment to gauge competence in utilizing the
mental health screening tool. Researchers found that 12.8% of the 1,607 students screened
positive for suicide risk during their Spring 2018 primary care visit. Of the 136 surveyed
graduate students, the percentage that screened positive for suicide risk was 11.03%. The
researchers found the most at risk population for suicide were minority students, as 34.78% of
American Indian, 14.22% of Hispanic, and 13.83% of Black students screened positive for
suicide risk compared to 11% of Caucasian students (Frick et al.). Students that scored equal to
or greater than seven on the Annual Suicide Behaviors Questionnaire were also screened with the
Columbia Suicide Screening Rating Scale and scheduled for an urgent mental healthcare visit
within one to three business days or an emergent same-day appointment based upon the score.
Following the interventions of the suicide-screening program and training healthcare staff
members, the college student health center saw an increased utilization of mental health
resources from 66 mental health referrals pre-intervention to 237 post-intervention. Results
showed statistically significant (p = 0.005) positively improved staff learning and comfortability
with quickly screening students and using motivational interviewing. This program demonstrated
the feasibility of quickly identifying at-risk graduate students.
Evaluations of Wellness in Nurse Anesthesia Educational Programs
McKay et al. (2010) conducted a prospective, descriptive within-subjects design
investigation of stress measures and performance of 18 SRNAs in a convenience sample of 78
WELLNESS PROGRAMS FOR HEALTH 23
during simulated induction and intubation care sequences. Baseline, acute and recovery measures
of stress and anxiety demonstrated significant elevations in stress and anxiety levels during task
performance. Researchers found a statistically significant 68.8% increase in salivary a-amylase
levels, a 14% increase in heart rate, and a 28% increase in anxiety compared to the measured
pre-simulation levels. Stress was measured by salivary a-amylase levels and heart rate, and
anxiety was measured via a validated tool, the State-Trait Anxiety Inventory (STAI). Based on
an objective checklist scored by experienced nurse anesthetist observers of the induction
sequence, participants were divided into low, medium and high-performance groups. Low-
performance groups experienced a 119% increase in salivary a-amylase levels; high
performance groups experienced a similar 114% increase in salivary a-amylase. No statistical
difference was found between performance groups and increased heart rate, as heart rate
increased across all groups. There was no statistical significance found between stress and
anxiety levels between performance groups, which may be attributed to the small convenience
sample size (McKay et al., 2010).
Chipas et al. (2012) conducted a descriptive convenience sample survey of 1,374 SRNAs
using a Likert-type scale, and found statistical differences in SRNA perceived stress levels. The
results revealed multiple wellness challenges reported by SRNAs. Overall, a 10% reduction in
perceived stress levels was observed in SRNAs with a front-loaded didactic curriculum instead
of a mixed clinical and didactic course load. Age did not play a statistically significant role in
differences in perceived stress levels. Male SRNAs self-reported statistically significant (p <
0.05) lower levels of stress compared to female counterparts. Regardless of whether or not the
surveyed SRNAs had children, divorced students reported significantly higher mean levels of
stress. Student Registered Nurse Anesthetists who identified as belonging to a minority group
WELLNESS PROGRAMS FOR HEALTH 24
self-reported statistically significantly higher levels of stress. While the sample size of many
prior research studies regarding SRNA, CRNA, and graduate student populations are usually too
small to produce generalizability of results, it is important to note the relative lack of diversity in
SRNA programs and homogeneity of the population demographics. This study found coping
strategies used by SRNAs included exercising, working extra hours, working around the house,
receiving emotional support from family and friends, seeking help from a medical health
provider, choosing to see the glass half full, exercising humor, streaming television, going
outside, meditating, exercising, listening to music, spending time with animals, reading, having
sex, and sleeping. Seventeen percent of survey respondents reported management of stress
symptoms through utilization of prescription medications. Maladaptive coping mechanisms were
reported to include overuse of alcohol, compulsions, eating disorders, and cravings. Frequency of
stress symptoms were self-reported, with decreased concentration occurring on average at least
one and one-half times each week and sleep disturbance occurring at almost twice each week. It
was found that 47.3% of SRNAs self-reported perceived depression and 21.2% self-reported
suicidal ideation. Additionally, 6.3% of SRNA survey respondents personally knew someone
who committed suicide during their nurse anesthesia program training. The authors
recommended the following: teaching skills to reduce stress, build self-esteem, and use positive
coping approaches that may lower stress, risk of depression, and unhealthy eating amongst
SRNA students.
Bozimowski and colleagues (2014) utilized a cross-sectional, retrospective survey to
study known incidents of substance abuse among 2,439 SRNAs in 47 United States nurse
anesthesia programs over a five-year period from 2008-2012. Program directors were asked how
the incidents of drug abuse were identified, what interventions were employed, which drugs were
WELLNESS PROGRAMS FOR HEALTH 25
abused, and the resultant outcomes (Bozimowski et al., 2014). Of the 113 surveys sent, 47
program directors responded, and 23 program directors completed the full prevalence and
demographic evaluations. Program directors reported at least one incident of SRNA substance
abuse in the previous five years at 60.8% of participating programs. Of the reported incidents,
88% of SRNAs were white, 56% were between the ages of 20-29, and 69% had completed one
to two years of SRNA school. More incidents involved female SRNAs (8) compared to male
SRNAs (7), but more female students were enrolled during the time of this survey (1598)
compared to males (817). Only 36.5% of new CRNA graduates identified as males in 2012. The
most abused substances, in order of greatest to least, were opioids, alcohol, cannabis,
benzodiazepines, cocaine, and polydrug use. In this study, there were no reported cases of abuse
of propofol, ketamine, or inhaled agents. Half of the students did not have any known risk factors
for abuse. Three SRNAs had a history of substance abuse and another three SRNAs reported a
family history of substance abuse. Of the 16 reported incidents, 10 SRNAs voluntarily enrolled
in treatment, seven were dismissed from their programs, four students were lost to follow-up,
three completed treatment and graduated, two completed treatment and did not return, two lost
their nursing license, one completed treatment and did not graduate, and one SRNA died. The
most commonly reported screening practices were drug testing and pre-enrollment background
checks. Seven of 18 program directors promoted wellness with education, and two respondents
utilized the AANA Wearing Masks video series. Other reported wellness promotion activities
included speaking engagements with CRNAs in recovery, extension of education to SRNA
families and significant others, vacation time, institutional counseling, wellness inventory
assessments, faculty support, and an appointed student morale and welfare officer (Bozimowski
et al., 2014).
WELLNESS PROGRAMS FOR HEALTH 26
Griffin and colleagues (2017) utilized a salutogenic framework to study wellness and
academic success in the SRNA population. Salutogenesis defines wellness as comprising seven
inter-related domains including physical, social, emotional, spiritual, intellectual, vocational, and
environmental (Griffin et al, 2017). Findings from 75 SRNAs from three cohorts during a 16-
month period noted a drop in perceived SRNA wellness scores during the last two semesters of
anesthesia training. Measures including the Salutogenic Wellness Promotion Scale, Perceived
Self-Efficacy Scale, grade point averages, Caring Behaviors Inventory Scale and Client
Perceptions of Caring Scale were examined with SRNA demographics for relationships, and no
relationships were found. Of the 75 SRNAs, 64% identified as female and 36% identified as
male, the average age was near 32, 72% were married or in partnerships, 18% were unmarried,
three participants were divorced, and the average length of critical care experience was almost
six years. Researchers found a statistically significant direct positive correlation between SRNA
perceived self-efficacy and perceived wellness (Griffin et al., 2017). Stress and low self-esteem
were found to be often related to avoidant coping, depressive mood, stress, depression and
unhealthy eating behaviors. Interestingly, it was also found that SRNA Self-Evaluation
Examination (SEE) scores inversely correlated with perceived wellness scores. The SEE is taken
as a preparatory exercise for the National Certification Examination (NCE). While the research
showed higher SEE scores correlating with lower perceived wellness scores, the authors suggest
one possible reason is students scoring higher on the SEE examination focused less on wellness
attributes, and it is very important to note that the majority of the SEE scores were well above
the passing level.
WELLNESS PROGRAMS FOR HEALTH 27
Chapter 4
Results
Specific Aim #1 Explore the current literature on the history and utility of the wellness
movement in graduate healthcare programs.
This specific aim was met by a thorough review of the wellness initiative movement in
graduate training programs. Historical context was explored in reviews of wellness initiatives
going back to antiquity (Amaya et al., 2019; Finley, 2016; Hettler, 1976; Mattke et al., 2013;
Sharp & Burkart, 2017; Stone et al., 2016; Tipton, 2014; Wang et al., 2020). The psychology of
stress and coping was reviewed to provide an understanding of the underpinnings of wellness
and the relationship of wellbeing to effective coping (Berjot & Gillet, 2011; El-Goroury et al.,
2012; Folkman, 1984; Folkman & Lazarus, 1985; Lazarus & Folkman, 1984; Maslach & Leiter,
2016; O’Sullivan, 2011). Consequences of maladaptive coping were explored to provide a
rationale for the importance of wellness to success in graduate student education (Almojali et al.,
2017; Bozimowski et al., 2014; Davis et al., 2020; Finley, 2016; Garcia-Williams et al., 2014;
Hong, 2019; Howard et al., 2017; Loas et al., 2019). Finally, four studies investigating wellness
in programs of nurse anesthesia education were evaluated to apply wellness concerns to the
specific population of interest in this integrative review (Bozimowski et al., 2014; Chipas et al.,
2012; Griffin et al., 2017; McKay et al., 2010).
Specific Aim #2 Explore the importance of wellness initiatives to improved graduate student
outcomes.
This specific aim was met by examining positive student outcomes reported to be linked
to wellness initiatives in graduate educational programs (Chipas et al., 2012; Finley, 2017; Frick
WELLNESS PROGRAMS FOR HEALTH 28
et al., 2019; Griffin et al., 2017; Jennings & Slavin, 2015; Sharp & Burkart, 2017; Stillwell et al.,
2017; Wolfe et al., 2019).
Specific Aim #3 Describe wellness issues and challenges facing SRNAs.
This specific aim was met by examining current literature focused on issues facing
SRNA populations. Two studies examined graduate nurse anesthetist training programs (Chipas
et al., 2012; Griffin et al., 2017), one study focused on stress and anxiety experienced during
simulator training (McKay et al., 2010), and one study considered the issue of substance use
disorder in SRNA educational programs (Bozimowski et al., 2014).
Specific Aim #4 Formulate universal recommendations to improve wellness initiatives in
graduate programs of nurse anesthesia based upon a review of the current literature.
This specific aim was met by analyzing the literature directed toward the concept and
practices of wellness, wellness in different graduate programs, stress psychology and coping, and
wellness issues in programs of nurse anesthesia for improved approaches to current wellness
initiatives. The analysis process used several processes to examine the literature: identifying
common themes; looking for factors that predicted both positive and negative adaptation
behaviors; looking for studies that had positive outcome measures and examining those
relationships; and examining the limited literature specific to SRNAs. From this analysis,
recommendations to improve SRNA wellness programs were synthesized as presented below.
WELLNESS PROGRAMS FOR HEALTH 29
Recommendations for SRNA Wellness Program Improvements
1. Nurse anesthesia programs should provide a clear policy and procedural pathway for
students who are assessed to be at increased risk of maladaptive responses to the stresses
of training (Chipas et al., 2012; Frick, 2019).
2. Program directors and key faculty should receive training in the recognition of at-risk
students as early as possible in the training experience and be trained in effective
interventions that can be tailored to student needs (Sharp & Burkart, 2017).
3. Increased faculty involvement and buy-in to model wellness behaviors and support the
wellness initiatives should be encouraged, as they provide a safe wellness environment
for SRNA trainees and faculty members (Jones et al., 2011; Sharp & Burkart, 2017;
Wolfe et al., 2019).
4. The Council on Accreditation for Nurse Anesthesia Educational Programs should revise
and update the recommended curriculum components regarding wellness initiatives in
nurse anesthesia training programs to include: importance of faculty training in wellness
to identify at-risk students (especially minority students), plan early intervention, and the
importance of modeling wellness behaviors; resiliency training (Jennings & Slavin) and
financial wellness curriculum (Jennings & Slavin, 2015); diversity training with a focus
on minority student wellness (Chipas et al., 2012; El-Ghoroury et al., 2012; Frick et al.,
2019; Kilburn et al., 2019; West et al., 2011); and focus on inclusion of physical fitness
activities and scheduling the time to permit participation in these activities (Wolfe et al.,
2019).
5. Nurse anesthesia programs should conduct SRNA burnout assessments and wellness
needs assessments, with a wellness promotion intervention. Assessments should be based
WELLNESS PROGRAMS FOR HEALTH 30
on wellness program effectiveness, not attendance (Jennings & Slavin, 2015; Sharp &
Burkart, 2017; West et al., 2011; Wolfe et al., 2019).
6. Future research is suggested to investigate the current status of SRNA wellness, how the
current wellness initiatives are working, and how these might be improved (Bozimowski
et al., 2014; Chipas et al., 2012; Griffin et al, 2017; Jennings & Slavin, 2015; Kilburn et
al., 2019; McKay et al., 2010).
WELLNESS PROGRAMS FOR HEALTH 31
Chapter 5
Discussion
The wellness movement in graduate education is continuing to gain momentum. The
chief components of wellness initiatives typically include exercise, community, rest, and
mindfulness (Sharp & Burkart, 2017; Stillwell et al., 2017; Wolfe et al., 2019). As previously
elucidated, multiple studies have explored the reasonable theory of the positive effects of
wellness approaches on graduate student outcomes (Chipas et al., 2012; El-Ghoroury et al.,
2012; Griffin et al., 2017; Jennings & Slavin, 2015; Sharp & Burkart, 2017). By engaging in
regular physical activity and maintaining healthy sleeping patterns, students have been found to
have less self-reported stress and burnout and graduate with better depression scores (Almojali et
al., 2017; Chipas et al., 2012; Griffin et al., 2017; Jennings & Slavin, 2015; Sharp & Burkart,
2017; Wolfe et al., 2019).
There is a rationale underlying the synthesis of each recommended best practice for
wellness programs in nurse anesthesia graduate training programs, which relies on analyzing the
findings in the relevant literature. First it is of paramount importance programs of nurse
anesthesia provide a clear pathway in policy and procedure for students at increased risk to find
appropriate assistance (Chipas et al., 2012; Frick et al., 2019; Griffin et al., 2017). Providing
instructions for wellness assistance and maintenance sends a clear message to students that the
program supports and prioritizes wellness and may help remove any stigma associated with
seeking help.
Wellness initiatives are likely to provide more effective support if faculty are adequately
trained in support approaches and techniques (Chipas et al., 2012; Griffin et al., 2017; Jones et
WELLNESS PROGRAMS FOR HEALTH 32
al., 2011; Sharp & Burkart, 2017; Wolfe et al., 2019). Faculty wellness training is imperative to
not only model wellness behavior for students, but also to support a healthy learning
environment for both faculty and SRNAs. Faculty wellness training in how and when to
appropriately intervene and provide support will likely result in increased faculty buy-in.
Educated faculty are better equipped to help students successfully cope with their new role,
discuss any academic or clinical stressors, and build healthy wellness habits that will guide them
into their new profession. Establishing a safe, supportive culture of wellness in the educational
program will also help increase student involvement in the wellness initiatives and activities,
supporting better student outcomes.
The Council on Accreditation for Nurse Anesthesia Educational Programs should revise
and update the requirements for wellness curriculum in nurse anesthesia training programs
(Council on Accreditation for Nurse Anesthesia Educational Programs, 2019). Examining the
actual recommendation in the Glossary (p. 40) reveals a detailed list of components that could be
included, such as the importance of wellness to healthcare professionals; importance of healthy
lifestyles; choosing adaptive coping mechanisms; identification of and intervention for SUD; and
re-entry into the workplace following SUD diagnosis and treatment. A revision of this
description is recommended based upon this integrative review as follows. There is a need for
faculty training in recognition of students at risk---with especial attention to minority students,
early intervention techniques, and the teaching of wellness, and the importance of modeling
wellness behaviors. Financial wellness training for students should be offered that examines
approaches to easing the burden of student debt. Training in the importance of coping with
adversity as a component of the healthcare education and practice environment should be
emphasized. Programs should be encouraged to continue to devise innovative approaches to
WELLNESS PROGRAMS FOR HEALTH 33
increase the value of positive activities that improve resilience, such as taking time for oneself,
exercise, meditation, adequate sleep, and healthy social activities. Adding these requirements
will help guide program wellness activities and standardize approaches across the country
(Almojali et al., 2017; Chipas et al., 2012; El-Ghoroury et al., 2012; Frick et al., 2019; Griffin et
al., 2017; Jennings & Slavin, 2015; Kilburn et al., 2019; Wolfe et al., 2019).
As demonstrated in programs associated with positive student outcomes (Amaya et al.,
2019; Frick et al., 2019; Stillwell et al., 2017; Wolfe et al., 2019), initiating a wellness program
is not sufficient to assure success. It is essential to have an on-going assessment of such
programs, with clearly stated short and long-term goals, methods of assessing progress toward
meeting those goals, and adjustments made on the basis of longitudinal data on effectiveness.
Effectiveness of wellness programs should be based on improved student outcomes, not on
number of attendees, to assure maximum impact (Chipas et al., 2012; El-Ghoroury et al., 2012;
Griffin et al., 2017; Frick et al., 2019; Sharp & Burkart, 2016; Stillwell et al., 2017; Wolfe et al.,
2019).
Finally, there is an obvious need for on-going research. Currently, there is no data
supporting one approach to SRNA wellness over another, though clues are offered from studies
of similar populations as previously elucidated (Amaya et al, 2019; El-Ghoroury et al., 2012;
West et al., 2011; Wolfe et al., 2019). This investigation focuses on a pervasive wellness
challenge that may be conceptualized as endemic to not just the educational system, but the
profession of nurse anesthesia, in that there is limited diversity in this population, which begins
in its educational programs. Research on the impact of this lack of diversity on wellness, for not
just minority students, but for all students, will be useful as the profession seeks to become more
WELLNESS PROGRAMS FOR HEALTH 34
inclusive and diverse (Kilburn et al., 2019). Improvements for nurse anesthesia programs should
include increasing cultural humility, as defined as an open process of learning cultural
competency, continually self-critiquing efforts to improve power imbalances, and continuing to
address systemic barriers to nurse anesthesia program entry for students of color (Kilburn et al.).
Research supports the intent of increasing racial diversity in the healthcare workforce and
graduate student populations will increase access to healthcare, reduce health disparities, and
improve health equity in the United States (Kilburn et al.).
This integrative review discovered a potential weakness in empathetic and effective
wellness approaches to SRNA students of color. This weakness is possibly related to the lack of
diversity in student populations, as over 90% of CRNAs self-identify as white (Kilburn et al.,
2019). Prior studies identified racial and sexual orientation minorities as populations with an
increased risk of suicidality; further research needs to be conducted to promote diversity and
inclusion-based interventions to reduce stress, depression, and suicidality specifically in SRNAs
and also in the general population (Davis et al., 2020).
Conclusion
This integrative review discovered major findings regarding wellness programs, and the
potential for these programs to improve student outcomes in graduate nurse anesthetist training.
Elevated rates of depression and suicidal ideation, combined with the ongoing anecdotal reports
of SRNA SUD and suicide, underscore the dire need for a call to action. Nurse anesthesia
educational programs must improve wellness efforts. Important findings included: the most
stressful semesters of SRNA programs are the final two semesters of study, repressive coping
mechanisms may be associated with negative physiologic and cardiovascular outcomes, lack of
WELLNESS PROGRAMS FOR HEALTH 35
diversity within SRNA populations and sufficient support for minority students may be sources
of increased student stress, and weekly exercise of 150-minute duration may help improve
wellness outcomes (Blair et al., 1989; Chipas et al., 2012; Davis et al, 2020; El-Ghoroury et al.,
2012; 2011; Finley, 2016; Frick et al., 2019; Garber et al., 2011; Howard et al., 2017; Kilburn et
al., 2019; Rethorst et al., 2009; Tipton, 2014; West et al., 2011). Important recommendations for
future SRNA wellness program improvements based on this integrative review included: early
program intervention for at risk students, continued efforts to recruit and support minority
students, increased faculty training and involvement in wellness activities, focusing on financial
burden as a source of stress, time permitted for physical activity, and more research to
investigate the current wellness initiatives in the SRNA population.
WELLNESS PROGRAMS FOR HEALTH 36
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WELLNESS PROGRAMS FOR HEALTH 44
Figure 1
Prisma Flow Diagram
Note. Prisma flow diagram of articles reviewed.
Articles identified through database searching
PubMed, CINAHL Complete, Web of Science,
MBASE, Cochrane Library
(n = 383)
Additional articles identified through snowballing
references, Google Scholar, review articles
(n = 22)
Articles after inclusion criteria applied: articles published
within last 10 years, peer reviewed, English, search terms
(n = 79)
Abstracts screened
(n = 68)
Articles excluded for different
population of interest
(n = 39)
Full-text articles assessed for
eligibility
(n = 29)
Full-text articles excluded for low
levels of evidence,
(n = 13)
Articles included in qualitative
synthesis (10 studies, 1 systematic
review, 5 review papers)
(n = 16)
WELLNESS PROGRAMS FOR HEALTH 45
Figure 2
Wellness Program Development & Implementation Steps
Note. Original schematic denoting the implementation of a wellness program for graduate
students; based on Sharp and Burkart, 2017.
Organizational
Buy-In
Implement
Wellness
Committee
Perform
Needs
Assessment
Intervention
Trainee
Wellness &
Burnout
Assessment
Abstract (if available)
Abstract
Student Registered Nurse Anesthetists (SRNAs) are exposed to extreme levels of stress, and are at an increased risk of burnout, depression, and suicidal ideation. This investigation reviewed current literature on graduate student wellness initiatives, stress, and coping psychology, in order to recommend improvements to the existing wellness efforts in nurse anesthesia training programs. Sixty-eight articles were evaluated and after a quality assessment utilizing the (2005) Health Evidence Quality Assessment Tool (HEQAT), eighteen articles were selected for review. After an analysis of the literature a series of recommendations were formed, which include (1) ensuring SRNA wellness programs have a clear policy and procedural pathway for students who feel at risk, (2) provision of training for program directors and key faculty in the early recognition of students at risk, and effective intervention strategies, and (3) a suggestion for the Council on Accreditation of Nurse Anesthesia Educational Programs to revise and update the recommended curriculum components regarding wellness initiatives in programs of nurse anesthesia training. Future research is urgently needed to investigate the current status of wellness in SRNAs, the effectiveness of the current wellness initiatives currently implemented, and how these might be improved.
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Kent, Sara
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Wellness programs for healthcare graduate students: a literature review with recommendations for nurse anesthesia programs
School
Keck School of Medicine
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Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Publication Date
01/24/2021
Defense Date
01/23/2021
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certified registered nurse anesthetist,coping,graduate medical education,Higher education,medical education wellness,OAI-PMH Harvest,Stress,stress appraisal,student registered nurse anesthetist,wellness history,wellness movement,wellness programs health profession
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Tags
certified registered nurse anesthetist
coping
graduate medical education
medical education wellness
stress appraisal
student registered nurse anesthetist
wellness history
wellness movement
wellness programs health profession