Adv in Health Sci Educ (2015) 20:13031324

DOI 10.1007/s10459-015-9603-3

Replacing stressful challenges with positive coping

strategies: a resilience program for clinical placement
learning

C. Delany1 K. J. Miller1,2 D. El-Ansary1

L. Remedios1 A. Hosseini3 S. McLeod1,4

Received: 28 July 2014 / Accepted: 25 March 2015 / Published online: 3 April 2015
 Springer Science+Business Media Dordrecht 2015

Abstract Clinical education is foundational to health professional training. However, it is

also a time of increased stress for students. A students perception of stressors and their
capacity to effectively manage them is a legitimate concern for educators, because anxiety
and decreased coping strategies can interfere with effective learning, clinical performance
and capacity to care for patients. Resilience is emerging as a valuable construct to underpin
positive coping strategies for learning and professional practice. We report the develop-
ment and evaluation of a psycho-education resilience program designed to build practical
skills-based resilience capacities in health science (physiotherapy) students. Six final year
undergraduate physiotherapy students attended four action research sessions led by a
clinical health psychologist. Resilience strategies drawn from cognitive behavioural ther-
apy, and positive and performance psychology were introduced. Students identified per-
sonal learning stressors and their beliefs and responses. They chose specific resilience-
based strategies to address them, and then reported their impact on learning performance
and experiences. Thematic analysis of the audio-recorded and transcribed action research
sessions, and students de identified notes was conducted. Students initial descriptions of
stressors as problems outside their control resulting in poor thinking and communication,
low confidence and frustration, changed to a focus on how they managed and recognized
learning challenges as normal or at least expected elements of the clinical learning envi-
ronment. The research suggests that replacing stressful challenges with positive coping
strategies offers a potentially powerful tool to build self-efficacy and cognitive control as
well as greater self-awareness as a learner and future health practitioner.

& C. Delany
c.delany@unimelb.edu.au
1
Physiotherapy Department, School of Health Sciences, The University of Melbourne, Melbourne,
Australia
2
Department of Physical Therapy, University of British Columbia, Vancouver, Canada
3
Centre for Mental Health, Melbourne School of Population and Global Health, The University of
Melbourne, Melbourne, Australia
4
SAM (Seek Arrive Maximise) Centre, Melbourne, Australia

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1304 C. Delany et al.

Keywords Clinical education
Undergraduate
Learning stressors
Self-efficacy

Psychology and learning
Resilience training

Introduction

Clinical education is a crucial part of health professional training (McLeod et al. 1997;
Hobbs et al. 2000; Joffe 2005; Higgs and McAlister 2007; Lekkas et al. 2007). However, it
is also a time of increased stress for students (Walsh et al. 2010; Alzahem et al. 2011;
Jacob et al. 2012). A students perception of stressors and their capacity to effectively
manage challenges associated with clinical placements is a legitimate concern for
educators, because anxiety and decreased coping strategies can interfere with effective
learning, clinical performance and capacity to provide appropriate patient care (Rompf
et al. 1993; Firth-Cozens 2001a, b; Elliott 2002; Radcliffe and Lester 2003; Seaward 2004;
Walsh et al. 2010). In addition, students who are stressed or not coping with aspects of their
learning require more teaching time and educational resources (Lake and Ryan 2005).
Sources of stress include adjusting to the shift from structured university-based learning to
a more dynamic and complex learning environment (Delany and Bragge 2009), developing
professional identities (Monrouxe and Sweeney 2013), and adapting to more subjectively
based learning and assessment procedures set by clinical supervisors (OMeara et al. 1994;
Hayward et al. 1999; Dyrbye et al. 2005; Jacob et al. 2012, 2013). The effects of these
types of stressors on students have been reported as physiological (headaches, immuno-
logical alterations, respiratory infections, eye twitches, stomach upsets, heart palpitations)
(OMeara et al. 1994; Muchinsky 2003; Sarid et al. 2004; Hartup et al. 2010), psycho-
logical (depression, anxiety, nervousness, strain and fear, increased general health ques-
tionnaire scores) (Tobin and Carson 1994; Tyrrell and Smith 1996; Nelson et al. 2001;
Omigbodun et al. 2006; Tucker et al. 2006; Nerdrum et al. 2009) and behavioural (diffi-
culty concentrating and learning, sleep disturbance) (OMeara et al. 1994; Haines et al.
1996; Tyrrell and Smith 1996; Hayward et al. 1999; Dunn et al. 2004).
As clinical education occurs in clinical workplaces where context, relationships and
institutional systems dynamically shape a students learning (Billett 2001; Egan and
Chrystal 2009; Van De Wiel et al. 2011), a useful conceptual framework to position and
analyse learning challenges is a workplace stress model (Fig. 1, adapted to reflect elements
of the clinical learning environment). Kahn and Byosiere (1992) model categorises both
extrinsic (e.g. organisational factors, workload, demands of supervisors) and intrinsic (e.g.
personality, perceptions and beliefs) sources of stress, their impact on health, coping and
performance, and factors which can mediate these stressors (e.g. supervisor and social
support) (Kahn and Byosiere 1992).
The contexts, relationships and systems which shape Australian physiotherapy students
experiences of clinical placement learning include spending up to twelve weeks in a single
health institution rotating through different wards and being supervised primarily by
clinician physiotherapists who have varying levels experience (Higgs et al. 2009). Students
are given increasing autonomy to perform clinical tasks, beginning with observation,
taking a history then developing treatment plans and following patients throughout their
hospital stay. A consistent feature of this placement experience is the supervisor as both
their mentor and assessor (Higgs and McAlister 2007; Buccieri et al. 2011). Assessment of
student competency includes direct observation; questioning a student about their plans for

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Replacing stressful challenges with positive coping 1305

Properties of the person as stress mediators

Type A/B
Self-esteem
Locus of control

Physical Physiological
Noise Cardiovascular
Organisational Treatment areas Biochemical Health and
characteristics Patient availability Gastrointestinal illness
Size Psychosocial Musculoskeletal Organisational
Work schedule Role ambiguity The appraisal Psychological effectiveness
Study schedule Role conflict process Depression Performance
Hospital systems Role overload Perception and Anxiety
in other life
Hierarchies beliefs Study satisfaction
roles
Behavioural
Turnover
Absenteeism

Properties of the person as stress mediators

Supervisor relationship and support
Colleagues/peers social support

Fig. 1 A model of clinical learning stress [adapted from Kahn and Byosiere (1992)]

and justification of their treatment and/or evaluation of treatment outcomes (Dalton et al.
2011). It can occur continuously throughout this time and supervisors can refer not only to
final examinations to score a students competency but also to their ongoing evaluation of
the student throughout the placement. In this environment, the clinical supervisor sets and
to some extent stage manages (Atkinson and Delamont 1977) a students learning expe-
riences by prescribing which patients or which aspects of the patient assessment and
treatment are suitable for students to engage with (Stiller et al. 2004; Trede and Smith
2014).
Educational responses to address clinical placement stressors have focused on the or-
ganizational or task specific components and mediating influences acting on the learning
environment. Examples of the former include reducing students academic workload
(Tucker et al. 2006); preparing students for clinical learning through pre-placement cur-
ricula (Rompf et al. 1993; Kampfe et al. 1995; Faure et al. 2002; Maidment 2003; Barlow
and Hall 2007; Molloy and Keating 2011); ensuring students who are at risk of failing are
identified early (Kampfe et al. 1999; Chou et al. 2014); and developing targeted models of
teaching such as bedside teaching and learning (Janicik and Fletcher 2003; Williams et al.
2008), teaching on the run (Billett 2001; Lake and Hamdorf 2004), peer teaching (Faure
et al. 2002; Secomb 2008) and simulation (McGaghie et al. 2010, 2011). Strategies to
address mediating influences have included enhancing educators skills in supervising and
communicating with students (Kampfe et al. 1995; Dyrbye et al. 2005; Delany and Bragge
2009; Boud and Molloy 2012), emphasizing the importance of positive and dynamic
student/supervisor relationships (Mitchell and Kampfe 1993; Mason 2006; Nerdrum et al.
2009; Walsh et al. 2010), a supportive network of friends or family, (Omigbodun et al.
2006; Marshall et al. 2008; Nerdrum et al. 2009; Jungbluth et al. 2011) and paying
attention to students work/life balance (Tucker et al. 2006).

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To date, less attention has been given to the impact of students individual perceptions
and subjective appraisal of stressors or supports on their clinical learning (Chan 2002;
Delany and Bragge 2009), including the influence of perfectionism or high achieving
personalities (Elliott 2002; Muchinsky 2003; Sarid et al. 2004; Pritchard et al. 2007; Dahan
and Bedos 2010). There is also little empirical knowledge of how personal efficacy and a
sense of agency might influence capacities to provide patient care and to be critically aware
and self reflective (Trede and Higgs 2009). However there is increasing interest in shaping
students responses and perceptions to learning challenges by developing positive coping
skills for managing specific academic stressors (Martin and Marsh 2006; Martin and Marsh
2008) and more broadly for working in the healthcare environment (Howe et al. 2012). For
example, in the physiotherapy clinical learning setting, Frank and Cassady (2005) suggest
that equipping individual students to manage stress has the potential to not only benefit
them on this individual level, but also contribute to better patient care; stating that
physical therapy students who are able to manage their own stress and anxiety may be
more likely to become practitioners who can help their patients manage stress and anxiety
(Frank and Cassady 2005, p.11). The value of students developing positive coping skills
has been recognized in nursing (McAllister and McKinnon 2009), and in medical educa-
tion (Howe et al. 2012; Risdon and Baptiste 2013) as a potential means of assisting
students to cope with challenges associated with clinical learning, and also for future
transitions to the workplace as confident and critically reflective professionals (Tobin and
Carson 1994; Shechtman 2003; Gammon and Morgan-Samuel 2005; Tucker et al. 2006;
Kilminster et al. 2011).
The concept of resilience is emerging as a potentially valuable construct to underpin
positive coping strategies within the clinical learning environment and beyond (Lazaras
and Folkman 1984; Risdon and Baptiste 2013). Psychology-based definitions of resilience
identify it as an adaptive stress resistant personal quality that permits one to thrive in spite
of adversity (Ahern et al. 2008, p. 32; Luthar and Cicchetti 2000; Lindstroem 2001). In
the school (classroom) setting, Martin and Marsh (2008, p. 55) reframe this psychological
notion of resilience with its emphasis on coping with trauma or extreme adversity by using
the termacademic buoyancy; which they define as a students ability to successfully
deal with academic setbacks and challenges that are typical of the ordinary course of
school life (Martin and Marsh 2008, p. 54). Such setbacks, they suggest, include low level
stress and confidence, dips in motivation and engagement, and difficulty dealing with
negative feedback. They propose concepts of positively-oriented buoyancy and every-
day resilience as a means to enhance students capacities to effectively respond, not only
to everyday academic challenges, but also to achieve improved wellbeing for their current
learning, future work performance and for living (2008, p. 54). Seen as a process of
adaptation, developing skills of resilience therefore means not only bouncing back from
situational adversity, but more broadly developing sufficient self-efficacy to problem solve,
think creatively and purposefully and develop trusting relationships with a sense of moral
connectedness (Padesky and Mooney 2012). This type of resilient self-efficacy is par-
ticularly relevant to clinical learning settings where students rely on others to define and set
the learning agenda; where their abilities are evaluated subjectively and regularly and
where they must develop their clinical competence not by isolated practice and learning
from texts, but through collaboratively interacting and participating with peers, colleagues,
and patients (Delany and Watkin 2009; Rowe et al. 2012).
Martin and Marsh (2008) identified five dimensions of resilience (five Cs) which are
predictive of individual student resilience: (1) Confidence or self-efficacy; (2) Capacity to
plan; (3) a sense of Control of the learning environment and of learning strategies; (4)

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Replacing stressful challenges with positive coping 1307

Composure and low levels of anxiety, and (5) Commitment or persistence to study (Martin
and Marsh 2008). Although their education context is learning mathematics, their notions
of everyday resilience are potentially relevant to the clinical learning and working envi-
ronment where students encounter similar setbacks, challenges and pressures of perfor-
mance (Lofmark and Wikblad 2001; Elliott 2002; Dornan et al. 2007). Associations
between resilience and positive experiences of learning (Firth-Cozens 2001a) suggest a
need to consider how to assist students to develop resilience in the form of positive coping
skills to respond to every day and expected stressors, and setbacks in the clinical learning
environment, and how to raise awareness in clinical educators of how they can influence
(both build and detract from) student resilience and learning agency.
In this paper, we report the implementation and evaluation of a psycho-education
program (resilience program) designed to address the personal perceptions and responses
component of the workplace stress model (Fig. 1). The program focused on explicitly
building practical skills-based resilience capacities in health science students. The four
specific goals of the resilience program were to:
1. Raise students awareness of their personal stressors including, how they think about
and respond to them,
2. Assist students to recognize and then draw from their personal strengths and past
successes to increase self-efficacy
3. Teach students resilience-based strategies such as cognitive restructuring, mindfulness
and controlled breathing to decrease anxiety and negative behavioural responses to
clinical learning stressors
4. Evaluate the impact of resilience-based learning strategies on students self
perceptions of their learning experience.

Study design: the resilience program

Drawing from Martin and Marshs 5 dimensions of resilience the resilience program was
designed to integrate cognitive behavior therapy (CBT), strengths-based positive psy-
chology, and performance psychology (See Table 1). CBT is based on fundamental psy-
chological propositions that cognitive processes affect feelings and behavior; that they can
be monitored and altered, and that desired behavior may be influenced through cognitive
change (Dobson and Khatri 2000). The strategies developed for the resilience program
were not intended to ameliorate student stressors, but instead, to promote positive coping
(Table 1). The CBT component focused on building students cognitive awareness and
skills to repair and/or ameliorate distress and to learn to use cognitive control and be-
havioural tools to optimise their learning and clinical performance (Balague 2005; Table 1,
strategies 110). Positive psychology (PP) was used as a psychological reference point for
introducing strengths and goal-based strategies focused on what the students wanted rather
than what they didnt have (Table 1, strategies 613). The goal was to generate positive
outcomes such as wellbeing, optimal health and functioning, and general satisfaction
(Linley et al. 2006). Sports and performance psychology (SP) was used as a basis for
strategies aimed at improving learning, where the process of learning is construed as a type
of performance. For example, to improve sports performance, it is necessary to recognize
the factors which impact on an individuals concentration, strength endurance and tech-
nique (Balague 2005). Applied to the clinical learning environment, students were asked to

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Table 1 Resilience strategies and psychology approaches
Resilience strategies Psychology Confidence Coordination Cognitive Composure Commitment
theory control

1 Dialogue rehearsal for learning scenarios CBT 4 4 4

2 Recognizing locus of control CBT 4 4
3 Controlled breathing CBT 4 4
4 Time management CBT 4 4 4 4
5 Increasing pleasurable activities/exercise, diet CBT 4 4
6 Pacing learning and managing goals CBT and PP 4 4 4
7 Monitoring self talk CBT and PP 4 4 4
8 Emotional regulation CBT and PP 4 4
9 Arousal monitoring CBT and PP 4 4
10 Increasing mindfulness CBT and PP 4 4
11 Coping statements based on strengths and past experiences PP 4 4
12 Log achievements PP and SP 4 4
13 Identify career vision; link current learning to long-term career goals PP and SP 4 4 4
14 Identify peak performance and arousal level SP 4 4 4
15 Focusing on process of learning versus outcome of learning SP 4 4 4 4

CBT cognitive behavioural therapy, PP positive psychology, SP sports psychology

C. Delany et al.
Replacing stressful challenges with positive coping 1309

identify how stress and anxiety impacted their learning performance, including their ca-
pacity to take in information, to problem solve; to express their learning needs and to
recognize situations where they learnt best. (Table 1, strategies 1215).

Study design: action research

A key tenet of action research is to enable participants to learn and create knowledge about
a concept on the basis of concrete experience including trialing, evaluating and reflecting
on an experience (McNiff and Whitehead 2006). Because little is known about whether and
how increasing resilience impacts on a students learning experience, we wanted students
to identify and learn about the impact of resilience strategies on their learning experiences.
On the premise that students perceptions and beliefs about the learning environment can
influence their self-efficacy to learn more effectively, participating as action research
participants enabled them to monitor their beliefs and trial and refine strategies to
positively change unhelpful responses (Harland 2012; Padesky and Mooney 2012).

Methods: setting and participants

All final year physiotherapy students at three universities in XX attended a 1 hour lecture
delivered by SM and CD. The lecture was timed to occur at the midpoint of their final year
prior to coincide with their final series of clinical placements. The concept of resilience
was introduced to students with an emphasis on its potential for building positive coping
skills for clinical placement learning. At the completion of the lecture, students were
invited to provide their details as an expression of interest to participate in the action
research sessions. Twenty-seven students initially consented to participate in the study,
however a total of 6 students (3 male and 3 female) from two universities (4 from XX and 2
from XX) attended the four 90 min evening sessions facilitated by SM and CD, occurring
once per fortnight for 8 weeks. The mean age of the participants was (22.5 years). The
8 week research period (in July/August 2013) coincided with students final clinical
placement blocks. This represented a busy time for students with a number of competing
academic requirements. When followed up by the researchers, overwhelming work and
study commitments were the main reasons cited by the 21 students who chose not to go on
to participate in the study. The sessions were held at XX University where four of the 6
participants were current students. Students from each separate university were peers and
knew each other well. To encourage attendance and a relaxed environment during the
evening sessions, food and refreshments were provided. Ethics approval was obtained from
the [xx] University Human Research Ethics Committee.

Analysis

The four resilience sessions were audio-recorded and transcribed as the primary data
source. Secondary sources of data were students notes documenting the resilience strategy
they trialed and their record of the impact of these strategies on their learning experience.
Two researchers (CD and SM) independently coded these data sets drawing from both
content (Downe-Wamboldt 1992; Grossman et al. 2004) and thematic analysis (Braun and
Clarke 2006). Content analysis was used to categorise the list of students reported

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stressors, and the suggested resilience-based strategies to address them. Thematic analysis
was used to identify the broader concepts and themes to arise about students clinical
learning experiences (Attride-Stirling 2001). Data is attributed to individual students using
pseudonyms. Over regular meetings, coding results were compared and synthesized by CD
and SM.

Methods: the action research sessions

The action research sessions were run using a deliberately collaborative approach where
SM sought to actively engage with the students so that they mutually constructed and
explored both clinical placement stressors and resilience strategies which might be trialed
to address them (Padesky and Mooney). Although the group was small, the environment
within the session was supportive and non-judgmental and confidentiality and privacy was
stressed as an important ground rule for the sessions (Finn 1999). Students spoke freely
about their learning issues and seemed to derive support from hearing similar problems
being expressed by other students. Table 2 provides a summary of the processes followed
throughout the four sessions.
The culture within the action research sessions was friendly, supportive and at times
humorous, as students were encouraged to relate stories about their experiences and re-
sponses. In the first session, SM explained the principles of CBT to the six students and
outlined the links between antecedentss (events, specific acts, situations or thoughts), their

Table 2 Resilience program steps and facilitation methods

Program steps Methods for educators/facilitator

1. Identify personal stressors and
responses
2. Choose a resilience strategy
3. Trial the resilience strategy and
record what happens.
1. Create a culture of safety in discussing sources of stress
2. Involve psychology department or psychologist
a. Have students identify the stressors and their causes that they
encounter during clinical placement learning
b. Ask students to identify how they feel when the stress occurred
c. Ask students to be specific about their concerns
d. What are they worried will happen?
3. Ask students to identify how they cope with similar stresses in
other areas of their life
4. Categorise them as internally (within their control) or externally
based (outside of their control)
5. Validate/normalize these stressors
6. Acknowledge the influence of high achieving personalities and
perfectionism
1. Invite students to nominate a positive coping strategy which
matches and potentially counters their beliefs and concerns and
feelings stated in step 1 above (see Table 1 strategies)
2. Ask students to indicate how and when they will use this strategy
in their clinical placements
1. What is your example of a stressor on clinical placements?
2. Which resilience strategy did you choose?
3. What action did you take? How/when did you try this strategy?
4. How did this change your thinking (self talk)
5. What were the outcomes/what happened/how did you feel?

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Replacing stressful challenges with positive coping 1311

self-talk and beliefs about the antecedent and the emotional, cognitive or behavioural
consequences of those beliefs (ABC) (Ellis 1980; Beck 2011). The text below illustrates
how SM explained this to students and how they were invited to articulate their own
experiences:
I dont know if any of you have had any psychology before, but basically we are
going to use what we call the ABC Model which is a cognitive behaviour model so it
will help us understand what are your situations that you are having trouble with in
your placements? What do you think about it? That tells me the cognitive stuff that is
going on for you. What is actually happening behaviourally as well as your feelings
and we will record them after you use some strategies. So because we are focusing on
resilience it is a little different from clinical psychology where you might just be
recording your negative self-talk and looking at negative behaviour. We are actually
turning that around and we are going to give you the strategies, so try this strategy in
these situations and tell us what happens and we are hoping for positive responses
and positive self-talk. That is what resilience is about. It really comes from positive
psychology (SM in session 1)
Within the first discussion, students were asked to identify and describe typical clinical
learning stressors they had encountered, their personal skills and strengths and their
specific goals and desires. As the students related examples of stressors, they were
encouraged by SM to also describe their reactions:
We are also interested in getting you to monitor your behaviour, so how you behave;
how you feel; and whats happening to your body, if there is a body symptom
nausea and any of that sort of stuff. You might feel angry, scared and nervous and
you dont say anything (SM in session 1)
After students had discussed different stressors and how they reacted to them, they were
then invited to choose a resilience-based strategy. They were shown how to record their
responses and how to record the actions they took to change their response (Table 3).
So on your sheet, in this column here, there will be a lot of reflecting about these
stressful situations rather than thinking you can change them. That is the A column.
What, where, when and who. So thats where you describe the situation. Now, what
we are going to focus on is when you choose a strategy that is related to something
that you guys feel is specific to you. You are then going to tell us when did you try to
apply it in those situations. So we are moving into: We know this is stressful for you,
but we are actually going to combat it with a strategy straight away and then see if it
actually changes your Bs and your Cs.(SM in Session 1) (see also Table 4 for the
recording sheet example)
Table 1 lists the types of strategies matched to dimensions of resilience from which
students could choose. During each of the four sessions SM and the students mutually
constructed their understanding of stressors and appropriate strategies to use. For example
in response to a students description of a time when they become overly anxious, SM
states:
Remember when we went through this the fight or flight response. So I would say if
any of you are getting overwhelmed, composure would be the first place to go as an
appropriate coping strategy, because feeling anxious shuts off your executive
thinking functioning. You cannot think. The supervisor cannot expect an answer and

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Table 3 Student responses within action research session one

Student Action Beliefs/perceptions- Consequences-
What happened What did you think? What did you
feel or do?

Ethan Discrepancies between allocated I want to focus on all my work but I Confused
marks and feedback from am starting to think too much about Angry
supervisors the fact that I might do really poorly Anxious
I think also I am a bit of a perfectionist Nervous
and I should be able to make this
right
That situation really throws me off
balance
It isnt fair-I shouldnt have to get
lower marks because they dont
know what they are doing
Margot They (supervisors) say you are I start to really focus on the marks Confused
heading in the right direction but the which are low and I feel I cant
marks are low improve even if the comments are
good
I wonder if they are just trying to be
nice because they know I am
disappointed
Margot Supervisors who jump in too early and It makes me feel like I am going to Frustrated
take over because sometimes it takes make a mistake Uncertain
you longer to think when you are a Unsure
student Doubtful
Cautious
Hesitant
Gillian Supervisors who use their authority Presume because they are not very Worried
too much they really let it be confident, that they are not going to Frustrated
known about the hierarchy that approve of what I am doing Lacking
exists between the student and the confidence
supervisor
Gillian Supervisors who want specific I felt like they were going to laugh at Frozen and
answers me if I didnt give them the right blank
answer, just mocking my attempts Embarrassed
I thought if I cant answer this, I must Fearful
be stupid
Margot Supervisors who watch you really I feel like theyre judging everything I Low
closely do, and then I judge what I do and I confidence,
assume that I am doing it wrong blank
even though often Im not. So then I Doubtful
second judge myself and then I
stumble.

it would be better for you to say Ive actually gone blank. Ill go to the toilet and Ill
come back. Because you need to compose yourself and get back to your executive
functions. Does anybody else feel they sometimes get rattled to the point you cant
access your knowledge, your reasoning, or you are all okay? (SM first session)
In subsequent sessions, the same collaborative and mutual sense making approach was
used to validate students reports of their experiences, to help them understand their
responses and to continue to educate them about how to apply their positive coping

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 Table 4 Building resilience: recording form (Gillian)
Examples Student example Strategies Reflection: A Reflection: B Reflection: C
What action did you take? What did you How did you feel afterwards or at the time?
What, where, when, who think/say to What were the outcomes/consequences
yourself?

Cognitive Locus of Process versus During midway feedback, tried to I was able to take on board comments, think
control control outcome. focus on feedback and about them and start thinking about how
Mindfulness/ Focus on comments, rather than marks to modify my practice accordingly
arousal process, not on
Monitoring outcome
Composure Emotional Tendency to be
regulation quiet during
Arousal feedback.
monitoring Freezing when
Centering being watched
Replacing stressful challenges with positive coping

Breathing
Mindfulness
Confidence Link to long- Critical voice Positive self talk Positive statements throughout You can do I am now on a different placement. I am
term career Im not good You are good the day this. You will continuing the positive self talk, however I
goals enough yet enough, you Log achievements as they occur be a good am in a supported positive learning
Vision Is it too late to are still competent environment where I am receiving good
Identify peak quit? learning, you new graduate detailed feedback, I think I would have a
performance are improving I did this more positive outlook compared with my
Log (treatment) last placement anyway
achievements well
Coping
statements
based on
strengths and
past
experiences
1313

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 Table 4 continued
1314

Examples Student example Strategies Reflection: A Reflection: B Reflection: C

What action did you take? What did you How did you feel afterwards or at the time?

123
What, where, when, who think/say to What were the outcomes/consequences
yourself?

Coordination Time Focused on marks During midway feedback, giving Ignore the Comments were well received by
management during midway supervisors feedback. Letting marks, just supervisors, we talked through strategies
Process versus feedback them know my learning style focus on the to improve my performance and study
outcome Calculating in my and the drawbacks of the comments skills. Feedback became a helpful session,
Pacing head what the placement rather than feeling criticized
final result will
be
Commitment Mapping goals
C. Delany et al.
Replacing stressful challenges with positive coping 1315

strategies. In the following exchange, from session 3, Agnes is describing her response to a
series of questions asked by her supervisor. SM takes the opportunity to both validate and
reinforce the positive coping skill, and to build further understanding:
Agnes: Initially I thought I would freak out because I was being bombarded, and
obviously I got a bit stressed, even though I had coped with this the day before so we
will see what happens tomorrow.
SM: And what would be happening to your beliefs?
Agnes: They changed in a day. Yesterday I was very confident and then, today, I
was: here we go again. I had a different supervisor and feedback change it wasnt
good quality feedback
SM: It changes quite quickly and what I want you to realise is remember we said how
important repetition is. So even though you are trying and going with the flow and
things are good and you are trying to focus on process: that environment allowed you
to do it. When it is different the old belief will get retriggered, so the here we go
again perfection self-talk will appear to recruit the old belief. So you have got three
weeks which you have built on and it has built your confidence, what would you be
saying to yourself? What self-talk would you use to keep that going even if the
context changes. Because its about you, not about what supervisors think. So tell me
what would be different about how you could think about that old belief appearing
again? (SM session 3)
Between sessions 24, students returned to their clinics to trial their specific resilience
strategy and to record the impact of their strategy by responding to three questions:
1. Action what happened (in your clinical placement)what was stressful and what
positive coping strategy did you try?
2. Beliefs/perception what did you think?
3. Consequences What did you feel or do?

Results from action research discussion sessions

The results are presented below in chronological order of the sessions. These results are
drawn from the audio-recorded and transcribed discussion sessions.

Session 1: identifying stressors

In the first session, each student discussed a range of different stressors relating to the
demands of balancing study and other commitments, their own concerns and worries and
their view of the supervisory process. This list below represents a composite of those
stressors:
1. Constant assessment in clinics
2. Needing to read supervisors minds
3. Extra pressure of assignments whilst on clinics
4. The apparent subjectivity of the assessment process
5. Demanding supervisors (expect too much/watch too closely/quiz for more
information)
6. Uncertainty about assessment processes, standards and tasks

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1316 C. Delany et al.

7. Balancing work and university in the context of changing timetables

8. Worrying about meeting expectations
9. Concerned about the extra burden, their learning placed on supervisors clinical
load
10. Worrying about not being good enough
In response to questions by SM about the impact of of being watched closely, and
quizzed for more information, students described consequences of going blank,
freezing and feeling confused and off balance. Their beliefs (or self-talk) about such
concerns included fear of failing and resentment of authority or feelings of not being
good enough. Their described emotional responses included anger, frustration, disap-
pointment, confusion, and decreased confidence (Table 3).
Students then nominated, via the collaborative discussion process described above, one
or two of the resilience strategies (Table 1) they believed best matched their situation/
performance or goals. For example, where a student described the behavioural conse-
quence of decreasing confidence, a relevant positive coping strategy was to shift their focus
from fear or anticipated failure to building efficacy by recognizing past achievements and
strengths (see Table 1, strategy 11).
Students who reported being very nervous when their supervisor watched them closely
and as a consequence, doubting their ability or losing their capacity to think clearly, chose
a cognitive regulation strategy such as focusing on what was within their own ability to
control (Table 1 strategy 15). This process over outcome strategy involved students
focusing their attention on the specific skills or processes needed to effectively treat their
patient, and to block their thinking about the likely outcome of their performance, such as
guessing their supervisors impression or the marks they might be assigned. Other
strategies included gaining composure, and communicating clearly about learning needs
(Table 1, strategies 12). Where a student mentioned that their response to criticism or
questioning was to freeze, or to lose their capacity to think and problem solve, the strategy
recommended for their response was to take time to breathe deeply and regain enough
composure to ask for time to refocus (Table 1, strategy 3).
In sessions 24, students discussed the stressors they encountered and described their
responses. Each student was given time to describe what they had tried and what effect it
had on their feelings and responses.

Session 2

In session two, the focus of the discussion reflected an emerging awareness of personal
responses to stressors and methods for altering such a response. In the quote below, Agnes
replaces worrying about or dwelling on a negative thought, by letting it go and moving on:
If I have a worrying situation or Ive made a mistake Ill try not to think about that
concept of mistake in a positive light or a negative light not at all. Just letting it go
and moving on and I have found the more I have done that the quicker its going
away and it is sort of like thoughts will come up and Ill be like oh yeah then Ill
just try and think about something else and it sort of happens faster and faster and
then I dont feel like Im probably getting stuck on one thought and dwelling on it
because it is pointless. (Agnes)

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Replacing stressful challenges with positive coping 1317

In the quotes below, Margot and Gillian discuss how they shifted their focus from guessing
the possible outcomes and marks given for their clinical work, to focusing on the process of
treating the patient:
I have been putting more emphasis on the process and whats the next thing you have
to do to get this to work, so focusing on the patient and not the mark and what the
supervisor thinks of you. (Margot)
(this week)I had a thing where the supervisor is jumping in I was a little bit
hesitant with the patient and the supervisor-jumped in and that was okay and I kind
of stepped back and let her go for it because I was like well shes more experienced
and she knows best and will do whats best for the patient, and then afterwards I
thought I probably could have handled that situation and I could have treated the
patient, but because at the time I was like this is better for the patient and Ill just shut
up and let her take over. (Gillian)

Session 3

In session 3, students discourse shifted from recognizing and matching a stressor to a

resilience strategy, to more purposeful use of the resilience based strategies to address
specific stressors:
Before I went to placement I was thinking about the stuff Ive done. Just consciously
going through: okay Ive done this well in the past. I was thinking even back to
school, I was thinking all the way back. I didnt write it down but I thought about it. I
think that helped with confidence. I will keep doing that. (Danielle)
I tend to give myself a lot of negative feedback, rather than looking at the things I do
well. Which has changed a little bit as well, I think. So when I am seeing patients
now, more so in out-patients, I look more at balancing my feedback out; so this was
okay, this wasnt. I need to work on that, rather than just beating myself up. (John)
Im more positive. Im more confident as well when I go into another session with a
patient. Before it was sort of, you are no good, sort of thing. (Agnes)
We are doing a lot of home visitsmy supervisor is always is still kind of watching.
Sometimes I lose a bit of confidence, but I have been trying to think, like today
before we went into the house I was trying to think process vs. outcome. I was going
okay I know this is stressful, I will think what can I. I was preparing as I was going
in, what am I going to do? How am I going to deal with it rather than looking at the
whole picture? (Margot)

Session 4

In session 4, students reports of their clinical learning experiences, demonstrated an

increasing sense of being in control of their own learning:
I am trying to take away as many positives as I can every day. So I had the head
respiratory doctor at the hospital comment positively on my work the other day, so I
was like thats good, he likes my work, and I kept focusing on that. (Ethan)

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1318 C. Delany et al.

Im finding now I want to go to placement because I want to spend time with my

patient and help them and make an outcome. Like last week I was like, yeah I know I
can help these patients. I have a plan, Im going to go in there and do what I want to
do because I want to do that to help them. So I have found Ive been doing that a bit
more which is nice. (Ethan)

So I think Im learning. So when Im with the patient and I get a little bit stressed or I
start looking at the supervisor and wondering what she is thinking, I sometimes have
to tell myself again, focus on the patient, come back to the patient. I think I am doing
that. (Gillian)
Table 4 documents one students record of responses over the 4 sessions. This table
illustrates how the student chose resilience strategies, matched them to her nominated
stressors, and identified and monitored her responses to stressors after trialing the resilience
strategy. This single record is similar to the reports from the other five participating students.
The common theme in their written reports was a shift in how they perceived and responded
to challenges in their clinical placement experience from being overwhelming and caused by
extrinsic factors (outlined in Fig. 1), to issues they could deal with and which they could
understand as normal or expected elements of the clinical learning environment.

Discussion

In this project, we trialed a psycho-education program using action research methodology

to assist students to develop, implement and evaluate the effects of resilience strategies on
their self-perceptions of their clinical education experience. Students descriptions of the
impact of trialing targeted and personalised positive coping strategies within their clinical
placements suggest that they increased their levels of confidence and cognitive control in
specific areas previously identified as stressful. Our findings indicate that using this pro-
gram, students can be assisted to address clinical learning stressors by understanding their
own triggers and responses, and planning and implementing specific and targeted be-
havioural changes. The findings affirm the important role for clinical educators, to go
beyond changes to curricula and structural organization of learning, to more personalized
approaches to support students in shifting their perceptions and responses to clinical
learning challenges (Shiralkar et al. 2013) including implementing effective relaxation
techniques, focusing on successes and strengths (Grossman et al. 2004) and specific
positive coping strategies to deal with the challenges associated with clinical learning.
In this study, students initial descriptions of clinical learning stressors as problems
outside of their control, resulting in poor thinking capacity, anxiety, lack of confidence and
frustration in their clinical placements are consistent with findings widely reported in
health professional literature (Tucker et al. 2006; Alzahem et al. 2013; Jacob et al. 2013).
Between the first and the fourth action research sessions, students descriptions evolved
from describing a learning stressor as a negative and extrinsic force beyond their control, to
a focus on how they were (intrinsically) managing and planning for it. This shift was
facilitated by a collaborative approach between the psychologist as facilitator and the
students as action research participants. The shifts in students attitudes suggest that de-
veloping skills of resilience may be an example of what Meyer and Land (2003) refer to as
a threshold concept or a dispositional shift, whereby students must pass through (in their
thinking) a portal which opens up new and previously inaccessible ways of thinking about

123
Replacing stressful challenges with positive coping 1319

and perceiving experiences and challenges (Meyer and Land 2003). Transformative change
as a learning outcome (Grace and Trede 2013) resonates with educational goals related to
developing professional identities, and attributes of agency and lifelong learning (Billett
2001; Monrouxe 2010; Trede et al. 2012). An alternative explanation for students change
in perceptions of stressors was that by encouraging them to focus more on the process of
treating the patient rather than their personal emotional or somatic responses, they were
able to re-discover their motivations and aspirations for studying as a health professional
(Greenfield 2006). This research suggests that an explicit focus on building students
resilience may be a useful pedagogic strategy to assist in the expected transformation of
students from passive learners to agentic health professionals (Billett 2001), who
demonstrate confidence, initiative, motivation to be lifelong learners (Kilminster et al.
2011) and have capacities to be critically reflective of their own practice (Delany and
Watkin 2009; Chipchase et al. 2012). It may also assist in linking experiences of clinical
learning with appropriate pedagogies that recognize the sociocultural and psychological
factors at play in clinical placement environments (Kilminster 2009).
The novelty of the resilience program as a clinical education method is to shift the focus
of clinical education improvement from changing the organization and processes of aca-
demic support for clinical learning (Billett 2001; Eraut and Hirsh 2010), to recognizing and
drawing from the intrinsic skills and capacities within the students themselves. Previous
educational methods to influence students subjective appraisal and filtering of the learning
environment have emphasized skills of critical reflection; where students learn to analyse
and unpack their learning experiences to gain greater perspective (Delany and Watkin
2009; Mann et al. 2009; Smith and Trede 2013). However, these approaches do not
explicitly and positively provide strategies to change behavioural, attitudinal and emo-
tional responses to perceived stressors. Drawing from three related psychological
philosophies (CBT, strengths-based positive psychology, and goal oriented performance
psychology), the underpinning pedagogical premise of the resilience program trialed in
this study was that students can learn to construct a personal cognitive-based model for
remaining resilient in the face of adversities and academic setbacks (Padesky and Mooney
2012).
Limitations to the generalisability of these research findings are recognized. The in-
tervention was undertaken in a small sample of participants within a particular cultural and
geographic context (Crouch and McKenzie 2006). The clinical health psychologist (SM)
was a key facilitator in the action research sessions and this raises some uncertainty as to
the influence of her specific skills and interaction with students on the observed results. In
this project, changes in resilience were inferred based on student self-reports of their
learning experiences, and extrapolated from their descriptions of improved confidence and
control within their learning experiences. Data which relies on participants descriptions
and interpretations can be open to differing and subjective interpretations. Furthermore,
while the self-reported impact of using the strategies suggested a strong shift towards
achieving greater resilience, these reports were not compared to formal assessments of
learning performance by supervisors (Green and Britten 1998; Morse and Singleton 2001).
There is a need for future research to systematically evaluate the impact of resilience
strategies on measures of actual learning performance via assessment results, or supervisor
evaluation. In addition within-year comparisons of students who learn resilience strategies
and students attending standard clinical program may better distinguish the impact of a
resilience program and pre and post measures of resilience would also be useful to
quantitatively explore potential effectiveness of the resilience program on student
learning. This research did not measure learning outcomes following the resilience

123
1320 C. Delany et al.

program. However, emerging evidence suggests that students who are more emotionally
stable, have a good level of cognitive control and are able to develop a level of detachment
from harmful stress, are likely to be better able to assimilate and integrate new information
and organize high academic workloads (Tyrrell and Smith 1996; Martin and Marsh 2008;
Risdon and Baptiste 2013).

Conclusion

Clinical education is a crucial part of health science student training and yet it can also be a
time when students feel most stressed in their professional training. We developed and
trialed a program that integrated principles of CBT, strengths based positive psychology,
and goal oriented performance psychology to assist students to develop positive coping
strategies and to leverage changes in students behavior across five dimensions of re-
silience. Students self-reported responses to clinical learning stressors, suggest they de-
veloped increased confidence, cognitive control and self-efficacy after using specific
resilience-based strategies in their clinical placements. The research suggests that replacing
stressful challenges with positive coping strategies offers a potentially powerful tool to
build self-efficacy and cognitive control as well as greater self-awareness as a learner and
future health practitioner. These strategies are vital to equip students for the challenges
they face as health professionals.

Acknowledgements The authors wish to acknowledge the contributions of Lara Edbrooke and Birgit
Campbell, research assistants supporting the study, and the participating students in the study. This research
was supported by an Australian Physiotherapy Association Trust Fund, The Pat Cosh grant.

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