Heal the Healers: A Roadmap to Utopian Healthcare

Kim Byrd-Rider  

Harvard University Extension School  

PSYC E-597 Section 1 

Theory and Research in Human Development 

Dr. Julia Hayden Galindo EdD 

12/13/2020 

Heal the Healers: A Roadmap to Utopian Healthcare 

As a physical therapist working in an inner-city hospital, I was packing the bullet wounds of a post-surgery unconscious boy. He was laboriously breathing from a tube inserted down his throat (intubated). He woke up and I could tell it was his first alert moment by the terror in his face. He could not speak because of the tube, but his eyes were as big as saucers as he fearfully stared into my eyes looking for answers. What should I say? I knew this was a monumental and pivotal moment, and that he would remember it throughout his lifetime. What I said or did not say could make the event calmer or more intense for him. Should I say, “Everything is going to be fine.” I knew that was wrong. Should I say, “Wow, you got really lucky!” I knew that was wrong. Saying nothing was wrong too.  

I was competently trained to pack his wounds, but I never took a course to help me with this critical psychological and social moment in my life as a healthcare provider. My education was lacking in how to psychologically assess the moment for myself and to socially communicate with this young man in such an intense moment. That was over 13 years ago. I still remember this event vividly to this day. It not only traumatized him, but my lack of abilities to help him mentally traumatized me. Millions of daily episodes across America like this one can be avoided with bio-psycho-social education courses for healthcare professionals. 

An article by Dubey and colleagues report that healthcare is tragically missing a psychological and social healthcare model that trains healthcare workers for the plethora of events like this one and a model should be urgently developed for them by either the government, healthcare personnel themselves, or by their healthcare administrators (2020, p.787). The multitude of stressful risk-factors with poor personal outcomes for healthcare professionals is heavily researched with the research authors unanimously calling universities into supportive action (Velez et al., 2019, p.10). Researchers beseech universities to intervene at multiple levels by teaching mental health promotion strategies like self-care and healthy coping styles through formal or informal programming (Velez et al., 2019, p.10). They suggest that universities foster institutional and cultural change to support their students’ self-care efforts (Velez et al., 2019, p.10).  

This paper provides an option for healthcare culture change that researchers like Velez et al. are specifically suggesting(2019). This paper begins with a research review of conditions in healthcare schools and workplaces. This is followed by a research review of healthcare workers’ current skillsets for processing psychological and social job stressors. As a solution to the problem, a literature examination of best-practice medical models will then be examined. Finally, the paper will propose a medical fellowship to rectify the problem and it will outline the first course of 12 which is named Bio-Psycho-Social Rituals, Practices, and Habits for Self-Care. The problem begins in healthcare universities. 

Psychological and Social Stress in Healthcare Universities 

Being accepted to medical school is excitedly celebrated by hardworking students and their jubilant families, but many students in medical training end up compromising their wellbeing and mental health for that very degree (Hoper, 2014; Kotter, Pohontsch, & Voltmer, 2015). Graduate healthcare education is challenging, and students can experience greater stress during their academic years than their age-matched peers (Dyrbye, Thomas, & Shanafelt, 2006). Indeed, medical students consistently report higher rates of suicidal ideation (10%), stress, anxiety, burnout (50%), depression, and a larger decrease in empathy than age-matched students who major in other disciplines (Bellini et al., 2005; Brazeau et al., 2014; Dyrbye et al., 2006; Dyrbye et al., 2008; Heinen et al., 2017; Hojat et al., 2002; Rotenstein et al., 2016; Schwenk et al., 2010). These psychological and social stumbling blocks result in impaired academic performance, self-medication, compromised patient care, medical errors, unprofessional behavior, attrition from medical school, and decreased quality of life for medical students (Kreitzer, & Klatt, 2016).  

Research for stressors on nursing students is very similar to the research for medical school students with relief coming in the form of improved coping mechanisms, individual resources, and more hospitable environments (Pulido-Criollo et al., 2018). Research for the stressors on physical therapy and occupational therapy students, again, repeats the medical school stressors and poor wellbeing outcomes with relief from resilience strategies, coping self-efficacy, and emotional intelligence for student success (Van Veld et al., 2018). The conditions of various types of healthcare students shadow one another whether they are dentistry students or physician assistants, because they all require licensures with high-stakes examinations, early exposure to death and suffering, and high volumes of knowledge intake as compared to other university degree seekers (Dyrbye, & Shanafelt, 2016). 

Psychological and Social Stress in the Healthcare Workplace 

The psychological and social problems do not end upon graduation for healthcare students. The big stressors begin as healthcare students transition into work. This issue was extremely problematic even before the 2020 pandemic of Covid-19. Before the pandemic, one nurse from New York City’s Mt. Sinai Hospital reports, “Every day I go to work, I feel like I am going into a war zone,” (Bowden, 2019, p.1). Traumatic stress for healthcare workers is the cost of caring for people in emotional pain (Figley, C., 2002; Figley, C., 2013). Risks of working in healthcare are well documented and include personal compassion fatigue, poor quality care to the patient, moral distress, and job burnout (Asai et al., 2007; Balboni et al., 2015; Best et al., 2016; Cole, 2009; Kearney et al., 2001; Peters, 2012; Meier et al., 2001). Increased work stressors have been predicted to grow exponentially nationwide for many years (Canadian Nurses Association, 2009). 

Hospitals are predicted to become extremely short of all healthcare workers due to growing elderly populations and increasing healthcare complexity (Canadian Nurses Association, 2009). Starting in 2022, the Canadian Nurses Association predicts that, like most other countries, they will be short 60,000 nurses (2009). In 2015, hospitals averaged an ongoing 7% nursing vacancy rate (University of New Mexico, 2016). Staff shortages in every healthcare field increase workloads and patient care stressors (Univ. of New Mexico, 2016).  

In addition to staffing shortages, healthcare workers experience something even more traumatic; verbal and physical abuse. Over the past two decades, many hospital employees operate under some level of post-traumatic stress disorder (PTSD) due to their hospital job. An average of 40% of U.S. nurses meet the diagnostic criteria for PTSD (Mealer et al., 2009). Long-hours, under-staffing, and poor stress coping skills escalate job burnout, fatigue, and poor health which are ever-present risk-factors prohibiting hospital staff from producing quality patient care (Mealer, et al., 2009). Hospital employees experience the third largest amount of workplace violence in the nation (King et al., 2017). Hospital staff receive 10% of all workplace verbal and physical abuse (King, et al., 2017). Workplace violence affects job performance, job productivity, job morale, job retention, and job satisfaction (King, et al., 2017). As an example of the amount and kind of stressors hospital staff undergo in one year, a study by Speroni and colleagues (2014) explain that 76% of hospital nurses experience violence with emergency nurses at 88.1%. The perpetrators were primarily 26-35-year-old white males who were confused or influenced by drugs or alcohol (Speroni et al., 2014). Events such as shouting, swearing, grabbing, scratching, and kicking occur. Physical abuse to nurses averages 29.9% from patients and 3.5% from visitors (Speroni et al., 2014). Reported abuses are believed to be under-reported due to hospital employee justifications for their patients’ and visitors’ behavior (King, et al., 2017).  

These stressful healthcare worker conditions are real and growing without any pandemics. The trauma for healthcare workers only increases when pandemic situations arrive. A study by Shechter and colleagues showed 57% of healthcare workers experience acute stress, 48% depression, and 33% anxiety during the Covid-19 virus pandemic of 2020 (2020). Healthcare workers’ coping skills for these problems are 59% exercise and 33% counseling according to Shechter and colleagues’ research (2020). The workers in the study did not show a vast knowledge of habits, practices, and rituals for mentally processing stress or for exhibiting stress coping skills during the pandemic (Shechter et al., 2020).  

The Processing and Coping Skills of Healthcare Workers 

There is a great deal of research on which specific coping skills help alleviate stress for healthcare workers. On the psychological front, self-care and self-awareness are the largest best-practice coping predictors for improving healthcare workers’ quality of life, while traditional healthcare training and physical-only self-care did not have a positive effect on healthcare workers’ coping skills (Balboni et al., 2015; Best et al., 2016; Cole, 2009; Kearney et al., 2001; Sansó et al., 2015). On the social front, The World Health Organization Framework for Action on Interprofessional Education and Collaborative Practice states that interprofessional social education improves healthcare worker collaboration and patient health outcomes (Bode et al., 2016). Some medical schools are following the recommendations of this research, like McGill University in Quebec, Canada. 

Medical School Solutions to improve Coping Skills 

In 2013, McGill University built a psycho-social solution-based adjunct curriculum to resolve the medical students’ educational deficit and published the findings in 2019 (Velez et al.). McGill University chose a longitudinal wellness program lasting throughout their 4-year medical curriculum. The goal of the program was for physicians to sustain their own reserves and also provide optimum, whole, and compassionate care to patients (Velez et al., 2019). Velez and colleagues define the mission of the McGill University wellness curriculum as promoting self-care, self-awareness, wellbeing, and resilience for medical students’ personal and professional development through social, emotional, physical, and intellectual states of wellbeing (2019). McGill University chose to make their curriculum optional during the first two years and mandatory during clinical practice; years three and four (Velez et al., 2019).  

The first two years offer 10 elective courses to choose from with holistic topics on global health, respiration, circulation, renal, digestion, defenses, infection, movement, sexual health, human behavior, and transitioning to clinical practice (Velez et al., 2019). The first year offers personal-psychological lectures (30 min-1.5 hours) and are also offered on topics like anxiety, self-management, mindfulness, resilience, coping strategies, study skills, healthy relationships, core values, and student mistreatment. The second-year offers social-oriented short lectures like diversity sensitivity, inclusivity, suicide prevention, and gender minorities with mandatory safe-space small-group meetings of 20 students for self-reflection, professional vulnerabilities, and peer support. Years three and four are a series of mandatory lectures on time management, building professional relationships, applying mindfulness, psychology rounds, financial wellness, Rx wellness, and motivation. The third-year mandates participation in safe-space, small-group meetings of 10-14 students, which are similar to the second year (Velez et al., 2019). 

Additional universities joining McGill University are Vanderbilt University School of Medicine (the first published model with an advisory program, a wellness committee, and longitudinal curriculum in 2010) and Northwestern University’s Feinberg School of Medicine (4-year longitudinal wellness curriculum with a small group of eight formats in 2016), (Agarwal, & Lake, 2016; Drolet, & Rodgers, 2010). In addition to longitudinal curriculums, up to 80% of healthcare universities are now offering elective courses, extra-curricular courses, and activities for students to build psychological and social skills for personal wellbeing as compared to 2% in 1993 (Mitchel et al., 2007; Williamson, Lank, & Lovell, 2017). Only 7% of the 80% make the courses required meaning the healthcare university system has marginally converted to educating healthcare workers in psychological and social domains of the bio-psycho-social medical model (Mitchel et al., 2007; Williamson, Lank, & Lovell, 2017). 

Bio-Psycho-Social Medical Model as Best-Practice for Workers and Patients    

The originator of the bio-psycho-social medical model was George Engel (1977). Engel writes in 1977, “The average physician today completes his formal education with impressive capabilities to deal with the more technical aspects of bodily disease, yet when it comes to dealing with the human side of illness and patient care he displays little more than the native ability and personal qualities with which he entered medical school.” Engel incorporated psychological factors like personality, mood, and behavior in addition to social factors like socioeconomics, family relationships, and culture into the fabric of his medical model (Engel, 1977). His ideas displayed a more complicated yet accurate patient picture for an illness diagnosis and solution (Engel, 1977). In his bio-psycho-social medical model, Engel strived to develop a solution for both the medical field patients and the psychology field patients by using a holistic patient approach (Engel, 1977). Engel’s model was created for patients, although in this paper the healthcare worker is the person in health and wellness distress. 

Engel argued that the bio-medical model of 1977 was flawed and reductionist in nature, hence he regenerated the idea of dualism (mind and body) which was classically established in the 1600s by the renowned French philosopher, mathematician, and scientist Rene Descartes (Nobleman, Allen, & Perry, 1995). In this classical sense of dualism, health issues are not limited to one domain of human experience like the bio-medical domain, but to multiple domains instead (bio-psycho-social). In the philosophy of mind/body dualism, the biological, psychological, and social domains influence one another to determine a person’s health (Gatchel, & Haggard, 2014). A patient may have a predisposition for a disease, but a social or psychological factor may trigger it. For example, psychological and/or social stressors are known to trigger and even worsen over 50 different auto-immune diseases (Stojanovich, & Marisavljevich, 2008).  

The medical field has put this information to use by developing bio-psycho-social medical prescreening questionnaires such as Gatchel and Haggard have done for spinal cord patients (2014). The World Health Organization even adopted the bio-psycho-social model as a basis for the International Classification of Function (Hopwood, 2010). In the 1970s, there were two more similar yet less popular theories in circulation. 

In 1977, Russian born American psychologist Urie Bronfenbrenner published his groundbreaking gene-environment interactions in human development research called the Ecological Systems theory (Bronfenbrenner, 1979). His theory later evolved into the Bioecological model, with the help of Stephen Ceci, where they stress the effects of the environment on a person’s physical health (Ceci, 2006). Bronfenbrenner is more known for co-founding the 1965 U.S. government Children’s Head Start program in America that still operates today (Derksen, 2010). 

Yet another similar model surfaced in the same time period. Hettler’s 1976 Interconnected Model of Wellness, which is currently used by McGill University’s Wellness program for medical professionals, expands on the three domains of Engel (Velez et al., 2019). Hettler parses the three domains into six domains: physical, emotional, intellectual, spiritual, social, and occupational (2019). 

Engel’s bio-psycho-social medical model has been dubbed best-practice for health outcomes from diverse medical field journals such as the Pain Medicine Journal (Baria et al., 2018), the Global Spine Journal (Salathé et al., 2018), the American Journal of Psychiatry (George, & Engel, 1980), the American Psychological Association (Gatchel et al., 2007), and collaborative worldwide healthcare reviews (Teal et al., 2018) as long ago as 1980 and up to today. The scientific community’s support for the bio-psycho-social-medical model is overwhelming. Another important fact is that Engel’s model is supported biologically by the science of epigenetics.  

The science of epigenetics establishes that the environment can affect heritable phenotype gene activity and expression (Dupont, Armant, & Brenner, 2009). Chemical tags on the DNA strand have the ability to turn themselves on or off (Dupont, Armant, & Brenner, 2009). The on or off position of the gene can be influenced by the environment, in other words, by psychological and social contexts (Dupont, Armant, & Brenner, 2009). The gene change can later be inherited by the next generation (Richards, 2006).  

Epigenetics is not new. The word epigenetics can be traced back to embryologists Ernest Just in 1916 and Conrad Waddington in 1942 (Waddington, 2012). Because of 21st century modern technology, the 20th-century epigenetic theories can now be proven (Tollesfbol, 2011). Epigenetic proof has been ongoing since 2003. Every year epigenetics is strengthening and broadening its scope of effects on medicine (Tollesfbol, 2011). For instance, a new finding in 2019 has linked epigenetics to affecting cell metabolism (Zang et al., 2019). Science is changing and an effective curriculum for healthcare providers needs to evolve with it. 

Developing Healthcare Curriculum for Biological, Psychological, and Social Domains  

A healthcare curriculum with moral dimensions to train students in self-care practices that promote professionalism is missing from the bio-medical education of most healthcare professionals, says an article by Mitchel and colleagues as early as 2007. Researchers Mitchel and colleagues present an exciting and precise roadmap to resolve this problem based on qualitative data derived from 44 Harvard medical students, Harvard divinity students, and Harvard medical school faculty (2007). According to the article, no known prior research had been published on this topic, making their article the seminal article for developing healthcare curriculum with biological, psychological, and social domains specifically for healthcare professionals (Mitchel et al., 2007). The elements of Mitchel and colleagues’ foundational research work later gives rise to and can clearly be seen in the bio-psycho-social healthcare curriculums developed by Vanderbilt University School of Medicine in 2010, McGill University in 2013, and Northwestern University’s Feinberg School of Medicine in 2016, which is reported on previously in this paper (2007). 

Chaplain students and faculty were included in the study because they are highly trained in and provide psychological and social assistance to people within institutions, including hospitals (Mitchel et al., 2007). One-to-one interviews were used with all faculty members to collect their information, while all students participated in focus groups led by senior peers. Five medical school focus groups were led by fellow senior medical students and two divinity focus groups were led by a recent divinity school graduate. All divinity students had completed or were currently enrolled in Clinical Pastoral Education or chaplaincy training (Mitchel et al., 2007). 

The consensus from the groups are as follows (Mitchel et al., 2007). The groups decided a longitudinal curriculum would be best taught throughout the four-year medical program as opposed to all in one semester, giving students time to reflect (Mitchel et al., 2007). Most of the participants agreed that the curriculum should be elective and not required but that was hotly debated. The argument was that the healthcare workers that need the curriculum most would be less likely to electively take the courses. A combination of lecture and experiential practice won the ideal format vote among the students and faculty. The medical students expressed exhaustion from continuous lectures and preferred experiential learning but understood the need for some lectures (Mitchel et al., 2007). 

The curriculum content was divided into five areas of critical dimensions for medical school students. These themes were arranged according to multiple levels of learning and development beginning with the individual level and expanding out to the societal and/or global level (Mitchel et al., 2007).  

Figure 1 

Psychological, moral, and spiritual wellness for medical students (Mitchel et al., 2007). 

Utopian Healthcare Institute (U-Hi) Fellowship’s First Course 

 I plan to incorporate all five areas of the Harvard critical dimensions curriculum into a large program of approximately 12 courses. The 12 courses will collectively be a fellowship: Utopian Healthcare Institute (U-Hi) Fellowship. The fellowship will be available for all branches of healthcare workers and students. The focus of this paper is only on the first course within the U-Hi Fellowship. The course title and subject matter are a result of examining the previous research. Personal growth is the first area of the critical education dimensions, self-care is highlighted in the literature as having a positive effect on improving quality of life, and the bio-psycho-social medical model supports epidemiologic changes to improve health (Balboni et al., 2015; Best et al., 2016; Cole, 2009; Kearney et al., 2001; Mitchel et al. 2007; Sansó et al., 2015; Tollesfbol, 2011). So, the proposed course title is Bio-Psycho-Social Rituals, Practices, and Habits for Self-Care. In addition to these research considerations, researchers Perkins and Blythe have produced a four-part framework for the Harvard Graduate School of Education and this course will follow those guideline steps: 1. Generative Topics, 2. Understanding Goals, 3. Performances of Understanding, 4. Ongoing Assessment (1994). 

Generative Topics for the Course. 

The research of Sanso and colleagues showed that physical self-care alone did not have a positive effect on healthcare workers’ coping skills (2015). Due to Sanso and colleagues’ data, isolated physical practices will not be offered as a choice for rituals to practice. Only physical practices that incorporate proven psychological or mindful attributes will be options for the students to choose from. Psychological or social rituals and practices will also be available as student choices. Choice or human agency is an important aspect of a person’s coevolution to transcend their current lifestyle (Bandura, 2006). In the first session of the course, students will brainstorm 10-15 self-care rituals to possibly explore for themselves during the course. Each student will choose their own personal set. This allows for personal preferences, diversity of interests, and human agency (Bandura, 2006). In the second session, students will be required to present research representing the bio-psycho-social domains of their activity choices to foster understanding (Perkins, & Blythe, 1994).  

Possible psychological rituals include any hobbies or activities that bring the student peace of mind which include but are not limited to hypnosis, meditation, massage, working puzzles, craniosacral therapy, acupuncture, wellness coaching, psychotherapy, watsu, reiki, leisure reading, breathwork, etc. (Tnau, & Nadu, 2017). Time efficiency improves if the ritual involves two domains or even three. Examples of two domain activities (bio-psycho) include but are not limited to yoga, Pilates, tai chi, chi gong, Feldenkrais, nature walks, animal play/care, etc. (Jung et al., 2016). Examples of three domain activities (bio-psycho-social) include but are not limited to participating in group classes or inviting a friend to join in any of the previous activities listed for two domains. 

Understanding Goals of the Course. 

The goal of the course is to help healthcare workers and students develop the coping skills needed to handle the stress and trauma associated with their healthcare jobs or classes. Objectives or course goals are listed below. 

By the end of this course: 

1. Participants will understand psychological research and philosophical findings concerning necessary activities (rituals, practices, and habits). 

2. Participants understand the plethora of activities (rituals and practices) to choose from that qualify as bio-psycho-social activities to help them with activity choices now and in the future. 

3. Participants will create a personalized daily habitual schedule with timelines that fits their individual likes, dislikes, and lifestyle. They will learn how to hone the document with personal experimentation and refinement. 

4. Participants will understand the meaning, value, and necessity of habits in rituals and practices. They will know how to create a habit through consistency and discipline. 

Performances of Understanding Built into the Course 

Habits are automatic responses that cue from past episodes and habits are rigid repetitions without intensions (Neal, Wood, & Jeffrey, 2006). This means that a person must practice or ritualize the episode that he/she wants to become automatic. Habits shape coping skills because they drive our choices, social processes, inform moral reasoning and then become shared among one’s social groups (Neal, Wood, & Jeffrey, 2006). A key component of this course will focus on how to make the bio-psycho-social practices and rituals habitual and fit conveniently into the students’ busy life. The students will do this by practicing their chosen rituals over and over or at least daily throughout the course. If they discover that a particular ritual is not working well in their schedule, then they continue to make changes to it until it does work. They may even have to choose another ritual that works better. The student will assess the ritual fit daily or every two days in order to understand performance. 

Ongoing Assessment as Self-Assessments. 

The challenge or gap the participants will face is changing their mindset. According to researchers Haimovitz and Dweck, some people have a fixed mindset or a belief that their talents, intelligence, and basic abilities are fixed, and some people have the opposite; a growth mindset (2017). Converting any students from a fixed mindset to a growth mindset is important in changing their coping skills (Haimovitz, & Dweck, 2017). With a growth mindset people believe through hard work, instruction from others, and good strategies that they can change their quality of life (Haimovitz, & Dweck, 2017). This course will require a weekly reflection journal. At the end of the course, a summary of the weekly journals will be required. This summary will provide an opportunity for fixed mindset students to convert into a growth mindset as they witness and reflect on their personal growth.  

Conclusion 

Healthcare work is more than just being a good technician (Kinghorn, 2010). Their role as healers is partly defined by their level of moral development and character development (Kinghorn et al., 2007; Puchalski et al., 2009). The proposed continuing education course (Bio-Psycho-Social Rituals, Practices, and Habits for Self-Care) attempts to begin “healing the healer” by providing much-needed psychological and social coping skills education to the healthcare community.  

This need, if not addressed, has epic potential to cripple our healthcare system, mentally damage the workers in it, and escalate the suffering experience of patients. This is not an exaggeration. Inadequate psychological and social skills training in healthcare providers is the strongest predictor of poor patient care (Balboni et al., 2013; Balboni et al., 2014). The epidemiology evidence presented in this paper shows that by improving a person’s psychological health and social interactions, healthcare workers and patients can change and improve their health-oriented gene expressions at a biological level. This is not only important to a person’s health but the inherited health of his/her eventual children and grandchildren. The exponential effect of birthing generations with healthy genes would have a positive health effect on America’s entire culture. 

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