Nineteen participants were recruited (Table 1) comprising: nine medical students, eight program administrators, and two clinical teachers. Four emergent themes contribute to an understanding of the development of resilience in the LIC: (1) Evidence of distress, (2) A Safe Haven, (3) Journey within and (4) Staying on course. Each theme was elucidated through subthemes

Table 1 Research participants Full size table

Evidence of distress

Participants reported that all students experienced stress and some students became distressed due to the pressure they faced during their first clinical year, providing evidence that students are required to adapt to significant challenges (adversity) in order to succeed. High stakes exams were seen as the major cause of stress, however students also highlighted their new role as novice clinicians and relocation as stressful.

Apprehension

Students reported apprehension even in anticipation of the year.

“…the myth of third year. People call it the Olympics, the worst year. You see the third years. You smell the third years by the end of it, and they just act like crazy. So I was feeling physically nauseous before the week started and I was getting irritable at home because I was visiting my parents and I said to them “I know I am uptight, I’ll be better once it starts” …Now…. I like being here.” S3_1.

Participants reflected on ethical dilemmas and human suffering they were experiencing.

Enough courage to get up every day and go in [laughs] to see what you’re going to face. I had one week where I got a bit down because I identified three people in ten days that had cancer and that was a bit shit. S3_1

Pressure to achieve

Clinical teachers reported that strategic learners put considerable pressure on themselves to achieve.

“I find the ones that we've had more trouble with have been those that have come down [to the LIC site] so focussed on getting an HD [high distinction] that everything else has just gone out the window and if something upsets the cart along the way it can be pretty stressful.” CT2

As the year progressed the end of year barrier exam was the major focus. Stress levels heightened and fatigue set in.

“…probably two weeks out from the exams …I do remember quite clearly driving home and just thinking about “if I just ran my car off the road into that tree, I wondered if it would hurt?”…I was reaching the end of my tether.S4_1

Safe Haven

Participants described how support was provided during the LIC, encouraging students to fully explore different clinical contexts. Students could return to ‘home base’ (the rural clinical school office in their PRCC region) to debrief and rejuvenate when needed. Staff described getting to know the students individually over time. With small cohorts of students forming close relationships, peer-support occurred. Students reported sharing their learning journey with peers, staff and clinicians and therefore they did not feel alone. This safe haven provided students with emotional support, guidance and a sense of belonging and was described as a foundation for the LIC learning journey.

Culture of respect

Administrators recognised the student cohorts vary in age, gender and cultural origins. The staff and clinical teachers reported actively working to establish a deep culture of mutual support, openness, equity, respect and trust with their student groups.

“You’ve got to realise that not everybody’s the same. We’ve got different cultural backgrounds, different family backgrounds …you just have to have that respect”.A7

Knowing the students

Students reported that continuity with clinical teachers and administrators provided a sense of stability. They felt well supported by administrators who came to know them individually:

“…she’s [program administrator] been somebody that’s been a constant, which has been really lovely, because I feel that she knows me….she just helps”. S3_1

Administrators provided pastoral care, and liaison between students and the academic and clinical staff. There was a strong focus by administrative staff on student physical and emotional support. They described consciously monitoring wellbeing and anticipating when students may struggle.

“we [administrative staff] always encourage the students to come to us. I feel like they have approached me on occasions when they’re anxious and where I can I’ve taken them out for coffee and discussions, given them ideas about how they may deal with it and whether it’s talking to their clinical educator, academics or family. … I guess there is some times where they’re not feeling so chipper, but it’s not visible. You can hear them laughing and you think everything’s fine and as I’ve often heard, you can hear teaching going on and heaps of laughter and then at the end when everyone’s going you’ve got one left behind crying “A5

In contrast, a few students reported some tension related to the familiar relationships they had with University staff in local sites. One student described disclosing to a clinical supervisor that s/he was struggling with isolation. The student suspected the information was passed from a clinical supervisor to the university. Students reported these blurred boundaries between informal support and formal responsibility to the university could occasionally reduce their comfort with accessing staff support.

Peer group support

The orientation program proactively provided opportunities to develop positive peer relationships which enhance group interaction throughout the year, as this student comments:

“We had not a lot of contact because we had such different friendship groups ….you kind of pull together in orientation week because you’ve all relocated from the city, so you’re in this together, so that kind of got us all talking” S3_1.

Establishing constructive peer dynamics was important for maintaining a sense of security within the group. Students reported developing a sense of team-cohesion as they studied together, supported each other and socialised.

“having everybody with a common goal and a common method of managing those problems really helps because I feel like I am part of a team…” S4_2

However, it was recognised that the stress of looming exams could undo this team-cohesion as people prioritised their own needs making trusting relationships with staff and academics vital.

“as the pressure builds towards the end of year exams cracks appear in the group and stress is amplified”.CT2

The safe haven theme represents the strong perceptions students have of assistance being available to them while they adapt to the stressors of clinical work and looming exams. These supportive resources were demonstrated to include: emotional (such as nurturing), informational, companionship, and intangible (such as personal advice).

The Journey Within

Participants identified that students developed or drew upon positive coping strategies including: being self-aware, practising self-care, optimism, help-seeking behaviour and accepting personal limitations.

Self-awareness

According to students, self-awareness was important for monitoring their own wellbeing. Some students described previous experiences with adversity and demonstrated the maturity to draw upon their life experiences. Students identified a need to seek assistance early.

“…I sent her [academic coordinator] an email going, I think I’m at the bottom bit of the dip in the graph that you showed us and I know I am there because all of these other things have just seemed way too hard, and way overwhelming” S3_3

Self-Care

Staying healthy and making time to relax when feeling stressed was reported as important. Self-care strategies described included enough sleep, eating well, avoiding alcohol and drugs, exercising, listening to music, meditating, visiting family, debriefing with peers, socialising or just getting outdoors.

“In those situations I think I just need to ride the depression out… get outside a bit more often, get a bit more sunlight, more physical activity.” S4_4

Students reported being advised to find their own doctor and being provided with access to independent counselling services. Self-care was also reported to involve self-compassion.

“… giving yourself permission to feel that way. And that it’s a period of three or four days, or whatever, over a longer period of time, where you just feel like this is all gone to wrack and ruin” S3_3

Taking time to enjoy nature and other more spiritual pursuits were described as ways to realize a more balanced life.

Optimistic attitude

Students reported ongoing, incremental learning in the clinical setting: “you’re doing it, purely through exposure”. They reported feeling more resilient when they were able to “be flexible” and “laid back’ and ‘enjoy the ride’. Participants recognised that the learning journey was challenging and “it is OK to struggle” but students were determined to succeed in their meaningful career goals.

Accepting limitations

Participants described more resilient students were able to be “realistic about what’s achievable”. One student clearly acknowledged personal limitations:

“I guess I see strength there in just about knowing my own limitations and when to ask for help too, which is I think something that people and medical students and doctors generally are not very good at is asking for help. S4_2

The theme ‘journey within’ recognises that resilience was a dynamic internal dialogue whereby students can build on their personal attributes and developed new strategies to reframe and cope with clinical experiences and exam pressures.

Staying on course

Participants reported the importance of the LICs organisational structures in providing students with educational supports. Students received coherent advice on navigating the LIC curriculum reinforced by the continuity of supervision from clinical supervisors who were invested in their success. Wellbeing sessions in stress management and self-care were included in the formal curriculum. A clear protocol was established for students to confidentially seek help and for staff and faculty to assisting students in distress.

Curriculum compass

Academics shared their perspective on their learning journey. Academic and clinical staff prepared students for the challenging times ahead and reinforced the way LIC students would experience a learning journey differently from block rotations.

“part of our O (orientation) week, we have the academic talk about those peaks and troughs [observed emotional highs and lows students experience at identified times during the LIC academic year] and how you're going to feel. But we feel that we need to expand on that” A1

Some students perceived the LIC curriculum to be unstructured in comparison to the discipline based block rotation. Clinical teachers described the students’ adjustment to an integrated curriculum as challenging until they became familiar with the learning milestones. Timetabled teaching and clinical activities reportedly provided opportunities for frequent feedback enabling students and their clinical supervisors to adjust their learning goals as needed. These structures were not initially recognised and appreciated by students as systematic.

“…we have this system where you have to pick it up over the whole 12 months and they tell you along the way "just have faith, the system works" and it does, you do get through it, but at the time it causes you so much stress …” S4_1

Expert guides

When clinical teachers and local academics were strongly engaged, their expert guidance was recognised and valued by students:

I think it’s important that you’ve got somebody [GP supervisor] who’s more experienced than you, who’s got more runs on the board than you have, where you can go to them and go, “I saw this. What should I do with it? Should I do anything with it? How should I actually approach this?”S3_3

Participants reported that clinical teachers encouraged students to participate actively in clinical environments while ensuring they were safe, and learned from mistakes.

“…You learn in an environment where you feel it is alright to make errors and mistakes and make a bit of a fool of yourself and if you are afraid of doing that, then I don’t think you learn to your best capacity …..I think by putting yourself in situations in the medical course where you are confronted by your own limitations and lack of knowledge you can learn a great deal.” S4_2

Local academics reported continually monitoring students through multisource feedback.

“I try and sit down with them or have a phone conversation periodically through the year; on just pretty much how things are going. More formally through the faculty meetings… we have a discussion about each student then – and I rely on the staff … they get a good feeling of whose not coping or whose having a lot of issues… and follow up on that.”CT1

Plans for troubled waters

Participants described the formal wellbeing program, which provided sessions on self-care early in the year and stress management activities near the end of the year as beneficial. When problems were identified, participants reported that students were assisted to get ‘back on course’ through: local counselling services, sick leave and negotiated learning plans, before instituting formal remediation.