Article Information

Ron J.M.G. Hameleers¹, A. Jasmijn Terlouw², Roland F.J.M. Laan³, Marjolein H.J. van de Pol^1*

¹Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands

²Radboudumc Health Academy, Radboud University Medical Center, Nijmegen, the Netherlands

³Scientific Director Radboudumc Health Academy, Radboud University Medical Center, Nijmegen, the Netherlands

^*Corresponding Author: Marjolein H.J. van de Pol, Director of Medical Education, Professor ‘Student wellbeing and lifelong le,’ general practitioner, coach, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands.

Received: 16 April 2024; Accepted: 25 April 2024; Published: 07 May 2024

Citation: Ron J.M.G. Hameleers, A. Jasmijn Terlouw, Roland F.J.M. Laan, Marjolein H.J. van de Pol. Developing a Longitudinal Program to Improve Medical Students' Wellbeing: A Designbased Educational Research Approach. Journal of Psychiatry and Psychiatric Disorders. 8 (2024): 111-121.

Abstract

Keywords

Student wellbeing, Design based educational research, Curriculum development, Mental health.

Article Details

1. Introduction

Scientific as well as popular media report historically high levels of mental health concerns among medical students [1, 2]. Some already suffer from burnout before even starting their professional career [3, 4]. This raises many concerns about the sustainable employability and subjective wellbeing of these future healthcare professionals, since workload is bound to increase during their professional life [5]. Stress and mental illness levels are high among medical interns, and recent surveys revealed that up to 25% of them consider cessation of their postgraduate medical specialty training for this reason [6, 7]. These mental health concerns are not limited to medical students; they are widely spread throughout the academic world [8, 9]. Many universities have recognized issues regarding students’ personal development and subjective wellbeing and invested in mental health services, tutoring and wellbeing programs [10-12]. Despite all these initiatives, psychosocial distress and mental health problems remain substantial [8, 11, 13, 14]. This might be related to the structure of programs that focus on counselling and support when distress arises, but only partly on maintaining or improving subjective wellbeing. Moreover, most programs with regard to mental health, tutoring and wellbeing are organized outside core curricula and are mostly reactive and problem-solving in nature. However, there are far fewer proactive or preventive programs that focus on coaching and improving subjective wellbeing. The lack of preventive programs implies that students who are experiencing uncomplicated academic and personal development, but could benefit from these programs as well, are overlooked [15-18]. Improving subjective wellbeing throughout the entire student population carries the additional benefit of building resilience against mental illness and improving subjective wellbeing [19]. We propose that it is of vital importance for all students to receive training in order to acquire the skills that have been shown to be of essential importance for a successful professional and personal life [19-22]. In the past few months, several authors made moving pleas to focus on developing the student as a whole, since mental health and subjective wellbeing are vital for student success, and to change university culture in this regard [9, 14]. Moreover, increasing stress levels in medical students and physicians not only undermine their subjective wellbeing but also put the quality of patient care at risk [4, 14, 23]. In contrast to the majority of academic studies, a personal–professional development program is part of most medical undergraduate curricula [24, 25]. However, these programs are often short or with low intensity [26, 27]. Several years ago, our medical faculty recognized the major wellbeing challenges among students and young graduates and called for strategies to improve student wellbeing. Therefore, we decided to develop a longitudinal program – aiming to improve student wellbeing – integrated in our medical undergraduate curriculum that is based upon self-determination theory and lifelong learning principles [28]. Research on self-determination and lifelong learning suggests that supporting personal development and psychological needs may help to protect students’ subjective wellbeing and enhance their growth as well as improve the quality of patient care [29-31]. We therefore designed this wellbeing program building on the paradigm that in order to sustainably take care of others and deliver high-quality and safe patient care, (future) health professionals should take care of their own wellbeing first. The aim of this research was to design a theory-informed program on student wellbeing allowing students to acquire skills in this regard. In this paper, we describe the iterative design process and the first results of our longitudinal program on student wellbeing.

2. Methods

2.1 Setting

This study was conducted at the Faculty of Medical Sciences of the Radboud University Nijmegen, the Netherlands and describes the design, adjustments and evaluation of our new longitudinal program on student wellbeing (WB-program).

2.2 Context and setting

Our medical faculty features a compulsory longitudinal professional development (LPD) program embedded into the core curriculum.[32] The Dutch undergraduate medical program lasts six years in total and comprises two phases of each three years, namely the Bachelor's and the Master's program. This differs from the majority of international medical programs, which span four years and are preceded by a pre-med preparatory program. Figure 1 shows a visual comparison of these curricula. The LPD program is organized in groups of eight students and one teacher-coach and covers the entirety of the three-year bachelor curriculum of medicine. Every year, each student attends six individual coach sessions with the teacher-coach and eight group meetings [32]. All bachelor of medicine students at Radboudumc participate in the LPD program (~1000 students). The WB- program is offered in the same small student groups, consisting of approximately eight students and one teacher-coach, as in the LPD program.

Figure 1: Undergraduate medical curricula

2.3 Timeline

This study took place between March 2019 and September 2021. From March 2020 onwards, the entire world faced the COVID-19 pandemic. The design of our WB-program seemed almost serendipitous in its timing. We will reflect on this in the discussion section of this paper.

2.4 Design

We used an educational design approach to construct the program in order to simultaneously develop new insights and practical solutions, which is important when designing and developing new educational programs [33]. We formed a design group consisting of a core of two physician educators and one educationalist and invited undergraduate students, young professionals, medical educators and student counselors to participate and collaborate. We implemented the four phases of educational design research as follows [33]. Phase 1, the orientation phase, consisted of a review of the literature as well as a context and needs analysis to acquire understanding of the problem, in order to draft design principles and requirements (March 2019–August 2019). Phase 2 consisted of the cyclical and iterative process of design, construction and interim evaluation and adjustments of the WB-program (September 2019–July 2020). In phase 3, evaluation and reflection, the program was implemented and evaluated (September 2020–June 2021). Phase 4 consisted of the ongoing maturation and theoretical understanding of the program (from September 2021 onwards). The different phases are closely linked and merge into one another as depicted in Figure 2, which summarizes the phases and data-collection activities. Phases 1–3 are discussed in detail in the Results section; phase 4 is discussed in the Discussion section.

Figure 2: Schematic outline of the design process

2.5 Evaluation (Phase 3)

In May 2021, at the end of academic year 2020/2021, the developed WB-program was evaluated in phase 3, using a combination of structured group discussions and an individual online survey. At the end of the final education session of the year, every student group of second- and third-year bachelor students participated in a structured group discussion, based upon several open-ended questions (Table 1) [34, 35]. Every group as a whole wrote down their collective answers in an online database (Lime survey). Next to the questions that were discussed in the group, every student filled out a personal online survey with both open- and close-ended evaluation questions (Lime survey) (Table 1). The narrative answers on the open-ended questions were independently reviewed by two authors (RH and AJT); themes emerging from these responses were identified and analyzed [36]. These themes were then discussed in the research team (RH, AJT, RL and MvdP); discrepancies were resolved by consensus discussion. Likert scales (Table 1) were used to quantify the close-ended questions.

Table 1: Outline of evaluation survey

3. Results

3.1 Phase 1: Analysis and exploration

The design process started in 2018 after alarming reports about deteriorating wellbeing and increasing stress levels among (medical) students [1, 38]. Two physician educators (RH and MvdP) with extensive experience in coaching and mentoring and an educationalist (AJT), who is also a student counselor, formed the design group. The design group started the project with exploring the problem through discussions with students, student counselors and teachers (initial orientation).

These informal discussions took place during regular drop-in hours, coffee breaks with students, and after educational evaluations and regular faculty meetings. These first discussions led to a broad problem definition and background questions: What are effective solutions and preventive measures to reduce mental illness and incorporate the promotion of wellbeing? How can we educate students in this regard?

In order to answer these questions, the design group held interviews with stakeholders (see Appendix A) and subsequently studied written reports about student wellbeing in the Netherlands (initial context analysis). Based upon these, the design group conducted a narrative literature review that served as a starting point for the in-depth stakeholder interviews and the definition of the design requirements (context and needs analysis). Appendix A provides a more detailed step-by-step overview of the narrative review process. Based upon the literature review, the design team concluded that brief positive psychology interventions can enhance subjective wellbeing; however, most effects last only a short time and most studies had small sample sizes [39-42]. The need to invest in student wellbeing has been assimilated, over the past decade, by the health sciences; most investments are brief or positioned outside the core curricula [19, 27]. Providing an effective learning environment for the improvement of subjective wellbeing asks for transformative educational approaches [27, 43-45]. Results of the narrative review were discussed with stakeholders, which led to the following problem definition: Can we improve subjective wellbeing of medical students with an educational program? And how can we do that? The corresponding generated design requirements are depicted in Table 2. This resulted in the following design proposition: ‘To design a longitudinal preventive and proactive wellbeing program for students, in order to improve their subjective wellbeing.’

Table 2: Design requirements for the first cycle of design and development of a wellbeing program

3.2 Phase 2: Design and construction

The development team consisted of the design group (RH, AJT and MvdP) regularly consulting students, teacher colleagues, clinician colleagues and student counselors to test ideas, teaching methods and the program outline.

First design cycle: In September 2019, we piloted the first few educational components and outlineof the program for first- and second-year bachelor students. The first design cycle comprised self- study assignments with additional literature, brief web lectures and accompanying group sessions. The program was developed as a ‘buffet,’ inviting students to mix and match modules to their own liking. Lessons were divided into themes and placed on our digital learning environment platform (Brightspace). Prior to a coach-group session, the student group collectively selected a lesson of their choice from the WB-program website and prepared the group session. In every coach-group session from the LPD program, 30–60 minutes were reserved for the lesson from the WB-program. Every teacher-coach undergoes training in coaching and mentoring skills, with regular participation in training sessions and peer evaluations throughout the year. As part of the design-cycle, a general teacher meeting was organized for teacher-coaches to prepare them for the innovative teaching methods of the WB-program. Additionally, a comprehensive teacher manual was created for each component of the WB-program. During the first quarter (September 2019–December 2019), the design group regularly contacted groups of students and their teacher-coaches to discuss the experiences with the WB-program. Students as well as teacher-coaches appreciated the themes of the WB-program and reported needing more guidance to achieve the learning objectives. The purpose of design cycles and testing is to reinforce and validate principles for the design. After the first testing, we added more educational instruction for both students and teacher-coaches. At the end of the first semester (February 2020), we ran a short online survey to ask all participating students what they learned from and missed in the WB-program. Overall, students stated that the key learning experience of the new WB-program was the realization of the importance of taking care of their own wellbeing. There was much appreciation for the topics, and students asked for more practical tools. As one student described it very aptly in the online survey: “How can I improve or maintain my subjective wellbeing on a daily basis, please provide some tools or tips and tricks.” One of the important learning points from testing and adjusting the interim evaluation was the validation of the design requirements. However, the WB-program needed further development: the outline of the WB-program on the digital learning platform needed refinement, and not all lessons were intuitive enough and required practical tools to help students implement taking care of their wellbeing.

Second design cycle: Upon the results of the short online survey and informal discussions with colleagues and student counselors, great effort was invested in creating more interactivity and practicality in the lessons. The adjusted WB-program was implemented during the second semester. At the end of that semester (July 2020), 14 students volunteered to participate in an individual interview with the design group, invited by their teacher-coaches. The interviews confirmed the earlier findings that students highly appreciate the content of the WB- program. During the lessons, students start to conceptualize the elements of their individual wellbeing and develop a vocabulary in this regard. Several students expressed their desire for more exercises stimulating in-depth discussions about wellbeing with their fellow students, because this stimulates normalizing the need for consideration about wellbeing. As one student stated: “In one of the lessons, I discovered that my fellow students have the same uncertainties as I have.” While students appreciated the WB-program in general, they preferred a longitudinal design with mandatory topics as opposed to the current mix-and-match cafeteria model (‘buffet’). One student described it as follows: “There are so many lessons and topics to choose from; how do I know what will teach me the most valuable lessons…?” All students would prefer a longitudinal program with a gradual build-up of the topics and still more practical assignments, starting with the ‘lighter’ topics and working their way up toward interpersonal development with regard to wellbeing. One student stated: “If I can choose, I tend to avoid heavy topics even though I learn the most from them.” Some topics needed additional repetition and elaboration with regard to integration of the WB-program with the LPD program. New topics that emerged from the individual interviews were ‘reloading and rest’, as well as ‘transition stress’ (from high school to university).

Third design cycle: Based upon the individual interviews, we restructured the existing content of our WB-program from a ‘buffet’ to a program with a step-by-step structure in order to guide students in their development. We integrated and connected the WB-program with the structure and the gradual build-up of the LPD program. The outline of the final WB-program is depicted in Table 3. Typically, students prepare by studying background materials and watching a concise web lecture or e-learning module. Within group sessions, we delve further into the subject through a blend of experiential learning, hands-on exercises (including mindfulness activities, time management games, language exercises, etc.), and in-depth discussions. Our teacher-coaches receive training in identifying issues among students. Given that our WB-program covers topics that can be challenging for students, particularly those with pre-existing mental health concerns, we have placed special emphasis on this aspect in the teacher manuals. In addition, we rescheduled the layout of our digital learning environment platform (Brightspace) to both visualize the main themes of the program and provide guidance in counselling and referral possibilities (Figure 3). The result of our iterative design and construction process was a longitudinal WB-program for all bachelor of medicine students that is embedded in the curriculum and its LPD program.

Figure 3: Thematic layout of the WB-program

Table 3: Designed wellbeing program in relation to the professional development program

3.3 Phase 3: Evaluation and reflection

As of September 2020, the WB-program has been implemented in all three years of our bachelor of medicine curriculum (Table 3 and Figure 2). In May 2021, at the end of academic year 2020/2021 all student coach-groups of bachelor years 2 and 3 participated in the structured group discussion (80 coach-groups of eight; 640 students in total). 74% of these students (476 students: 231 second-year students and 245 third-year students) also filled out the individual online questionnaire.

3.4 Analysis of the structured group discussions

Analysis of the Likert-scale questions: Over 82% of the student coach-groups (score ≥4 on a 5-point scale) report discussing their subjective wellbeing always with their teacher-coach during their individual meetings. The topics of the WB-program are considered useful or very useful for their personal development by 81% (score ≥4 on 6-point scale). When queried about the teaching methods of the WB course, 62% (score ≥4 on 6-point scale) found them appealing. The balance in the course could be improved. About 63% thought the amount of attention paid to wellbeing in the program is exactly right (score 3 on a 5-point scale), 15% thought there was too little attention (score 1 on a 5-point scale) and 22% considered it too much (score 5 on a 5-point scale).

Analysis of the narrative group answers: The structured group discussions were centered around three open-ended questions (see Table 1). Several themes emerged as positive elements of the WB- program. The most important and most frequent mentioned was the mere fact that wellbeing is on the agenda. One student coach-group summed it up with: “It is very instructive to make wellbeing a priority in education as well. Through discussions with other students, we personally grow, and we realize that we are not alone. We are often in the same boat and can learn from each other.” Other important positive themes that emerged from the group answers were: ‘many topics to choose from’ and ‘a variety of assignments and lesson types.’ One coach-group stated: “Some lessons don’t seem interesting at a first glance, but because we discuss them in the group, we always learn something from them.”

On the negative side, some student groups would prefer more interaction in the lessons, and they missed long-term goals or learning objectives. One coach-group wrote: “It would help if we were stimulated to define long-term goals with regard to our personal wellbeing and that necessary topics are repeated.”

The content of the program is based on scientific evidence about the specific topics. Some student groups valued discussion about the scientific background, while other groups preferred the more practical lessons.

When asked, ‘what did you learn from the program?,’ all coach-groups responded that they learned how important self-care and wellbeing are and received practical and scientific based tools to maintain and improve subjective wellbeing. One of the coach-groups gave the following answer: “The combination of studying wellbeing literature with practical assignments on the topic really inspired us to pay more attention to self-care.” Moreover, the coach-groups appreciated that the WB-program is taught in the same student coach-group as the professional development (LPD) program, which guaranteed a well-known and trusted group environment enabling informative discussions. The program stimulates an environment that is open to discussing mental health issues and guides students who need professional help in a stepwise approach toward professional healthcare.

3.5 Analysis of responses of individual questionnaire

Analysis of the narrative individual answers: In the individual open-ended questions, students gave us useful insights in how they could apply the learning objectives of the WB-program into their lives. About half of the students responded that they initially found it difficult to name behavioral changes with regard to their wellbeing. However, many students mentioned in their narrative responses that the fact that attention is paid to wellbeing made them somehow feel better. Students who were able to define behavioral changes mentioned ‘practicing gratitude,’ ‘eating healthier,’ ‘following a stricter sleep regime,’ ‘being able to discuss my feelings with others’ and ‘reframing stress.’ One student wrote: “I feel more reflective now and am able to deal with stress in a different way. A bit of pressure helps me to perform better, too much stress asks for a period of rest.”

The importance of discussing topics related to wellbeing became evident from both the group and individual answers.

4. Discussion

With our educational design-based approach to construct a wellbeing program, we were able to design, construct and evaluate an evidence-informed longitudinal proactive wellbeing program for all bachelor of medicine students at our faculty. This study makes an important contribution to the development of longitudinal integrated wellbeing programs. To our knowledge, this is the first study to develop and evaluate the effects of a longitudinal course on subjective wellbeing that is fully integrated in the bachelor of medicine curriculum. Working through iterative cycles of design and interim evaluation offered new theoretical and empirical knowledge on what elements in education can improve student wellbeing. Previous research has established that wellbeing can be taught and can exert small increases in subjective wellbeing [22, 40, 46]. Our results suggest that integrating a longitudinal and proactive WB- program into the bachelor curriculum enables students to actively change their behavior with regard to maintaining and improving their subjective wellbeing. A systematic review by Wasson et al. showed that there is limited evidence that learning environment interventions can improve medical student wellbeing [27]. However, most studies in that review were focused on supporting students with mental health issues instead of coaching mentally healthy students toward sustainable wellbeing.

A study by Greeson et al. found reduced stress and anxiety, better mood and higher distress tolerance after a short four-week workshop program [47]. Against this background, our program is longitudinal during the entirety of our three-year bachelor curriculum and includes a combination of practical and theoretical lessons. Therefore, we expect the program to have a lasting effect on the subjective wellbeing of our students, especially since the majority of students were able to make behavioral changes. A recent study by Dewa et al. – integrating a seven-lesson mental wellbeing course in the graduate plant biology program – showed behavioral changes with regard to positive wellbeing in their students as well [48]. Acquiring practical skills and making behavioral changes positively influences wellbeing and may also stimulate an attitude of lifelong learning that is necessary for every medical professional [29, 49].

Strengths and limitations

Our study has several important limitations. First, the program is developed based upon a needs analysis of a narrative review, not a systematic one. It is therefore possible that we missed publications about student wellbeing that could have deepened our understanding of the topic. However, we used the literature review as a basis for discussions with a broad panel of stakeholders with extensive experience in the field of wellbeing, which was part of our iterative process and enabled us to define design requirements for our WB-program. Before future adjustments of our program, we will expand our literature review. A second limitation concerns the fact that the first evaluation of the WB-program is evaluated by second- and third-year students. Due to logistics in the end-of-year program, the first-year students were not able to participate in the panel discussions. Fortunately, first-year students did participate in the interim evaluations. Moreover, the second- and third-year students who participated in the evaluation did participate in the first-year program in academic year 2019–2020. In our ongoing further development in the future, we will include first- year students’ evaluations as well. A third limitation concerns the unavailability of long-term evaluations of the WB-program. Our evaluation results indicate behavioral changes in students, which instills confidence regarding the long-term outlook [39, 50]. Phase 1 and the start of phase 2 of the design of the WB-program took place before the COVID-19 pandemic. Further iterative design, implementation and evaluation occurred largely during the COVID-19 pandemic, which might have influenced our findings, since the mental health of society at large was under pressure due to all COVID-measures [51, 52]. We consider it positive that we were able to support students in actively change their behavior toward maintaining subjective wellbeing during these challenging times regarding the COVID-pandemic. It is possible that the subject of our program gained momentum due to the heightened demand for it during these challenging times. Attendance at coach-group meetings and participation in the WB program are compulsory, and this requirement might have influenced the outcomes of our design. However, previous evaluations of our LPD-program, of which the WB-program is part, have shown that students value the mandatory aspect as it assists them in addressing challenging subjects [32]. Should a particular topic provoke significant discomfort, individual students always have the option to hold back somewhat in group meetings. In such cases, the teacher-coach can address this matter during follow-up one-on-one conversations with the student. If there are significant mental health concerns, the student can be referred to the appropriate resources (see Figure 3). Our study has several strengths as well. First, we used a systematic educational design base, which is suitable for developing innovative educational programs [33]. Second, we involved a large interdisciplinary group of stakeholders, including many students, and we adjusted the program to emerging insights. A third strength is the fact that our WB-program normalizes talking about wellbeing and mental health, which empowers students in this regard. And fourth, the WB-program is fully embedded in our bachelor of curriculum, which emphasizes the importance of wellbeing and self-care.

Phase 4: Ongoing maturation and theoretical understanding of the program

The most noteworthy result from our WB-program thus far is that students who are exposed to a longitudinal program with recurring focus on improving and maintaining wellbeing learn to value the importance of self-care and wellbeing and develop skills in this regard. We consider the results of this educational design-based development of our WB-program as a proof of concept for a longitudinal integrated program. We would like to share the chief lessons we learned during the research, design and evaluation process. Firstly, involving students in all phases of the process enables the alignment the program to their needs. Different students have different needs with regard to maintaining and improving their wellbeing. In the ongoing maturation, we therefore aim to further develop the WB-program with both students and experts from different fields of wellbeing research. Currently we are also expanding the WB-program to our master’s curriculum to further ensure persistent behavioral changes. Secondly, students considered that a safe environment is important to discuss their wellbeing concerns with peers. We think that the already existing student coach-groups contributed to the positive results and advise curriculum designers to take this into account when designing a program. Thirdly, further research is necessary to deepen our understanding of the active elements and to help us to improve the WB-program. Moreover, we need to further investigate how to support lifelong learning with regard to maintaining subjective wellbeing after graduation, when other challenging factors such as work culture, workload and work–life balance put subjective wellbeing under pressure [4, 23, 29].

5. Conclusion

We developed a longitudinal proactive WB-program for bachelor of medicine students that contributes to positive behavior changes with regard to subjective wellbeing. Taken together, our study suggests that it is possible to integrate wellbeing in a core undergraduate curriculum on a large scale.

Declarations

Ethical approval and consent to participate

The research participants are not subjected to acts that are subject to the Medical Research Involving Human Subjects Act (WMO). On this basis, the Central Medical Ethical board region Arnhem-Nijmegen the Netherlands (CMO) declares that the research does not fall under the remits of the WMO (Dossier number: CMO-020-6518). Subsequently the research protocol was approved by the Research Board of the faculty of Medicine Nijmegen the Netherlands (Dossier number COMOS-4550714-4566939). All participating students and teacher/coaches gave written informed consent, which is faculty policy for all research conducted at our medical faculty in which people participate.

Consent to publish

All data are anonymized, no identifying information is present (consent identifying information: not applicable).

Research code of conduct

The research is conducted in accordance with the Declaration of Helsinki and the Netherlands Code of Conduct for Research Integrity (Netherlands Code of Conduct for Research Integrity | NWO).

Availability of data and materials

Alle underlying data that are available upon request from the corresponding author

Funding

No funding

Conflicts of interest

None

Author contribution

Ron Hameleers and Marjolein van de Pol designed the study, Jasmijn Terlouw and Roland Laan were part of the research group discussing the design. Ron Hameleers, Jasmijn Terlouw and Marjolein van de Pol acquired and transcribed the data. Analyses were discussed in the whole research team. Ron Hameleers and Marjolein van de Pol drafted the article. Jasmijn Terlouw and Roland Laan improved the figures upon discussion. All authors reviewed the manuscript and agreed on the content.

Acknowledgements

None

Availability

This paper is posted as a preprint [37].

References

1. Rothenberger DA. Physician Burnout and Well-Being: A Systematic Review and Framework for Action. Dis Colon Rectum 60 (2017): 567-576.
2. Dopmeijer JM. Running on empty: The impact of challenging student life on wellbeing and academic performance (2021).
3. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ 50 (2016): 132-149.
4. Dewa CS, Loong D, Bonato S, et al. The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. BMC medical education 17 (2017): 195.
5. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 283 (2018): 516-529.
6. Kleijne I. Kwart aiossen overweegt te stoppen met opleiding. Medisch Contact (2020).
7. Bustraan J, Dijkhuizen K, Velthuis S, et al. Why do trainees leave hospital-based specialty training? A nationwide survey study investigating factors involved in attrition and subsequent career choices in the Netherlands. BMJ Open 9 (2019): e028631.
8. Jacobsen B, Norup I. Young people's mental health: Exploring the gap between expectation and experience. Educ Res-Uk 62 (2020): 249-265.
9. Leshner AI. Target student mental well-being. Science 371 (2021): 325-325.
10. Stallman HM. Embedding resilience within the tertiary curriculum: a feasibility study. High Educ Res Dev 30 (2011): 121-133.
11. Baik C, Larcombe W, Brooker A. How universities can enhance student mental wellbeing: the student perspective. High Educ Res Dev 38 (2019): 674-687.
12. Gander F, Proyer RT, Ruch W. Positive Psychology Interventions Addressing Pleasure, Engagement, Meaning, Positive Relationships, and Accomplishment Increase Well-Being and Ameliorate Depressive Symptoms: A Randomized, Placebo-Controlled Online Study. Front Psychol 7 (2016): 686.
13. Park SY, Andalibi N, Zou Y, et al. Understanding Students' Mental Well- Being Challenges on a University Campus: Interview Study. JMIR Form Res 4 (2020): e15962.
14. Veal CT. We Burn Out, We Break, We Die: Medical Schools Must Change Their Culture to Preserve Medical Student Mental Health. Academic Medicine 96 (2021): 629-631.
15. AMY L. EVA How colleges today are supporting student mental health (2019).
16. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry 10 (2010): 113.
17. Vogan CL, McKimm J, Da Silva AL, et al. Twelve tips for providing effective student support in undergraduate medical education. Med Teach 36 (2014): 480-485.
18. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 388 (2016): 2272-2281.
19. Tempski P, Santos IS, Mayer FB, et al. Relationship among Medical Student Resilience, Educational Environment and Quality of Life. Plos One 10 (2015): e0131535.
20. Diener E, Chan MY. Happy People Live Longer: Subjective Well-Being Contributes to Health and Longevity. Appl Psychol-Hlth We 3 (2011): 1-43.
21. Covey SR. The seven habits of highly effective people. Natl Med Leg J 2 (1991): 8.
22. Yaden DB, Claydon J, Bathgate M, et al. Teaching well-being at scale: An intervention study. Plos One 16 (2021): e0249193.
23. Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin Proc 93 (2018): 1571-1580.
24. Better standards, better physicians, better care.
25. Medical training framework (2020).
26. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med 89 (2014): 573-577.
27. Wasson LT, Cusmano A, Meli L, et al. Association Between Learning Environment Interventions and Medical Student Well- being: A Systematic Review. JAMA 316 (2016): 2237-2252.
28. ten Cate TJ, Kusurkar RA, Williams GC. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE Guide No. 59. Med Teach 33 (2011): 961-973.
29. Babenko O, Daniels LM, Ross S, et al. Medical student well-being and lifelong learning: A motivational perspective. Educ Health (Abingdon) 32 (2019): 25-32.
30. Tjin ATS, de Boer A, Croiset G, et al. How basic psychological needs and motivation affect vitality and lifelong learning adaptability of pharmacists: a structural equation model. Adv Health Sci Educ Theory Pract 23 (2018): 549- 566.
31. van der Burgt SME, Nauta K, Croiset G, et a. A qualitative study on factors influencing the situational and contextual motivation of medical specialists. Int J Med Educ 11 (2020): 111-119.
32. Ede A, Gorgels W, Reuzel R, et al. Professionalism to connect the student with the curriculum and healthcare society. In: AMEE-2019. Austria (2019): 1147.
33. McKenney S, Reeves TC. Educational design research: Portraying, conducting, and enhancing productive scholarship. Med Educ 55 (2021): 82-92.
34. Cook DA. Twelve tips for evaluating educational programs. Med Teach 32 (2010): 296-301.
35. Edmunds S, Brown G. Effective small group learning: AMEE Guide No. 48. Med Teach 32 (2010): 715-726.
36. MB Miles AH. Qualitative data analysis: An expanded sourcebook: Sage (1994).
37. J.M.G. Hameleers, A.J. Terlouw, R.F.J.M. Laan, et al. Investing in student wellbeing: A design-based educational research approach to develop a longitudinal proactive program to improve wellbeing of medical students (2022).
38. Aggie van Huisseling, Danique Keiman, Nina van Liere, et al. Welzijn onder studenten: Radboud Cares. Radboud university (2018).
39. Lyubomirsky S, Sheldon KM, Schkade D. Pursuing happiness: The architecture of sustainable change. Rev Gen Psychol 9 (2005): 111-131.
40. White CA, Uttl B, Holder MD. Meta-analyses of positive psychology interventions: The effects are much smaller than previously reported. Plos One 14 (2019).
41. Seligman MEP, Steen TA, Park N, et al. Positive psychology progress - Empirical validation of interventions. American Psychologist 60 (2005): 410-421.
42. Bolier L, Haverman M, Westerhof GJ, et al. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 13 (2013).
43. Tempski P, Martins MA, Paro HBMS. Teaching and learning resilience: a new agenda in medical education. Med Educ 46 (2012): 345-346.
44. Calo M, Peiris C, Chipchase L, et al. Grit, resilience and mindset in health students. Clin Teach 16 (2019): 317-322.
45. Cook DA, Artino AR, Jr. Motivation to learn: an overview of contemporary theories. Med Educ 50 (2016): 997-1014.
46. Sin NL, Lyubomirsky S. Enhancing Well-Being and Alleviating Depressive Symptoms With Positive Psychology Interventions: A Practice-Friendly Meta-Analysis. Journal of Clinical Psychology 65 (2009): 467-487.
47. Greeson JM, Toohey MJ, Pearce MJ. An adapted, four-week mind-body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care. Explore (NY) 11 (2015): 186-192.
48. Dewa CS, Nieuwenhuijsen K, Holmes-Sullivan KJ, et al. Introducing plant biology graduate students to a culture of mental well-being. Plant Direct 4 (2020): e00211.
49. Deci EL, Ryan RM. Facilitating Optimal Motivation and Psychological Well-Being Across Life's Domains. Can Psychol 49 (2008): 14-23.
50. Kahneman D. Thinking, Fast and Slow. Fortune 172 (2015): 20-20.
51. Zhai Y, Du X. Addressing collegiate mental health amid COVID-19 pandemic. Psychiatry Res 288 (2020): 113003.
52. Hossain MM, Tasnim S, Sultana A, Faizah F, et al. Epidemiology of mental health problems in COVID-19: a review. F1000Res 9 (2020): 636.

Appendix A. Exploration phase – Analyzing the problem

Initial orientation

Background problem and questions

The student population is facing historically high levels of mental illness. What are effective solutions and preventive measures to reduce mental illness and incorporate the promotion of wellbeing? How can we educate students in this regard?

Stakeholders

1. At our university: Students and young professionals, educators, clinicians, student counselors, psychologists, pastors and researchers in the field of (student)
2. At a national level: platform studentenwelzijn (student wellbeing platform) – educators and student

Initial context analysis

Discussions and interviews with stakeholders: During regular education evaluation meetings (groups of students and groups of teachers) the design team discussed the background problem and questions. Moreover, the design team held interviews with student counselors and teacher-coaches. Themes that emerged: Subjective wellbeing, pressure, stress/distress, burnout, resilience, positive psychology, (self-)reflection, lifelong learning, time management, vitality, student success, happiness versus depression, adolescence and emerging adulthood problems, meaningful life, reduce stress, social media stress and social comparison, relationships, self-determination, self-care, leadership, empowerment, enthusiasm/inspiration versus doubt, self-criticism, cynicism and emotional exhaustion, grit, compassion.

Written reports and platforms from stakeholder groups:

1. Actieplan Studenten Welzijn (action plan on student wellbeing): https://www.ecio.nl/wp- content/uploads/sites/2/2020/10/Actieplan-Partnership-Studentenwelzijnversie-def.pdf
2. Project plan to improve student wellbeing: https://www.radboudnet.nl/nieuws- activiteiten/actuele-projecten/studentbegeleiding-2023/t4-studentenwelzijn/
3. Student wellbeing plan: https://www.inholland.nl/media/16741/onderzoeksagenda- onderzoekslijn-studentenwelzijn-v10.pdf
4. Dutch student wellbeing platform: https://ecio.nl/landelijke-werkgroep-studentenwelzijn/
5. Dutch Association for Medical Education (Nederlandse Vereniging voor Medisch Onderwijs). Working group wellbeing of (future) healthcare professionals : https://www.nvmo.nl/index.php?page=76

Discussions led to three central questions

1. What defines subjective wellbeing? (And on the negative side: What causes pressure among students? What causes stress/distress? When do students experience burnout?)
2. What are the challenges and supportive strategies with regard to wellbeing, and how to improve resilience?
3. How can we support students in their personal and professional development? (Academic studies in general and medicine in particular place high demands on students. Self- regulation, self-determination [including lifelong learning] and self-care play an important role in both professional and personal development of )

Literature review

Narrative literature review

We performed a narrative review using a topical approach to search for pivotal information on the topic of student wellbeing and educating wellbeing. To familiarize ourselves with the topic of student wellbeing, we started with a broad Google search on student wellbeing in higher education. Based upon this initial broad search, we searched Web of Science, PubMed and Google Scholar for articles about ‘student wellbeing,’ ‘wellbeing interventions’ and ‘education.’ Additional records were identified by scanning the reference lists of relevant studies and reviews published until June 2019. Furthermore, we searched for gray literature (i.e., government documents, university websites and business and industry materials on the topic of wellbeing) and performed background reading in popular scientific books of authors who also published about wellbeing.

Resulting in:

1. Key articles on student wellbeing
2. University platforms and courses on wellbeing and mental health
3. Background information from popular scientific books

1. Key articles on student wellbeing

1. Akinla O, Hagan P, Atiomo W. A systematic review of the literature describing the outcomes of near-peer mentoring programs for first year medical students. BMC Med Educ. 2018;18(1):98. doi: 10.1186/s12909-018-1195-1. Erratum in: BMC Med Educ. 2018;18(1):167. PMID: 29739376; PMCID: PMC5941612.
2. Alborzkouh P, Nabati M, Zainali M, Abed Y, Shahgholy Ghahfarokhi F. A review of the effectiveness of stress management skills training on academic vitality and psychological well-being of college students. J Med Life. 2015;8(Spec Iss 4):39-44. PMID: 28316704; PMCID: PMC5319270.
3. In my experience: how educators can support a medical student with mental illness. Acad Med. 2019;94(11):1638-1639. doi: 10.1097/ACM.0000000000002953. PMID: 31425192.
4. Atkinson PA, Martin CR, Rankin J. Resilience revisited. J Psychiatr Ment Health Nurs. 2009;16(2):137-145. PMID:19281544.
5. Bakker AB, Demerouti E. The job demands-resources model: state of the art. J Manag Psychol. 2007;22:309-328
6. Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77:911-917. PMID:12228090.
7. Balogun JA, Pellegrini EA, Miller TM, Katz JS. Pattern of physical therapist students' burnout within an academic J Phys Ther Educ. 1999;13(1):12.
8. Bird JM, Markle RS. Subjective well-being in school environments: promoting positive youth development through evidence-based assessment and intervention. Am J Orthopsychiatry. 2012;82(1):61-6. doi: 1111/j.1939-0025.2011.01127.x. PMID: 22239394.
9. Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health. 2013;13(1):119. PMID:23390882.
10. Boot CRL, Vonk P, Meijman FJ. Health-related profiles of study delay in university students in the Int J Adolesc Med Health. 2007;19(4);413-423.
11. Butler J, Kern ML. The PERMA-Profiler: a brief multidimensional measure of flourishing. Int J Wellbeing. 2016;6(3).
12. Calo M, Peiris C, Chipchase L, Blackstock F, Judd B., Grit, resilience and mindset in health Clin Teach. 2019;16(4):317-322. doi: 10.1111/tct.13056. PMID: 31397107.
13. Centre for Education Statistics and Evaluation. Student Wellbeing. Literature review. NSW Department of Education and Communities;
14. Cho E, Jeon S. The role of empathy and psychological need satisfaction in pharmacy students' burnout and well-being. BMC Med Educ. 2019;19(1):43. doi: 10.1186/s12909-019-1477-2. PMID: 30717723; PMCID:
15. Cohen T, Legg J. Emotional well-being and stress among radiologic science students. Radiol Technol. 2019;90(5):450-458. PMID:
16. Conijn M, Boefsma HJMV, van Rhenen W. Burn-out bij Nederlandse geneeskundestudenten. Prevalentie en oorzaken [Burnout in Dutch medical students. Prevalence and causes]. Ned Tijdschr Geneesk. 2015;159:A8255.
17. Davies EB, Morriss R, Glazebrook C. Computer-delivered and web-based interventions to improve depression, anxiety, and psychological well-being of university students: a systematic review and meta-analysis. J Med Internet Res. 2014;16(5):e130. doi: 2196/jmir.3142. PMID: 24836465; PMCID: PMC4051748.
18. Dawson AF, Brown WW, Anderson J, et al. Mindfulness-based interventions for university students: a systematic review and meta-analysis of randomised controlled trials. Appl Psychol Health Well Being. 2020;12(2):384-410. doi: 10.1111/aphw.12188. Epub 2019 Nov 19. PMID:
19. Demerouti E, Bakker AB, de Jonge J, Janssen PPM, Schaufeli WB. Burnout and engagement at work as a function of demands and Scand J Work Environ Health. 2001;27:279-286.
20. Dewa CS, Loong D, Bonato S, Trojanowski L, Rea M. The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. BMC Med Educ. 2017;17(1):195. doi: 10.1186/s12909-017-1040-y. PMID: 29121895; PMCID: PMC5680598.
21. Diener Subjective well-being. Psychol Bull. 1984;95(3):542. PMID:6399758.
22. Divaris K, Barlow PJ, Chendea SA, et al. The academic environment: the students' Eur J Dent Educ. 2008;12(Suppl 1):120-130. doi: 10.1111/j.1600- 0579.2007.00494.x. PMID: 18289275.
23. Dodge R, Daly A, Huyton J, Sanders L. The challenge of defining wellbeing. Int J Wellbeing. 2012;2(3):222-235.
24. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 2008;32(1):44-53. PMID:18270280.
25. DuPont-Reyes MJ, Villatoro AP. The role of school race/ethnic composition in mental health outcomes: a systematic literature review. J Adolesc. 2019;74:71-82. doi: 1016/j.adolescence.2019.05.006. Epub 2019 Jun 3. PMID: 31170600; PMCID: PMC7081453.
26. Durkin M, Gurbutt R, Carson J. Qualities, teaching, and measurement of compassion in nursing: a systematic review. Nurse Educ Today. 2018;63:50-58. doi: 1016/j.nedt.2018.01.025. Epub 2018 Jan 31. PMID: 29407260.
27. Dvoráková K, Kishida M, Li J, et al. Promoting healthy transition to college through mindfulness training with first-year college students: pilot randomized controlled trial. J Am Coll Health. 2017;65(4):259-267. doi: 10.1080/07448481.2017.1278605. Epub 2017 Jan 11. PMID: 28076182; PMCID:
28. Dyrbye LN, Power DV, Massie FS, et al. Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students. Med Educ. 2010;44(10):1016-1026. PMID:20880371.
29. Elani HW, Allison PJ, Kumar RA, Mancini L, Lambrou A, Bedos C. A systematic review of stress in dental J Dent Educ. 2014;78(2):226-242. PMID: 24489030.
30. Farkas AH, Allenbaugh J, Bonifacino E, Turner R, Corbelli JA. Mentorship of US medical students: a systematic review. J Gen Intern Med. 2019;34(11):2602-2609. doi: 1007/s11606-019-05256-4. Epub 2019 Sep 4. PMID: 31485967; PMCID: PMC6848625.
31. Fenwick-Smith A, Dahlberg EE, Thompson SC. Systematic review of resilience-enhancing, universal, primary school-based mental health promotion programs. BMC Psychol. 2018;6(1):30. doi: 1186/s40359-018-0242-3. PMID: 29976252; PMCID: PMC6034212.
32. Fernandez A, Howse E, Rubio-Valera M, et al. Setting-based interventions to promote mental health at the university: a systematic review. Int J Public Health. 2016;61(7):797-807. doi: 1007/s00038-016-0846-4. Epub 2016 Jun 30. PMID: 27364779.
33. Finkelstein C, Brownstein A, Scott C, Lan YL. Anxiety and stress reduction in medical education: an Med Educ. 2007;41(3):258-264. PMID:17316210.
34. Frei E, Stamm M, Buddeberg-Fischer B. Mentoring programs for medical students – a review of the PubMed literature 2000-2008. BMC Med Educ. 2010;10:32. doi: 10.1186/1472-6920- 10-32. PMID: 20433727; PMCID:
35. García-Carrión R, Villarejo-Carballido B, Villardón-Gallego L. Children and adolescents mental health: a systematic review of interaction-based interventions in schools and communities. Front Psychol. 2019;10:918. doi: 10.3389/fpsyg.2019.00918. PMID: 31068881; PMCID:
36. Ghanbari S, Haghani F, Akbarfahimi M. Practical points for brain-friendly medical and health sciences teaching. J Educ Health Promot. 2019;8:198. doi: 10.4103/jehp.jehp_135_19. PMID: 31807589; PMCID:
37. Gillham JE, Hamilton J, Freres DR, Patton K, Gallop R. Preventing depression among early adolescents in the primary care setting: a randomized controlled study of the Penn Resiliency J Abnorm Child Psychol. 2006;34(2):195-211. PMID:16741684.
38. Grace TW. Health problems of college students. J Am Coll Health. 1997;45(6):243-250. doi: 1080/07448481.1997.9936894. PMID: 9164054.
39. Greeson JM, Toohey MJ, Pearce MJ. An adapted, four-week mind-body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care. Explore (NY). 2015;11(3):186-92. doi: 10.1016/j.explore.2015.02.003. Epub 2015 Feb 16. PMID:
40. Haglund ME, aan het Rot M, Cooper NS, et al. Resilience in the third year of medical school: a prospective study of the associations between stressful events occurring during clinical rotations and student well-being. Acad Med. 2009;84(2):258-268. PMID:19174682.
41. Hale AJ, Ricotta DN, Freed J, Smith CC, Huang GC. Adapting Maslow’s hierarchy of needs as a framework for resident wellness. Teach Learn Med. 2019;31(1):109-118. doi: 1080/10401334.2018.1456928. Epub 2018 Apr 30. PMID: 29708437.
42. Hardy SA, Francis SW, Zamboanga BL, Kim SY, Anderson SG, Forthun LF. The roles of identity formation and moral identity in college student mental health, health-risk behaviors, and psychological well-being. J Clin Psychol. 2013;69(4):364-382. doi: 10.1002/jclp.21913. Epub 2012 Oct PMID: 23044630; PMCID: PMC7871525.
43. Harrad R, Cosentino C, Keasley R, Sulla F. Spiritual care in nursing: an overview of the measures used to assess spiritual care provision and related factors amongst nurses. Acta Biomed. 2019;90(4-S):44-55. doi: 10.23750/abm.v90i4-S.8300. PMID: 30977748; PMCID:
44. Harrer M, Adam SH, Baumeister H, et al.. Internet interventions for mental health in university students: a systematic review and meta-analysis. Int J Methods Psychiatr Res. 2019;28(2):e1759. doi: 1002/mpr.1759. Epub 2018 Dec 26. PMID: 30585363; PMCID: PMC6877279.
45. Haynes NM. Addressing students’ social and emotional needs: the role of mental health teams in schools. J Health Soc Policy. 2002;16(1-2):109-123. doi: 10.1300/j045v16n01_10. PMID:
46. Hodder RK, Freund M, Bowman J, et al. A cluster randomised trial of a school-based resilience intervention to decrease tobacco, alcohol and illicit drug use in secondary school students: study protocol. BMC Public Health. 2012;12:1009. doi: 10.1186/1471-2458-12- PMID: 23171383; PMCID: PMC3562508.
47. Holt M, Monk R, Powell S, Dooris M. Student perceptions of a healthy university. Public Health. 2015;129(6):674-683. doi: 10.1016/j.puhe.2015.03.020. Epub 2015 May 6. PMID:
48. Hopkins L, Morgan H, Buery-Joyner SD, et al.; Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics. To the point: a prescription for well- being in medical education. Am J Obstet Gynecol. 2019;221(6):542-548. doi: 1016/j.ajog.2019.05.012. Epub 2019 Jun 7. PMID: 31181180.
49. Howe A, Smajdor A, Stockl A. Towards an understanding of resilience and its relevance to medical Med Educ. 2012;46(4):349-356. PMID:22429170.
50. Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: a systematic review. Clin Teach. 2013;10(4):242-245. doi: 10.1111/tct.12014. PMID:
51. Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs. 2007;60(1):1–9. PMID:17824934.
52. Jacobs SR, Dodd D. Student burnout as a function of personality, social support, and J Coll Stud Dev. 2003;44(3):291-303.
53. Jamal F, Fletcher A, Harden A, Wells H, Thomas J, Bonell C. The school environment and student health: a systematic review and meta-ethnography of qualitative research. BMC Public Health. 2013;13:798. doi: 10.1186/1471-2458-13-798. PMID: 24007211; PMCID:
54. Karasek R. Job demands, job decision latitude and mental strain: implications for job Adm Sci Q. 1979;24:285-306.
55. Kern ML. PERMAH: a useful model for focusing on wellbeing in schools. In: Handbook of Positive Psychology in Schools, Allen K-A, Furlong M, Vella-Brodrick S & Suldo S (Eds.), 3rd Milton Park, Abingdon, UK: Routledge; 2021.
56. Kinsella EA, Smith K, Bhanji S, Shepley R, Modor A, Bertrim A. Mindfulness in allied health and social care professional education: a scoping review. Disabil Rehabil. 2020;42(2):283- doi: 10.1080/09638288.2018.1496150. Epub 2018 Dec 5. PMID: 30517835.
57. Knoesen R, Naudé L. Experiences of flourishing and languishing during the first year at J Ment Health. 2018;27(3):269-278. doi: 10.1080/09638237.2017.1370635. Epub 2017 Sep 4. PMID: 28868951.
58. Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy DM, Volsch JM. Core personal competencies important to entering students' success in medical school: what are they and how could they be assessed early in the admission process? Acad Med. 2013;88(5):603-613. PMID:23524928.
59. Kötter T, Fuchs S, Heise M, et al. What keeps medical students healthy and well? A systematic review of observational studies on protective factors for health and well-being during medical education. BMC Med Educ. 2019;19(1):94. doi: 10.1186/s12909-019-1532-z. PMID: 30935393; PMCID:
60. Kroshus E, Wagner J, Wyrick D, et al. Wake up call for collegiate athlete sleep: narrative review and consensus recommendations from the NCAA Interassociation Task Force on Sleep and Wellness. Br J Sports Med. 2019;53(12):731-736. doi: 10.1136/bjsports-2019-100590. Epub 2019 May 16. PMID:
61. Langford R, Bonell C, Jones H, et al. The World Health Organization's Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC Public Health. 2015;15:130. doi: 1186/s12889-015-1360-y. PMID: 25886385; PMCID: PMC4339015.
62. Langford R, Bonell CP, Jones HE, et al. The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement. Cochrane Database Syst Rev. 2014;(4):CD008958. doi: 10.1002/14651858.CD008958.pub2. PMID:
63. Lattie EG, Adkins EC, Winquist N, Stiles-Shields C, Wafford QE, Graham AK. Digital mental health interventions for depression, anxiety, and enhancement of psychological well-being among college students: systematic review. J Med Internet Res. 2019;21(7):e12869. doi: 2196/12869. PMID: 31333198; PMCID: PMC6681642.
64. Lazarus RS, Folkman Stress, Appraisal, and Coping. New York, NY: Springer; 1984.
65. Lewis GM, Neville C, Ashkanasy NM. Emotional intelligence and affective events in nurse education: a narrative review. Nurse Educ Today. 2017;53:34-40. doi: 1016/j.nedt.2017.04.001. Epub 2017 Apr 7. PMID: 28426999.
66. Lovell B. What do we know about coaching in medical education? A literature review. Med Educ. 2018;52(4):376-390. doi: 1111/medu.13482. Epub 2017 Dec 11. PMID: 29226349.
67. Lyubomirsky S, Sheldon KM, Schkade D. Pursuing happiness: the architecture of sustainable Rev Gen Psychol. 2005;9(2):111–131.
68. Marx R, Tanner-Smith EE, Davison CM, et al. Later school start times for supporting the education, health, and well-being of high school students. Cochrane Database Syst Rev. 2017;7(7):CD009467. doi: 1002/14651858.CD009467.pub2. PMID: 28670711; PMCID: PMC6483483.
69. McCarthy ME, Pretty GM, Catano V. Psychological sense of community and student J Coll Stud Dev. 1990;31(3):211-216.
70. McConville J, McAleer R, Hahne A. Mindfulness training for health profession students – the effect of mindfulness training on psychological well-being, learning and clinical performance of health professional students: a systematic review of randomized and non-randomized controlled trials. Explore (NY). 2017;13(1):26-45. doi: 10.1016/j.explore.2016.10.002. Epub 2016 Oct PMID: 27889445.
71. McCormick R. Does access to green space impact the mental well-being of children: a systematic review. J Pediatr Nurs. 2017;37:3-7. doi: 10.1016/j.pedn.2017.08.027. Epub 2017 Sep PMID: 28882650.
72. McGrath H, Noble T. Bounce Back! A Wellbeing & Resilience Program. Lower primary K-2; Middle primary: Yrs 3-4; Upper primary/Junior secondary: Yrs 5-8. Melbourne, Australia: Pearson Education; 2011.
73. Monrouxe LV. Identity, identification and medical education: why should we care? Med Educ. 2010;44(1):40-49. doi: 1111/j.1365-2923.2009.03440.x. PMID: 20078755.
74. Montagni I, Tzourio C, Cousin T, Sagara JA, Bada-Alonzi J, Horgan A. Mental health-related digital use by university students: a systematic review. Telemed J E Health. 2020;26(2):131- doi: 10.1089/tmj.2018.0316. Epub 2019 Mar 19. PMID: 30888256.
75. Morrissette PJ, Doty-Sweetnam K. Safeguarding student well-being: establishing a respectful learning environment in undergraduate psychiatric/mental health education. J Psychiatr Ment Health Nurs. 2010;17(6):519-527. doi: 10.1111/j.1365-2850.2010.01551.x. PMID:
76. Nagji A, Brett-MacLean P, Breault L. Exploring the benefits of an optional theatre module on medical student well-being. Teach Learn Med. 2013;25(3):201-206. PMID:23848325
77. Noble T, McGrath H, Wyatt T, Carbines R, Robb L. Scoping study in approaches to student wellbeing – Final report. Canberra, Australia: Department of Education, Employment and Workplace Relations;
78. Noble T, McGrath H. The PROSPER School Pathways for Student Wellbeing: Policy and New York, NY: Springer; 2015.
79. Ong AD, Bergeman CS, Bisconti TL, Wallace KA. Psychological resilience, positive emotions and successful adaptation to stress in later J Pers Soc Psychol. 2006;91:730-749.
80. Orsini C, Binnie VI, Wilson SL. Determinants and outcomes of motivation in health professions education: a systematic review based on self-determination J Educ Eval Health Prof. 2016;13:19. doi: 10.3352/jeehp.2016.13.19. PMID: 27134006; PMCID: PMC4863137.
81. Ozer EJ. The effects of school gardens on students and schools: conceptualization and considerations for maximizing healthy development. Health Educ Behav. 2007;34(6):846-863. doi: 1177/1090198106289002. Epub 2006 Jul 21. PMID: 16861584.
82. Papadatou-Pastou M, Goozee R, Payne E, Barrable A, Tzotzoli P. A review of web-based support systems for students in higher education. Int J Ment Health Syst. 2017;11:59. doi: 1186/s13033-017-0165-z. PMID: 29021822; PMCID: PMC5613335.
83. Park C. The meaning making model: a framework for understanding meaning, spirituality, and stress-related growth in health Health Psychol Rev. 2013;2(15):40-47.
84. Paro HB, Morales NM, Silva CH, et al. Health-related quality of life of medical students. Med Educ. 2009;44:227-235.
85. Paro HBMS, Silveira PSP, Perotta BG, et al. Empathy among medical students: is there a relation with quality of life and burnout? PLoS ONE. 2014;9(4):e94133. PMID:24705887.
86. Partridge SR, Howse E, Llewellyn G, Allman-Farinelli M. Adequacy of data sources for investigation of tertiary education student's wellbeing in Australia: a scoping review. Healthcare (Basel). 2018;6(4):136. doi: 10.3390/healthcare6040136. PMID: 30486229; PMCID:
87. Pavletic AC, Dukes T, Greene JG, Taylor J, Gilpin LB. Health Services in boarding school: an oasis of care, counseling, and comfort. J Sch Nurs. 2016;32(5):304-314. doi: 1177/1059840516649234. Epub 2016 May 23. PMID: 27216247.
88. Phan HP, Ngu BH, Alrashidi O. Role of student well-being: a study using structural equation Psychol Rep. 119(1):77-105.
89. Quoidbach J, Mikolajczak M, Gross JJ. Positive interventions: an emotion regulation Psychol Bull. 2015;141(3):655. PMID:25621978.
90. Rahmati The study of academic burnout in students with high and low level of self-efficacy. Procedia Soc Behav Sci. 2015;171:49-55.
91. Russell K, Allan S, Beattie L, Bohan J, MacMahon K, Rasmussen S. Sleep problem, suicide and self-harm in university students: a systematic review. Sleep Med Rev. 2019;44:58-69. doi: 1016/j.smrv.2018.12.008. Epub 2019 Jan 23. PMID: 30721844.
92. Schaufeli WB, Martinez I, Marques Pinto A, Salanova M, Bakker AB. Burnout and engagement in university students: a cross national J Cross-Cult Psychol. 2002;33;464-481.
93. Schaufeli, WB, Bakker AM. Job demands, job resources, and their relationship with burnout and engagement: a multi-sample study. J Org Behav, 2004;25;293-315.
94. Schmidt M, Hansson E. Doctoral students’ well-being: a literature review. Int J Qual Stud Health Well-being. 2018;13(1):1508171. doi: 10.1080/17482631.2018.1508171. PMID: 30102142; PMCID:
95. Seligman ME, Steen TA, Park N, Peterson Positive psychology progress: empirical validation of interventions. Am Psychol. 2005;60(5):410. PMID:16045394.
96. Selligman M, Czikszentmihaly M (Eds.). Special issue on Happiness, excellence, and optimal human Am Psychol. 2000;55:5-183. PMID:11392865.
97. Siegrist J. Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol 1996;1:27-41.
98. Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. J Clin Psychol. 2009;65(5):467-487.
99. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular Acad Med. 2014;89(4):573. PMID:24556765.
100. Smith M, Segal J, Segal R. Preventing burnout: signs, symptoms, causes, and coping in: Doctors: Their Wellbeing & Stress (Cost of Employment: Case of Medical Professionals), Rajput RS (Ed.).
101. Stoffel JM, Cain J. Review of grit and resilience literature within health professions education. Am J Pharm Educ. 2018;82(2):6150. doi: 10.5688/ajpe6150. PMID: 29606705; PMCID:
102. Sulea C, van Beek I, Sarbescu P, Virga D, Schaufeli WB. Engagement, boredom, and burnout among students: basic need satisfaction matters more than personality traits. Learn Individ Differ. 2015;42:132-138.
103. Swann C, Crust L, Jackman P, Vella SA, Allen MS, Keegan R. Performing under pressure: exploring the psychological state underlying clutch performance in sport. J Sports Sci. 2017;35(23):2272-2280. doi: 10.1080/02640414.2016.1265661.
104. Tempski P, Bellodi PL, Paro HB, Enns SC, Martins MA, Schraiber LB. What do medical students think about their quality of life? A qualitative study. BMC Med Educ. 2012;12:106. PMID:23126332.
105. Tempski P, Martins MA, Paro HB. Teaching and learning resilience: a new agenda in medical Med Educ. 2012;46(4):345-346. PMID:22429168.
106. Thackery E, Harris M. (Eds). The Gale Encyclopedia of Mental Disorders: AL (Vol. 1). Farmington Hill, MI: Gale Group;
107. Tinto V. Taking student retention seriously: rethinking the first year of college. NACADA J. 2000;19(2);5-10.
108. Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: a systematic review and meta-analysis. Nurse Educ Today. 2018;63:119-129. doi: 1016/j.nedt.2018.01.009. Epub 2018 Feb 9. PMID: 29432998.
109. van der Riet P, Levett-Jones T, Aquino-Russell C. The effectiveness of mindfulness meditation for nurses and nursing students: an integrated literature review. Nurs Educ Today. 2018;65:201-211. doi: 1016/j.nedt.2018.03.018. Epub 2018 Mar 24. PMID: 29602138.
110. van der Walt S, Mabaso WS, Davids EL, de Vries PJ. The burden of depression and anxiety among medical students in South Africa: a cross-sectional survey at the University of Cape S Afr Med J. 2019;110(1):69-76. doi: 10.7196/SAMJ.2019.v110i1.14151. PMID: 31865946.
111. Volpe A guide to effective stress management. J Career Tech Edu. 2000;48(10):183-188.
112. Wald HS, Reis SP. Beyond the margins: reflective writing and development of reflective capacity in medical education. J Gen Intern Med. 2010;25(7):746-749. doi: 10.1007/s11606- 010-1347-4. Epub 2010 Apr PMID: 20407840; PMCID: PMC2881974.
113. Wasson LT, Cusmano A, Meli L, et al. Association between learning environment interventions and medical student well-being: a systematic review. JAMA. 2016;316(21):2237-2252. doi: 10.1001/jama.2016.17573. PMID: 27923091; PMCID:
114. Wearne S, Dornan T, Teunissen PW, Skinner T. General practitioners as supervisors in postgraduate clinical education: an integrative review. Med Educ. 2012;46(12):1161-1173. doi: 1111/j.1365-2923.2012.04348.x. PMID: 23171258.
115. Webster CS, Luo AY, Krägeloh C, Moir F, Henning M. A systematic review of the health benefits of Tai Chi for students in higher education. Prev Med Rep. 2015;3:103-112. doi: 1016/j.pmedr.2015.12.006. PMID: 26844196; PMCID: PMC4733099.
116. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi: 1016/S0140-6736(16)31279-X. Epub 2016 Sep 28. PMID: 27692469.
117. White CA, Uttl B, Holder MD. Meta-analyses of positive psychology interventions: the effects are much smaller than previously PLoS ONE. 2019;14(5). PMID:31141537.
118. Windle M, Grunbaum JA, Elliott M, et al. Healthy passages. A multilevel, multimethod longitudinal study of adolescent health. Am J Prev Med. 2004;27(2):164-72. doi: 1016/j.amepre.2004.04.007. PMID: 15261905.
119. Wolff T. Stress, coping and health: enhancing well-being during medical school. Med Educ. 2007;28:8-17.
120. Yang HJ. Factors affecting student burnout and academic achievement in multiple enrolment programs in Taiwan’s technical-vocational Int J Educ Dev. 2004;24(3):283-301.

2. University platforms and courses on wellbeing and mental health

Search terms: university wellbeing initiatives, university and mental support/student support

1. University of Bristol – Our Approach to Mental Health and Wellbeing: https://www.bristol.ac.uk/university/governance/constitutionaldocs/senior-staff/vice- chancellor-and-president-professor-hugh-brady/wellbeing-strategies/
2. Yale University – The Science of Well-Being: https://www.coursera.org/learn/the-science-of- well-being?utm_source=gg&utm_medium=sem&utm_campaign=09-ScienceofWellBeing- ROW&utm_content=B2C&campaignid=9722859275&adgroupid=100391762620&device=c&k eyword=online%20free%20study&matchtype=b&network=g&devicemodel=&adpostion=&cr eativeid=428330721290&hide_mobile_promo&gclid=EAIaIQobChMIgKedpfTR9QIVR- d3Ch2jBQRsEAAYASAAEgKy0_D_BwE
3. University of California, Berkeley – Greater Good Magazine: https://greatergood.berkeley.edu/
4. Inside Government Higher Education United Kingdom: https://blog.insidegovernment.co.uk/higher-education/creative-wellbeing-initiative- examples-that-can-help-boost-student-happiness
5. Universiteit Leiden – The Wellbeing Initiatives: https://www.universiteitleiden.nl/en/news/2021/03/the-wellbeing-initiatives-care-about- your-own-wellbeing
6. University mental health initiatives UK: https://studee.com/discover/15-of-the-best- university-mental-health-initiatives-in-the-uk/
7. University of Chicago: https://wellness.uchicago.edu/healthy-living/wellness-programming/
8. University of Amsterdam: https://www.uva.nl/en/current/coronavirus/initiatives-and-help- for-students.html?cb
9. Melbourne University: https://melbourne-
10. cshe.unimelb.edu.au/ data/assets/pdf_file/0016/2302603/MCSHE-Student-Wellbeing- Framework_FINAL.pdf
11. Newcastle University: https://www.ncl.ac.uk/wellbeing/newseventsandprojects/initiatives/#pianosoncampus
12. University of Pittsburgh: https://www.studentaffairs.pitt.edu/dean/healthandwellnessinitiatives/
13. Colorado State University: https://health.colostate.edu/well-being/
14. Erasmus University Rotterdam: https://www.eur.nl/onderwijs/studeren- rotterdam/studentenwelzijn/student-wellbeing-week
15. Great Value Colleges: https://www.greatvaluecolleges.net/rankings/innovative-mental- wellness-programs/
16. Radboud University Nijmegen: https://www.radboudnet.nl/nieuws-activiteiten/actuele- projecten/studentbegeleiding-2023/t4-studentenwelzijn/t4-nieuws-ontwikkelingen/hannah- markusse-coordinator-studentenwelzijn/
17. Harvard University – The Science of Happiness: https://gened.fas.harvard.edu/classes/science-happiness
18. Pursuit of happiness.org: https://www.pursuit-of-happiness.org/the-science-of-happiness- course/?gclid=EAIaIQobChMIpenA45rU9QIVieF3Ch13Nwd6EAMYAyAAEgLyzvD_BwE
19. UC Davis: https://grad.ucdavis.edu/faculty-academy-graduate-student-well-being

3. Background information from popular scientific books