The Role of Health Care Profession Accreditors in Promoting Health and Well-Being across the Learning Continuum
ABSTRACT: As health care professionals strive to address the nation’s physical and mental health care issues, they too are often at risk. The purpose of this paper is to inspire a national dialogue about the well-being and resilience of the people to whom Americans turn for care and how well their professions’ accreditation standards address those concerns.
Health and Well-Being Within and across Professions from the Perspective of Accreditors
Health care professions acknowledge the importance of health and well-being for their students, faculty, and preceptors/supervisory staff, and for the health care workforce . What is not clear is how closely accreditors from different health professions align their standards for addressing this critical concern with each other. In 2017, Cox et al. developed a model (see Figure 1) that represents the integration of health professionals’ roles in both education and practice settings with that of accreditors to meet four goals identified as the Quadruple Aim: population health, patient experience, per capita cost, and provider work life. Beginning at the entry (foundational) level, the learning continuum continues through graduate/post-graduate education to continuing professional development and intersects with other professions. This interprofessional continuum of learning includes accreditors who, by identifying areas of alignment and potential gaps, can create a framework addressing the well-being of the workforce.
Figure 1 | Role of Accreditors within and across Health Professions and Health Care Delivery for Fostering the Quadruple Aim
SOURCE: Cox, M., et al. 2017. The role of accreditation in achieving the quadruple aim for health .
Ideally, a comprehensive framework would include all health professions and their accreditors as described by Cox et al. (2017); however, a scaled-down approach was designed to start the conversation. Using this model, representatives from medicine, nursing, and psychology examined their professions’ educational models through an accreditation lens to look at how health and well-being fit within each profession’s learning continuum from education to practice, and across the three health professions. This information is detailed later in this paper as an environmental scan. A summary analysis of the scan appears in the sections below. The paper ends with concluding recommendations that describe potential areas of alignment and opportunities for different health professions—beyond just medicine, nursing, and psychology—to work in concert with the different accrediting bodies to build a culture of health and well-being for all.
Current State of Addressing Health and Well-Being through Health Care Profession Accreditors Areas of Alignment across the Learning Continuum
Accreditors in medicine, nursing, and psychology promote health and well-being across the education continuum that extends into the practice setting. In the foundational years—when learners are first introduced to their chosen profession—areas of alignment in accreditation standards require that organizations support students in developing a professional identity, cultivating skills associated with stress management and self-care, and learning how to work collaboratively as members of interprofessional teams. Organizations must provide student resources that include but are not limited to counseling, tutoring, financial aid, and career guidance. In terms of addressing health and well-being, nursing accreditation standards appear to emphasize the concept of “care of self in order to effectively care for others” . Accreditation standards in psychology emphasize the use of “appropriate professional role models” to guide students, and that students and trainees should engage in “self-reflection” addressing “personal and professional functioning” and in activities that “maintain and improve performance, well-being, and professional effectiveness” . Medicine, in the foundational years, often looks to support students through well-being programs that are guided by Liaison Committee for Medical Education (LCME) standards .
In the graduate/post-graduate years, accreditors have implemented standards that require support for transitioning new graduates into the practice setting. Areas of alignment across the professions include an expectation that learners will be provided with incrementally greater responsibility for patient care, clear performance expectations with documentation of milestones and competencies, and strategies to support their overall health and well-being. Organizations have adopted medicine and psychology accreditation standards more widely than such standards for nursing during this training phase, because accreditation standards for nurse residency/fellowship programs have more recently been established. Medicine and nursing have also worked together through a national collaborative to improve the clinical learning environment and develop strategies to support learners in transition , whereas psychology has more recently moved toward greater interprofessional engagement.
Continuing Professional Development
In continuing professional development, accreditation standards across the three professions support educational interventions focused on improving health and well-being. Nursing and medicine (with pharmacy) have formalized a partnership to accredit organizations that provide interprofessional continuing education (IPCE), because research supports the positive relationship between interprofessional collaboration, decreased stress on practitioners, and improved patient outcomes . This collaboration is being expanded to include accreditors from other professions.
From an accreditation perspective, medicine, nursing, and psychology have a tremendous opportunity to learn from one another’s efforts to improve the health and well-being of their students, trainees, and professionals. For example, accreditors of medical schools make sure programs are supporting student well-being, undergraduate nursing accreditors require that curricula include elements of self-care and stress management, and competencies that include well-being and professionalism are compiled during the foundational education for psychology—i.e., at the doctoral and internship level. By keeping data on each of these efforts, successes can be shared among the different professions at national gatherings such as the Health Professions Accreditors Collaborative that meets in conjunction with the Association of Specialized and Professional Accreditors. These findings can then be shared with faculty and preceptors in care environments or at collaborative meetings such as the Interprofessional Education Collaborative (IPEC) or the annual meetings of the National Center for Interprofessional Practice and Education or the National Academies of Practice.
Interprofessional Learning Continuum
There is a strong need for today’s health professionals to develop skills in interprofessional communication and conflict resolution, and to collaborate as members of the health care team. Improving collaboration can reduce the demand on one profession, thereby decreasing stress and enhancing job satisfaction . The Interprofessional Learning Continuum model (see Figure 2) lays out a pathway for interactions among health professions from education to practice. Applying this model can help address health and well-being and can include accrediting organizations to ensure compliance.
Figure 2 | The Interprofessional Learning Continuum Model
SOURCE: Institute of Medicine, 2015.
NOTE: For this model, “graduate education” encompasses any advanced formal and supervised health professions training taking place between completion of foundational education and entry into unsupervised practice .
But, more important is the opportunity for accreditors to promote continuous improvement, specifically in how education and training programs effectively attend to well-being among their learners, faculty, and preceptors. Data and other outcome measures detailed in the two red boxes shown in Figure 2 could help guide accreditors in monitoring not only learner outcomes related to health and well-being, but also downstream impacts of provider well-being on patients and population outcomes. Learning outcomes across the continuum, as well as health and system outcomes, are heavily influenced by the confounding factors in the green box shown in Figure 2. These factors involve organizational and professional culture and policies that can harm or benefit a learning and health system environment depending on how the organization approaches the factors. Weaving culture and policy into interprofessional accreditation requirements for the well-being of students, faculty, and professionals may be one way to influence the health and well-being of many professions. For example, in nursing, the American Association of Colleges of Nursing’s (AACN) Baccalaureate Essentials require graduates to promote a culture of safety and caring within the work environment; work collaboratively and interprofessionally with patients, families, and colleagues; and promote a blame-free culture of accountability . The Commission on Collegiate Nursing Education, AACN’s accrediting arm, evaluates an organization’s compliance against those standards during the accreditation review. Residency program accreditation standards require that organizations demonstrate a commitment to a culture of interprofessional collaboration and support to include support of residents and faculty [9,10]. In graduate medical education, common program requirements for residency and fellowship programs stress the critical importance of working in interprofessional teams, especially around issues of quality, patient safety, care coordination, and interprofessional activities within the healthcare system . In contrast, psychology focuses on preparing psychologists competent to work in interdisciplinary settings through knowledge acquisition and demonstrated behaviors representing the roles and perspectives of interdisciplinary care delivery. In addition, psychology education promotes a supportive learning environment that may include actual interprofessional activities for entry-level and advanced level competencies .
Interprofessional Collaboration for Continuing Professional Development
Because there are no specific standards for health and well-being and learning environments in continuing education/continuing professional development for medicine, nursing, or psychology, there is an opportunity to create new synergies for addressing stress and burnout across the health professions. Currently, accrediting bodies from medicine, nursing, and pharmacy are collaborating in the field of IPCE. They define CE/CPD as “educational activities, which serve to maintain, develop, or increase the knowledge, skills, and professional performance, and relationships that a healthcare professional uses to provide services for patients, the public, or the profession. The content of CE is that body of knowledge and skills generally recognized and accepted by the profession as within the basic healthcare sciences, the discipline of healthcare, and the provision of health care to the public” .
Accredited continuing education providers developing educational activities that focus on the health and well-being of health care professionals may award profession-specific or IPCE credit, assuming all other accreditation criteria requirements are met. Organizations that are jointly accredited to provide team-based education are particularly well-suited to developing education focusing on the health and well-being of health care professionals. Such activity planning requires:
- an integrated process that includes health care professionals from two or more professions;
- reflection of one or more of the interprofessional competencies to include values/ethics, roles/responsibilities, interprofessional communication, and/or teams/teamwork;
- the opportunity to learn with, from, and about each other; and
- evaluation that seeks to determine changes in skills, strategy, and performance of one’s role or contribution as a member of the health care team; and/or effect on the health care team; and/or effect on patient outcomes .
One of the goals of IPCE is to improve interprofessional collaborative practice. Over time, this may help contribute to a more cohesive and healthy working environment, and positively affect the health and well-being of those involved. Inviting additional professions such as psychology to join IPCE may enhance the focus on mental health issues through continuing interprofessional development.
Finally, the Interprofessional Education Collaborative and the National Center for Interprofessional Practice and Education represent opportunities to bring accreditors into conversations with emerging and seasoned health professionals from across the professions to share experiences and resources for improving the health and well-being of health professionals across the learning continuum.
Environmental Scan of Well-Being Efforts within Medicine, Nursing, and Psychology
Accrediting Agencies across the Professions
Medicine, nursing, and psychology have their own systems of accreditation based on the learner’s stage of education or training (see Table 1). For medicine and nursing, the foundational level is where learners are first introduced to the basics of their chosen health profession; graduate and post-graduate training is where learners transition into the practice setting; and continuing professional development is where established practitioners engage in lifelong learning. Although this is also generally true for psychology, the foundational level is more commonly at the doctoral level, and the goal of doctoral training, which includes an internship, is entry into practice. Post-doctoral psychology training offers advanced training in which more specialized, supervised experiences are provided. In some jurisdictions, post-doctoral supervised clinical hours are required for license eligibility.
For nursing, the foundational years are often during a four-year baccalaureate degree program, although two-year associate’s degree programs remain a popular entry point to ultimately obtaining a bachelor of science in nursing degree. For medicine, the foundational years are within a graduate, four-year medical or osteopathic school. Similarly, psychology requires a doctoral degree for entry into practice and license eligibility, although some practitioners holding master’s degrees and related credentials may also engage in independent practice. Both medicine and psychology require a bachelor’s degree to be considered for acceptance by a medical school or a graduate psychology degree program. However, the degree does not have to be in pre-medicine or psychology. Table 1 provides a detailed description of the US accrediting agencies for medicine, nursing, and psychology.
Education and Training for Health and Well-Being across the Professions
Although foundational educational programs for nursing, medicine, and psychology vary, each profession is committed to the health and well-being of its health professionals across the learning continuum (see Box 1). At the undergraduate nursing level, the emphasis is on creating environments that support and promote the health and well-being of students while maintaining rigorous academic standards. Academic curricula must include content related to self-care and stress management. Nursing students learn how to form a professional identity, maintain a professional image, engage in self-reflection, and deliver patient-centered, ethical care. Students must have resources such as academic counseling, tutoring, financial aid, and career guidance. Nursing schools are held by their accrediting bodies to demonstrate how they create a supportive learning environment beyond just the focus on curricular content. For example, the CCNE criteria require that nursing schools provide clinical practical experiences for interprofessional collaboration , and the Commission for Nursing Education Accreditation (CNEA) standards require nursing schools to demonstrate a culture of excellence and care . Nurse residency program accreditors, likewise, require program administrators to demonstrate a supportive practice-based learning environment . To maintain accreditation, psychology programs for all levels of training, including postdoctoral residencies, are expected to provide a “welcoming, supportive, and encouraging learning environment” for all their residents . Within medicine, the LCME standards require programs to support student well-being and personal counseling (when needed) in foundational medical education, and are part of the student survey administered as part of the LCME review process. The site visit also addresses the following question as part of the accreditation visit report:
Summarize medical school programs or other programs designed to support students’ well-being and facilitate students’ ongoing adjustment to the physical and emotional demands of medical school. Describe how students are informed about the availability of these programs/activities .
Graduate/Post-graduate Level Education and Training
In psychology and in medicine, accreditation attention to health and well-being presents more prominently at the graduate and post-graduate levels than at the foundational level. At the post-graduate level, duty-hour regulations for medical residents have been a major component of the common program requirements in graduate medical education (GME) for more than a decade. The ACGME also recently revised its program requirements. Section VI, “The Learning and Working Environment,” now includes a new subsection, “Well-Being” (Section VI.C), which goes beyond just duty-hour regulations and was implemented in 2017. The preamble for this section says the following:
In the current health care environment, residents and faculty members are at increased risk for burnout and depression. Psychological, emotional, and physical well-being are critical in the development of the competent, caring, and resilient physician. Self-care is an important component of professionalism; it is also a skill that must be learned and nurtured in the context of other aspects of residency training. Programs, in partnership with their Sponsoring Institutions, have the same responsibility to address well-being as they do to evaluate other aspects of resident competence. 
Section VI.D, “Fatigue Mitigation,” provides more explicit standards on preparing students and faculty to recognize fatigue and intervene for the sakes of learner and patient. Questions on duty hours and fatigue mitigation are included on the ACGME’s annual resident and fellow surveys, and supplemental questions on wellness are under consideration.
For psychology, the APA CoA uses the Standards of Accreditation for Health Service Psychology , which provides standards for education and training programs that include competencies that all students and trainees must acquire. These profession-wide competencies are specific to the level of training.
“Professional values, attitudes, and behaviors”—how trainees are to respond professionally in increasingly complex situations—is a required competency for trainees at the doctoral and internship levels . Trainees are to develop responses that reflect the “values and attitudes of psychology, including integrity, deportment, professional identity, accountability, lifelong learning, and concern for the welfare of others” . In addition, the use of self-reflection concerning personal and professional functioning, with engagement in activities to sustain and enhance performance, establish well-being, and provide effective professionalism are included. Openness and responsiveness to supervisory feedback are also elements of this competency. Accredited programs must include the development of all competencies within training and establish minimum levels of achievement as a requirement for successful completion of a program.
Although psychology accrediting agencies do not specify how competencies are to be taught or developed, a recent commentary written by Grus et al. (2017) described different methods of promoting well-being . These methods emphasized self-care and recommended program leadership, seminars, and committees for describing, promoting, and monitoring the climate and development of self-care activities. The authors recommended that training programs use specific activities such as those promoting student support and growth, especially given the stress associated with academic training from such challenges as managing multiple demands and maintaining a personal-work life balance.
At the nursing graduate level, less emphasis is placed on strategies that promote health and well-being and more is placed on developing leadership and interprofessional skills. Curricular content includes leadership theory, communication skills, conflict resolution, and building and nurturing effective teams. The graduate nursing student’s role in quality and safety is also embedded throughout the curriculum.
Transition to Practice
A new health professional is likely to be more successful when he or she addresses issues affecting health and well-being before beginning practice. Since 2012, the GME accreditation system for medical residents and fellows has included a Clinical Learning Environment Review (CLER) program. CLER is a continuous quality improvement (CQI) approach to institutional-level accreditation. The CLER process is designed to help institutional leadership integrate residents and fellows into the care processes of the institution, typically a hospital or clinic. CLER involves on-site review by trained surveyors looking at patient safety, health care quality, care transitions, supervision, professionalism, and well-being . The well-being subset has six embedded pathway domains that are designed to help institutional leadership ensure the well-being of its academic staff and learners.
In addition to CLER, the Milestones initiative , another continuous quality improvement–focused aspect of accreditation, is addressing health and well-being as part of a new “harmonized set” that will be used to guide the revision process in the coming years. One of the newer sub-competencies is self-awareness and help-seeking. Milestones describe a developmental trajectory that extends beyond the residency and fellowship period into clinical practice. In this sub-competency, for example, an advanced stage is described as follows: “Independently develops a plan to optimize personal and professional well-being” and “Independently develops a plan to remediate or improve limits in the knowledge/skills of self or team” . Thus, the GME accreditation model is multi-pronged, with standards (the common program requirements) that target individuals, programs, and institutions, but also CQI-driven processes that target institutional leadership and individual professional development through competencies and milestones.
For nursing, the transition to practice has long been recognized as an intensely stressful period. Marlene Kramer described the challenges in her book Reality Shock . Today, newly graduated nurses enter practice environments that are extremely demanding and require a high degree of clinical proficiency, critical thinking ability, and clinical leadership skill. Nurse residency and fellowship programs help to mitigate the stress of transition by incorporating activities that improve clinical skills, critical thinking and clinical reasoning skills, time management, and delegation skills. These programs also help reduce high levels of turnover and vacancy within organizations, as well as the loss of RNs within the profession [25,26]. Accrediting bodies for nurse residency and fellowship programs have embedded criteria that directly address identified stressors, such as programs to help the trainees manage stress and role transition. Residents and fellows learn to manage time, improve communication skills, and work as members of the interprofessional care team while developing strategies to prevent compassion fatigue, promote resiliency, and address ethical dilemmas.
Within psychology, in addition to promoting self-care in professional development, programs are required to document their actions and procedures that “maximize student success.” One mechanism to enhance student success—and on which programs are evaluated—is the institutional climate. Such evaluations determine the supportiveness of the program and the institution in creating such learning environments, so that health may be maintained.
Numerous studies have demonstrated that faculty within the health professions are experiencing significant levels of stress and burnout [27,28,29,30]. This means risking a further reduction of an already reduced number of educators within the health professions. For example, a 2010 study by Aquino et al. (2018) underscored the negative impact burnout is having on the severe nursing faculty shortage that, according to AACN, totaled over 1,500 faculty vacancies in 2016 [31,32]. The causes of burnout point to work overload and emotional exhaustion, which becomes a vicious cycle as the number of available faculty diminish [30,33].
At the post-graduate level in medicine, the CLER initiative explicitly calls attention to the importance of well-being among faculty members. For example, well-being pathway 2 says that the “clinical learning environment demonstrates continuous effort to support programs and activities that enhance the physical and emotional well-being of residents, fellows and faculty members” . In fact, all of the well-being pathways in CLER explicitly include faculty members along with residents and fellows. Without equal attention to faculty member well-being, it is hard to imagine how a training program can maximize well-being for its students.
System-Level Drivers of Burnout
System-level drivers of burnout that are negatively impacting health care professionals include but are not limited to perceptions of the inability to provide quality care, increasing administrative burden, verbal abuse from patients, heavy patient loads, staffing shortages, and lack of interprofessional collaboration . While the ability of accreditors to address system-level drivers can be a challenge, a unique collaboration of heath care professional organizations, including accreditors, has recently formed to explore how it can collectively work to improve the educational experience and patient care outcomes within clinical learning environments, thus addressing some of the system-level drivers. This group, the National Collaborative for Improving the Clinical Learning Environment (NCICLE), convened a summit in October 2017 to explore characteristics of a high-functioning, interprofessional clinical learning environment. Published on the NCICLE website, the six key characteristics of a positive clinical learning environment include: patient-centered environment, a continuum of learning for all, reliable communication, team-based, care, shared accountability, and evidence-based patient care based on interprofessional experience . The value proposition as depicted below in Figure 3 highlights the positive impact on patients, faculty, hospitals/health systems, and academic centers through a collaborative approach.
In addition to the opportunities for accreditors across the learning continuum, there are opportunities to advance well-being among health professionals from the perspectives of organizations where health care professionals practice. Nursing accreditors, for instance, have developed standards for organizations that promote the health and well-being of nurses in the practice setting. The ANCC’s Pathway to Excellence and Pathway to Excellence in Long Term Care programs set standards for positive practice environments with criteria that require credentialed organizations to demonstrate a healthy workplace for nurses. The following are pathway standards that reflect this mission:
- organizational policies or protocols that address care of self when ill or a new parent; and care of children, family members, or significant others;
- policies, descriptions, and/or examples that demonstrate a safe and healthy work environment;
- commitment to supporting nurses’ professional development, including mentoring;
- organizational support for ensuring that nurses maintain a balanced lifestyle; and
- demonstrating that collaborative relationships are valued and supported, including interprofessional relationships.
ANCC’s Magnet Recognition Program similarly promotes the health and well-being of nurses through a variety of strategies. Organizations that meet Magnet’s rigorous standards must demonstrate how they implement workplace advocacy, including addressing caregiver stress, supporting nurses’ continuing professional development and career advancement, taking action to support academic progression to the baccalaureate level or higher, and improving interprofessional teamwork and collaboration.
Within medicine, ACCME has been an active partner in the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience , as well as at the ACGME yearly conference. Per Graham McMahon, CEO of the ACCME, “all of our commendation criteria are about creating effective learning experiences—engagement in those activities has the ability to nurture self-awareness, provide intellectual fulfillment, create teams, and empower learners to engage in system change—all factors that can create a culture change and address wellness and burnout” (McMahon, personal communication, February 2, 2018). In addition, the ACGME has served the last several years as a convener, bringing experts in wellness and burnout together to explore how the community can help address the burnout physician suicide problem and improve health professionals’ wellness and well-being. This effort has included a yearly invitational conference in Chicago and the creation of a physician well-being resource page on the ACGME website . The ACGME is also collaborating with the LCME and ACCME in these activities.
Likewise, psychology is attending to the need to consider self-care activities within the profession. Authors [20,38,39,40] have described occupational risks to well-being within the profession of psychology and emphasized the need to develop and integrate effective self-care strategies. For example, Wise et al. have shared a number of more formal intervention techniques such as mindfulness-based training, and Wise and Barnett have presented a number of different activities across the stage of professional development, including graduate training . In addition, the APA convened a task force that published guidelines for supervision competence within multiple domains including supervisory relationships, professionalism, and ethics .
In reviewing the environmental landscape and previously published materials, the authors conclude that there are many opportunities for different health professions to learn from each other through health and well-being activities already underway across the learning continuum. However, unless there is a need or requirement forcing joint action, the likelihood is that the professions will work on initiatives from within their individual silos. One exception to this is interprofessional education. Promoting well-being using an interprofessional foundation is a logical approach. At the pre-licensure, foundational level, IPE exposes students to a wider health system than is typically possible from a single profession, and a systems approach has been promoted by individuals and groups at the National Academies as well as other organizations to decrease stress and promote well-being [1,36,41,42]. In addition, accrediting bodies can require demonstration of collaboration across the professions. The LCME requires programs in medical education to incorporate ACGME competencies, and the NLN CNEA and CCNE require evidence of interprofessional teamwork . Although not mandated through their accreditors, the APA is a member of the Interprofessional Education Collaborative and encourages interprofessional education at the foundational level [44,45].
The authors note great promise for collaborative efforts on well-being at the pre-licensure, graduate, and post-graduate levels; however, collaboration on promoting provider health and well-being across professions should start immediately at the practice level. The existing structure for CPD with nursing, medicine, and pharmacy is an ideal entry point for interprofessional continuing education that emphasizes a collective well-being of the workforce. This effort could be expanded to include other health professions in a similar way that HPAC now includes 24 different accreditors, the global forum has 19 different health professions, IPEC has expanded from its original six to now 20 associations, and the National Academies of Practice and the National Center for Interprofessional Practice and Education remain a powerful source of education and information sharing across professions. With all of these interprofessional opportunities in motion, the time to act is now. Representatives from accreditation, health professions education, and health professions practice must use these convening opportunities to promote the health and well-being of all professionals within the health and education system continuum.
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