Stress Management for Emergency Responders - What Agencies Can Do
This is the fifth in a series of five video podcasts on stress management for individuals, teams, and agencies working in emergency and humanitarian aid settings. These podcasts examine sources of stress at each level and what individuals, team leaders, and agency management can do to manage the stress. It gives practical guidance on ways to reduce stress and lessen its negative impacts on staff and the mission. The series is geared toward individuals and agencies working in various crisis settings. Created: 10/15/2008 by International Emergency and Refugee Health Branch (IERHB).
Date Released: 1/21/2009. Series Name: CDC Featured Podcasts.
Stress Management for Emergency Responders - Introduction
[Announcer] This podcast is presented by the Centers for Disease Control and Prevention. CDC - safer, healthier people.
Hi. I'm Dr. Leslie Snider with the Antares Foundation. This is the fourth in a series of four programs on stress management for individuals, teams, and agencies working in emergency and humanitarian aid settings. We will use the term "individual" or "responder" to refer to emergency responders, humanitarian aid workers, and personnel providing technical assistance in these settings.
This program is intended to help senior managers. We will cover:
• Responder stress,
• What costs to your agency,
• Stress management,
• What benefits for your agency,
• What steps your agency can take to improve well-being and stress management for staff, and
• Finally, we will describe a systems approach, utilizing the eight Antares Foundation principles.
Let’s start by looking at the costs. Stress is an inevitable part of emergency and humanitarian aid work. Some say, "If you go out in the rain, you should expect to get wet." Also, we tend to view responders as a tough group, but let's think about the realities of what staff are exposed to in this work and how they are affected.
Emergency and humanitarian aid work can be dangerous. The humanitarian sector is no longer protected space, and over the years there has been a deterioration in the security situation for responders. As respect for their work and life decreases, they may even be deliberately targeted for political or economic reasons. Aid workers are therefore at risk for exposure to critical incidents. Critical incidents are extreme or traumatic events out of the realm of normal, everyday human experience, and may include kidnapping of aid workers, accidents, or witnessing or hearing about traumatic events happening to others.
The unique stresses of emergency and humanitarian aid work take a toll on responders. One study showed that one third or more of returned responders show clinically significant signs of emotional distress, meaning severe enough to interfere with their work and life. Depending on their experiences in the field, the impacts on responders can range from clinical depression and post-traumatic stress disorder to emotional exhaustion.
Another term for emotional exhaustion is burnout. In addition to critical incidents, the day-to-day stresses of emergency and humanitarian aid work can pile up for the responder. Chronic stress, or strain, can lead to burnout among staff. Almost 50 percent of international staff were at moderate to high risk of burnout in one study of returned responders. Burnout can have serious impacts on individual’s job performance. Chronic feelings of depleted energy and loss of enthusiasm and motivation impair work efficiency and diminish their sense of personal accomplishment. Burned out staff may become jaded and may feel less commitment to the agency.
Team dynamics and relationships can make or break a mission. Burned out staff are worse "organizational citizens". They complain about minor issues, are less considerate toward co-workers and less likely to take the initiative to help a co-worker. When burnout affects teamwork, programs and quality of service suffer.
Not only does stress affect worker performance and productivity, it also seriously affects worker health and safety. Burned out staff become poor decision-makers and behave in ways that place other team members and beneficiaries at risk. Stressed out staff are not in a good position to make decisions about sensitive issues, such as security.
Stress is associated with more accidents and illnesses. In fact, according to the American Institute of Stress, 60 to 80 percent of accidents on the job are stress-related. Other staff must fill in for workers absent due to illness, wasting human resources. Health care costs also increase. Burnout increases staff turnover. As qualified personnel leave, it may be difficult to replace them, stretching existing staff and causing project delays.
Although many elements go into the experience of stress for an individual, including contextual and personal factors, organizational factors are often the most critical in determining stress or wellness for responders. In a survey of seven agencies, stress was found to be a significant factor in staff leaving the agency. Among the reasons cited were poor leadership, lack of career opportunities, frustration, bureaucracy, and poor agency functioning.
Adding up all these factors, stress has serious impacts on the agency. Loss of skilled and experienced staff increases recruitment and training costs and contributes to a loss of institutional memory essential for smooth field operations. The overall effectiveness of the mission is compromised. Finally, there is the potential for increased legal liability for agencies who do not properly support staff with the unique stresses of this work.
We've looked at the costs of stress to agencies. Now let's look at the benefits and savings for agencies who attend to staff care and good stress management practices.
Investing in staff care is cost-effective. A study of 42 worksite health promotion programs showed an average 28 percent reduction in sick leave absenteeism, a 26 percent reduction in health care costs, and a 30 percent reduction in workman’s compensation and disability claims.
Let's talk money. In 73 published studies in the U.S., every dollar spent on workplace health promotion produced an average savings of three dollars and fifty cents in reduced absenteeism and health care costs. That's over a three hundred percent return.
Since you invest time and resources in the hiring and training of your staff, they have value to you. It is both cost-effective and worthwhile then, to take steps to retain them and invest in their wellness. Remember, our programs are only as good as the people who deliver them. Well-being of individuals and teams is paramount to mission success, and staff wellness means a strong team, committed to the agency, physically and emotionally "fit" for the job.
The bottom line is risk reduction for your agency. Stress is inevitable in emergency and humanitarian aid work. There are many things we can’t control – responders are vulnerable to stress and trauma and incidents do happen. Your agency has a responsibility to ensure the safety and well-being of staff being asked to take on the risks of this work.
Let's now look at the steps you and your agency can take to improve responder care and support. There are various points of intervention in good stress management practices. Your agency can help to:
• Prevent or reduce the intensity, frequency, and duration of stressors through sound policies and procedures;
• Reduce the vulnerability and increase the resilience of responders, through preparedness and training;
• Improve stress monitoring and coping; and
• Intervene to prevent the long-term effects of stress, particularly in the event of critical incidents.
Effective stress management systems for agencies have certain characteristics. First, they recognize that the individual, team, and agency are inter-dependent and have responsibilities to each other in good stress management and operational practices. There are many things your agency can do to improve systems and to promote good care practices among your responders and teams.
Secondly, strategies for stress management are most effective when they are put in place for all phases of the mission: pre-deployment, in the field, and at the end of the assignment. Finally, effective systems employ measures that are pro-active, routine, and responsive in preventing, reducing, and managing stress in responders.
In the following section, we will discuss practical measures your agency can put in place at each of these levels. The potential outcomes for your agency are greater assurance that your responders and teams are in the best possible condition to do the job and your enhanced ability to support your staff in their mission, with comprehensive and well-functioning systems.
Now, let's examine the practical components of a systems approach. The Antares Foundation has developed guidelines for agencies to implement good stress management practices through the following eight principles. The principles relate to phases of the emergency and reflect the characteristics of good systems we have discussed. They are not prescriptive, but rather provide a framework for agencies which can be adapted to their unique culture and circumstances. Let's examine each principle briefly. We’ll start with the pre-deployment phase of a mission.
Principle One states that the organization has a written policy. In the policy, the agency accepts overall responsibility for reducing the sources of stress and acting to prevent or mitigate the effects of stress. In developing an effective organizational policy for stress management, the agency may find it helpful to assess and frequently update realistic risks for responders; examine the ways the agency inadvertently contributes to stress for responders; evaluate current risk-reduction and stress management policies and practices; and consider the impact of all new policies, practices, and programs, with respect to stress and stress management.
Principle Two is about screening and assessing the suitability of staff for the rigors of a mission. This relates both to hiring new staff and considering the current capacity of existing staff to cope with the anticipated stressors of an assignment.
What selection criteria does your agency currently use to recruit and screen staff for a mission? Technical expertise is only one attribute to look for when recruiting responders. Previous types of relevant experience and expertise should be considered, such as prior international work, cross-cultural savvy, and a history of good teamwork. Personality factors and professionalism are equally important in a responders’ ability to work effectively under pressure.
Keep in mind the following personal attributes when recruiting responders:
• Flexibility and creativity for navigating a constantly changing situation;
• Maturity and a stable sense of self;
• Clear motivation for why they have chosen this work and insight and mastery of past stressful experiences.
• Also, able to follow direction, expresses warmth, and has a demonstrated ability to cope with crisis.
A good team leader is an invaluable asset to any mission. Some criteria to consider in selecting team leaders include prior emergency or field experience; management expertise, such as someone who is able to foster team cohesion; is attentive to the safety, stress, and general wellbeing of their team; is able to engage the team in working together to solve problems, and who is alert to and can effectively manage team conflicts so they don’t adversely affect the mission. Finally, a good team leader models appropriate behavior and good self-care for their team members.
Principle Three relates to the preparation and training of all employees in stress management prior to their assignment. Preparedness and training helps to reduce the vulnerability of responders and increase their resilience. Information is power, and also protects responders because they know what to anticipate in the field, and have given thought to how to respond to the stressors that they encounter. Preparation of staff includes briefing them for their mission.
Let's consider two types of pre-deployment briefing. First is an operational briefing. An operational briefing orients staff to the context, such as the nature of the emergency; the place, including the security situation and climate; and the social, cultural, and political setting in which they will work. It also provides the responder information about the mission, what the agency is trying to accomplish, and their role, including their job description, the chain of command, and their place in the team.
A personal or "psychological" briefing prepares responders for potential stresses of the job and context, reviews good coping strategies, and alerts them to available agency supports. In developing pre-deployment training for responders, it is important to consider the what, who, and when of training.
First, what topics to cover? Some essential topics include policies and procedures, particularly related to safety and security; what to expect in terms of field conditions and operations; and potential stresses in the field and good stress management.
Second, who should your agency train? Since stress management is everyone’s responsibility, staff at all levels should be trained, including responders, team leaders, and management.
Third, when to train? Information in one-off trainings can easily be forgotten. Your agency may want to consider periodic, brief refresher courses to ensure everyone is ready and prepared to handle the stresses of a mission whenever they are called upon.
Let's move now to the "in the field" phase of deployments. Principle Four states that the agency monitors the response to stress of its staff on an ongoing basis. Your agency can help to set expectations for how individuals, team leaders, and supervisors at headquarters should monitor stress. For example, team leaders in crisis settings should monitor team stress levels and know how the team is doing on a daily basis, including if they're getting enough rest and taking time to eat. This can help team leaders be aware of particular stresses or difficult experiences and practical needs and concerns.
Similarly, supervisors, including those at headquarters, should check in regularly with team leaders to see how they’re doing, ensure they have everything they need, see how the team and individuals are functioning, and help trouble-shoot any concerns. This check-in is a good time to encourage and acknowledge the hard work of individuals and the team.
Principle Five states that the agency provides training and support on an ongoing basis to help its staff deal with the daily stresses of emergency and humanitarian aid work. Ongoing training can address relevant issues in a proactive, routine, and responsive way. For example, refresher trainings in the field on issues such as safety and security and coping strategies help to keep responders aware of agency protocols and good practices. Training can also be offered to build staff capacity to handle specific issues which may arise during the course of a mission.
Ongoing support includes encouraging and supporting teams in good daily self-care and team management practices, such as reasonable working hours, good nutrition, and getting proper rest, and providing team members access to confidential, professional emotional support, as needed. Again, taking the time to encourage, acknowledge, and appreciate your team sends a powerful message about their value to your agency.
Principle Six is about support to the team in times of crisis. It states that the agency will provide staff with specific and culturally appropriate support in the wake of critical or traumatic incidents and other unusual and unexpected sources of severe stress.
Let's look at the measures that agencies can put in place for crisis support. As a proactive measure, it is essential that agencies have a protocol in place for supporting and ensuring the safety of impacted staff before a crisis actually occurs. There should be clear policies and procedures for personnel at all levels of the agency. Referral sources for medical and psychological care of impacted staff should be identified and kept current. For routine measures, the agency should regularly review and update the critical incident plan to account for any changes in personnel or agency structures and resources and ensure all staff are trained and continually updated in policies and procedures. It is essential that teams and team leaders have readily accessible contact information in the field for logistical, safety, and emergency medical and psychological support.
Another useful routine measure is ensuring team leaders are trained in psychological first aid to provide immediate support to field staff exposed to critical incidents. This refers to basic, nonintrusive, pragmatic care for those impacted by a traumatic event. It is not high-level mental health treatment, and so team leaders, most of whom are not mental health professionals, can provide this in the field.
Psychological first aid includes ensuring safety and protecting the responder from further harm; assessing and ensuring that basic needs are met; a focus on listening, but not forcing the person to talk about the experience or their feelings; encouraging, but not forcing company from significant others; and providing information on how to access available professional support from the agency.
If a critical incident occurs, agency responsive measures should include rapidly implementing your support plan for the team, including ensuring all staff are safe and secure as the first step; ensuring access for all impacted staff to medical and psychological assessment and care, including evacuation, if needed; and, finally, conducting an agency review of the incident and evaluation of the response to gather lessons learned for future improvements. Let's move now to the end of mission phase.
Principle Seven relates to end-of-assignment support for responders. It states the agency will provide both practical and emotional support for staff at the end of an assignment or contract, including a personal stress review and an operational debriefing.
Let's first define operational debriefing. This is a formal review of the work of the responder at end of their assignment and is generally performed by a manager or their supervisor. Its purpose is to share information between the responder and agency to improve current and future operations. It provides the responder an opportunity to give feedback to the agency about the mission and their job, raise any issues of concern about the operation, and provide suggestions based on their experience. The agency also gives feedback to the responder about their job performance and acknowledges their contribution to the mission.
A personal stress review or personal debriefing is confidential. It is not part of the responder’s job record or performance review. It is generally conducted by a mental health professional. Its purpose is to provide the responder the chance to reflect on their personal experience of the mission and any stresses they may have encountered. It is an opportunity for the responder to receive support and to help them return to their usual life and resume productive work. It is also an opportunity to assess the responder’s wish or need for additional support, including referral for psychological care.
Principle Eight refers to post-assignment support as the responder returns to their usual life after the mission. It states that the agency has clear written policies with respect to the ongoing support they will provide to staff members who have been adversely impacted by exposure to stress and trauma through work during their assignment.
Why is it important for agencies to provide support during this phase? First, emergency and humanitarian aid missions are uniquely personal and potentially life changing experiences for responders. The return to usual life is not easy for responders who have witnessed massive devastation, large-scale human suffering, and who have possibly been exposed to various traumas. The return of the responder can also be stressful for loved ones who may not understand or know how to support them in recovering from their experiences. Further, the impacts of stressful events, particularly traumatic incidents, may manifest some time after the assignment has ended with the potential for post-traumatic stress symptoms.
Some strategies to support returning responders and their loved ones include providing information on the stresses of re-entry and referrals for support. Support can be in the form of individual, couple, or family therapy, or sometimes informal or formal support groups.
The agency can also consider having employee assistance or other mental health support staff check in with responders at regular intervals after their mission to see how they are and offer any needed support.
Putting in place post-assignment support helps the recovery process and mitigates the longer-term impacts of stress for the responder and your agency. Creating a system within your agency which includes all of these measures ensures staff wellness and enhances the effectiveness of your mission.
So they say, "If you go out in the rain, expect to get wet." We say, "If you go out in the rain, take an umbrella." There are many realities of emergency and humanitarian aid work your agency can't control. Implementing these measures will help you shield your staff and agency, as much as possible, as you continue to do this important work.
Additional programs in this series provide a more in-depth understanding of stress in your staff and practical strategies your responders and team leaders can implement to better manage stress. For further information and to download resources such as "Managing Stress in Humanitarian Workers: Guidelines for Good Practice," see the Antares Foundation website - www.antaresfoundation.org.
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