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Chapter 1: Introduction to the Study
Introduction
Humanitarian aid workers experience stressors from their professional,
contextual, and operational environment. Connorton, Perry, Hemenway, and Miller
(2011) found that aid workers, compared to the general population, suffer more extreme
and longer-term affects from stress and recommended that researchers should study how
to provide stress management support for field-based aid workers. The impact of
untreated stress may result in such long-term problems as anxiety, sleep disorders, and
digestive disturbances (Schwartz, Hunt, Redwood-Campbell, & de Laat, 2013). Eriksson
et al. (2009) noted that aid organization stress management services are challenged with
issues surrounding confidentiality concerns by aid workers, a lack of contextual
awareness by counselors, and limited capacity to address the issues raised by aid workers.
Developing an appropriate stress management service requires input from aid workers to
understand the aid workers’ experiences coping with stress and interacting with stress
management services, and the resultant impact on their capacity to deal with stress in a
timely and appropriate manner.
In Chapter 1, I review the problem of why some aid workers choose not to access
stress management services, the evidence with regard to occupational stress, stress
management in emergency services personnel, and stress issues for aid workers. I also
discuss the research approach I adopted to identify and analyze the themes raised by the
participants in the study.
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Background
Different situations cause stress in people. Stress is a natural process that enables
people to respond appropriately to the environment (Selye, 1938). During times of stress,
the body’s natural response is useful to help with fight or flight; however, when the stress
response is sustained or insufficiently resolved, the impact of the stress response may
lead to harmful and negative impacts (Lazarus, 1966).
In a review of the literature, I found a gap related to why aid workers choose to
access stress management services provided by their organizations or prefer not to access
the services. As with any group, humanitarian aid workers require support to facilitate
their ability to cope with stress (Curling & Simmons, 2010). Occupational stress has a
negative effect on not only employees’ performance levels (Nabirye, Brown, Pryor, &
Maples, 2011) and job satisfaction but also on aid recipients. In the humanitarian aid
sector, organizations are under pressure to provide timely, life-saving interventions for
crisis-affected populations. As aid workers experience stress, over time, their
effectiveness at work may decrease (Lopes Cardozo et al., 2013). Any contribution that
helps aid workers effectively manage their stress in ways that are productive and health,
with support productivity levels, benefits the affected population they serve (McCormack
& Joseph, 2012).
The negative impact of stress on humanitarian aid workers eventually influences
efficiency. Researchers (Connorton et al., 2012; Ehrenreich & Elliot, 2004; Eriksson et
al., 2012; McCormack & Joseph, 2012) who have examined stress management services
have revealed that aid organizations inadequately address the distress that aid workers
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experience. Workers in all job types experience issues with stress management, not just
aid workers. Research undertaken in other job types relevant to the aid sector, such as the
emergency services, provides lessons from which to enable efficient systems for aid
workers (O’Donovan, Doody, & Lyons, 2013).
This study was necessary to understand, from the perspective of aid workers, what
stressors they face and how they perceive stress management services. Aid organizations
have a responsibility to their aid workers. Using evidence gathered from aid workers can
help organizations to ensure that stress management services are appropriate and
adequate to meet the aid workers’ needs.
Problem Statement
Year after year, the number of people requiring humanitarian assistance continues
to grow. In early 2015, the United Nations Office for the Coordination of Humanitarian
Affairs (UNOCHA, 2015) estimated that 57.5 million people would need humanitarian
support, based on the trend of doubled need over the preceding 10 years. At the same
time, aid workers who provide humanitarian assistance face increasing challenges,
including poor security, violence, and stress (McCormack & Joseph, 2012). Researchers
have highlighted the impact of stress on aid workers (Allen et al., 2010; Connerton et al.,
2012; Cordozo et al., 2012; Curling & Simmons, 2010; Fecher, 2012a, 2012b; Roth,
2014; Willie & Fast, 2013). Untreated, this stress affects the aid workers’ ability to serve
those in need, as the aid worker is unable to work at an optimal level. Connerton et al.
(2012) found that many aid organizations have acknowledged the vulnerability of their
personnel to stress and the risk to the well-being of personnel. Although a number of aid
4
organizations have introduced some measure of stress management services, Cordozo et
al. (2012) noted that these services are inconsistent and often not comprehensive.
Absent from the existing body of evidence is the aid workers’ perceptions of the
existing services available to them and what services they need to adequately meet their
stress management needs. Ideal stress management for aid workers enables them to deal
with stressors, build resilience to future stress, and recover from stressful events in a
timely manner (Williams & Greenberg, 2014). This study was designed to contribute to
the scholarly literature on understanding the aid workers’ perspective of stress
management provided to them by their organizations.
Purpose of the Study
The purpose of this qualitative study was to understand, from the perspective of
aid workers, the stressors they encounter and how they decide or not to access the stress
management services provided by their organizations. Using a qualitative approach to
gather this information, I explored the aid workers’ experience with and perceptions of
stress management services (Tracy, 2010). This information, gathered through in-depth
interviews, informed an analysis of the common central elements to the participants’
experiences.
Research Questions
RQ1: How do aid workers perceive their work-related stressors?
RQ2: How do aid workers describe their experiences of in-house stress
management services?
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RQ3: How do aid workers describe their decision-making process about whether
to access and use in-house stress management services?
Theoretical Framework for the Study
The theoretical framework for this study was the conservation of resources theory
(Hobfoll, 1989, 2007). Hobfoll (1989) developed this theory as an integrated stress model
to explain how people’s perception of stress is influenced by possible threat or loss. In
this case, resources may be considered as tools, including physical items (such as
electronic devices, apparel, or furniture), social issues (such as friendship or social
standing), and personal characteristics (such as a person’s perceptions about himself or
herself, energy, and capacity to perform) (Hobfoll, 2007).
Based on the conservation of resources theory, Hobfoll (1989, 2007) theorized
that people are in a constant state of desiring to acquire and maintain resources, which
allows them to thrive. Once gathered, the resources must be protected and maintained,
which improves the possibility of survival (Alvaro et al., 2010). Additional details about
the theoretical framework are provided in Chapter 2.
In relation to this study, the conservation of resources theory was applied to
recognize how aid workers gain, preserve, and maintain resources. When stressed, people
tend to lose resources. For aid workers, the potential loss is great, as they live and work in
challenging environments with limited social support to help bolster their ability to cope
with the challenges of the stressor. The conservation of resources theory may help to
explain how resources are lost or eroded. According to the conservation of resources
theory, the loss or threat of loss of resources results in stress (Hobfoll, 2007). As such, the
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research questions were designed to gather information to understand how aid workers
lose resources and how in-house stress management services helps to gather and protect
resources to recover from their stressors’ impact.
Nature of the Study
The phenomenological approach was appropriate to identify the shared
experiences of the participants and to develop an understanding of their experiences
(Holt, 2010). By conducting an in-depth qualitative exploration, I was able to gather
information to understand why aid workers choose to access stress management services.
In the existing literature, explained in more depth in Chapter 2, I determined how
people’s perceptions vary in relation to their experience of stress and their individual
need to access stress management services (Allen et al., 2012; Bardoel, Petit, De Cieri, &
McMillian, 2014; Colley, Lincolne, & Neal, 2013; Creamer et al., 2012; Curling &
Simmons, 2010; De Borros, Martins, Slatz, Bastos, & Ronzani, 2012; Gist, Lubin, &
Redburn, 1998; Kashdan & Kane, 2011; Koesten, Fox, & Radel, 2012; Lopez, 2011;
Marchand, 2012). After analyzing the participants’ perceptions, I identified and analyzed
themes based on how they described their experiences.
Participants were identified through a purposive sampling technique. Those
selected to participate met a set of defined criteria, explained in detail in Chapter 3. Aid
workers are national and international staff, but for the purpose of this study, only
international aid workers were included. I anticipated that most of the aid workers were
based in various locations where humanitarian responses are ongoing; thus, I conducted
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interviews using a video chat online tool of their convenience. Each interview was
recorded electronically and transcribed for later analysis.
Definitions
Aid workers: National or international employees of not-for-profit aid
organizations who provide support to needy populations (UNOCHA, 2012). Aid workers
may work with nongovernmental organizations (NGOs), the United Nations (UN), or the
Red Cross/ Red Crescent movement. International aid workers were the target of this
study.
Distress: Negative stress that can be short or long lasting. Distress negatively
impacts how people can perform and has a negative impact on mood (Lazarus, 1966).
Eustress: Positive stress that tends to be transient. When present, eustress helps to
motivate and focus the individual and support coping mechanisms and improve
performance (Lazarus, 1966).
Emergency services personnel: Personnel involved in fire, medical, or rescue
activities, such as ambulance workers, emergency medical technicians, or firefighters
(National Health Service, 2014).
Hardship duty station: A difficult quality of life in the area of work or duty
station. Quality of life refers to housing, security, basic amenities, access to education,
climate conditions, and so forth (United Nations, n.d.).
Homoeostasis: A tendency towards balance or equilibrium, when influenced by
external forces (Dhara & Mandal, 2015).
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Induction: An orientation process that allows staff members to learn what is
required of them in their role, organization, and operational context (Duffield, 2012).
In house: Within an organization (Wright, 2014).
Occupational stress: Occurs when the demands or work environment outstrip an
individual’s capacity to cope (Babatunde, 2013). Occupational stress may be the result of
tensions between staff members of the same or different levels, an imbalance between an
individual’s ability and skill and the job requirement, or insufficient time or resources to
complete a task.
Productivity: A term used to measure outcomes based on the level of input
(Abramo & D’Angelo, 2014).
Resilience: In terms of psychological well-being, the capacity to resist or adapt to
stress and its impact (Fletcher & Sarkar, 2013).
Stress: A response to a stimulus (Selye, 1936). The resultant response may be
physical, emotional, psychological, or spiritual, and different people may have different
responses to the same stimuli.
Stress management: Any technique that allows someone to deal with the impact
of stress (Hargrove, Quick, Nelson, & Quick, 2011). These techniques may include
mindfulness, physical exercise, deep breathing, and debriefing.
Stressor: A stimulus that causes stress. The stimulus may be an event (real or
perceived), a chemical or biological agent, or environmental condition (Koolhas et al.,
2011).
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Traumatic event: An event that results in distress or physical, mental, emotional,
or psychological harm (Elhai, 2005).
Vicarious trauma: The impact on helpers following their empathetic interaction
with a traumatized person, where the helpers experience a change in their well-being. The
change may be cognitive, emotional, psychological, or spiritual, and it may result in a
change in mood, sleep patterns, and behavior (Vicarious Trauma Institute, 2015).
Assumptions
The success of the study was based in part on several assumptions. First, I
assumed that I would locate a sufficient participant pool to meet the criteria for
participation. In addition, I assumed that participants would provide honest and open
responses to the questions and would be willing to engage with the process and provide
verification on points needing clarification. Finally, I assumed that the participants in the
study were representative of the general aid worker population, including representing the
gender to which they affiliate.
In order to ensure effective planning for this study, I made the above assumptions.
Then, within the context of this study, I ensured that there was a plan outlined to address
each assumption to protect the integrity of the study, the participants, and the findings.
Where an assumption affected the findings, I acknowledged this to the reader in an
honest manner.
Scope and Delimitations
The research problem was specific to aid workers; therefore, international aid
workers were targeted as the participants. The sample participants were chosen from a
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broader set of aid workers based on a set of defined criteria. Each participant had to have
at least 5 years of experience as an international humanitarian aid worker, had to be able
to communicate in English, and acknowledged past job-related stress. Those working for
the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA)
were excluded, as I work for this organization, and I wanted to ensure that there would be
no risk of multiple relationships or coercion. Participant criteria are explained in more
detail in Chapter 3.
The phenomenological approach was designed to better understand the
perceptions of the aid workers’ lived experience. Twelve participants were interviewed to
achieve saturation (Guest, Bunce, & Johnson, 2006). Chapter 3 provides details of the
research method to allow the reader decide the capacity to transfer the findings to others.
Limitations
The transferability of this information to all aid workers is limited, as the
experiences of these aid workers may differ based on contextual elements and working
for different employers. The contribution this study makes to existing literature includes
opportunities for further study. As an aid worker myself, I acknowledge any bias related
to the issues and remained objective, interpreted the information open mindedly, and
presented accurate findings. I believe that there are benefits to accessing in-house stress
management services. If stress managers have appropriate knowledge of the context
within which the staff operates, then they have an understanding of the issues that the
staff experience. Conversely, I appreciate the concerns related to confidentially that staff
may consider when they consider sharing information with a representative of their
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organization. When their issues pertain to the organization, such as a poor relationship
with their manager, tension and stress can occur. These are biases I acknowledge.
A number of limitations must be acknowledged in the process. Data collection
took place using an online video tool, which may have limited the ability to pick up on
body language, which, in a face-to-face interview, would be seen. In addition, with an
online communication tool, participants were able to withdraw at any time, which could
more readily occur than in a face-to-face interview. Another limitation was a potential
participant’s access to a device and sufficient Internet bandwidth to allow participation in
an online interview. The techniques used to address these limitations are discussed in
Chapter 3.
Significance of the Study
The findings were expected to fill in a gap in the existing body of information
pertaining to stress management for international aid workers. The findings contribute to
advancing policy development in support of aid worker stress management. In a world of
growing humanitarian need, there is increasing pressure to do more with less financial
support. Limited resources place additional pressure on aid workers to deliver quality
support to populations in need. Supporting aid workers’ health and effectiveness in their
work helps to optimize their capacity, productivity, and efficiency. As such, people in
need of humanitarian assistance must rely on aid workers to be as mentally healthy as
possible in order for them to receive timely, appropriate, and effective care.
The study was undertaken with the hope that, in the future, international aid
workers who experience stress will be provided with stress management services that are
12
appropriate to their needs. This shift in their care has the potential to change and improve
the services that aid workers provide to populations in need, thus contributing to a
positive social change in the quality of humanitarian care and support. It may potentially
contribute to better stress management services, which could contribute to a decrease in
humanitarian aid worker burnout.
Summary
In a world of growing humanitarian needs, aid workers bear the brunt of coping
with the stressful operational environment. Aid organizations acknowledge that aid
workers must cope with stress. Although some aid groups provide stress management
support, such services tend to be inconsistent, unregulated, and inadequate to meet the
needs of the aid workers (Cordozo et al., 2012). In this study, I sought to add to the body
of knowledge to understand, from the perspective of aid workers, their experiences of
stressors and their choices to engage or not with stress management services. It is hoped
that this study may contribute to the existing body of knowledge with regard to
humanitarian aid organizations’ stress management services, and, ultimately, improve
those services.
Chapter 2 provides a detailed review of the literature to date in relation to
occupational stress, stress among emergency personnel, and stress among aid workers.
The chapter ends with opportunities for further exploration in the area of stress
management.
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Chapter 2: Literature Review
Overview of the Chapter
In any working environment, enabling personnel to work in a manner that
optimizes productivity but does not compromise personnel safety is paramount. Zeller
and Fang (2013) recommended that organizations should strive to achieve an acceptable
balance of stress management support for staff through the development of standardized
policies based on an understanding of the challenges that personnel encounter in the
working environment. Compounding the usual workplace issues, humanitarian aid
workers must provide timely, life-saving support to crisis-affected communities, which
adds further levels of stress. Aid organizations acknowledge that aid workers are not
immune to stress, and eventually, their capacity to cope with stress impacts on their
efficiency. On the other hand, Connorton et al. (2012) found inadequacies in the stress
management provided by aid organizations.
There are similarities between the issues faced by emergency service personnel
and aid workers; thus, possible opportunities exist to draw from stress management for
emergency services personnel to improve services for aid workers (Tuckey & Scott,
2014). In this study, I highlighted the experiences of aid workers when interacting with
existing stress management services provided to them by their organizations to better the
aid workers’ experience of these services. In the review of the literature, I examine
occupational stress and its management, with a central focus on the stress experienced by
humanitarian aid workers.
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Search Strategy
Although ample literature exists relating to occupational stress and stress issues
faced by emergency services personnel, fewer scholars have focused on the stress
experienced by frontline international humanitarian aid workers and how to manage and
prevent it. To identify relevant literature, I used refined searches in databases such as
ProQUEST, Emerald, SAGE, Oxford Journals, PsycARTICLES, and Taylor & Francis
Online to locate a majority of the articles, predominantly dated between 2009 and 2014. I
refined the search using the terms occupational stress, workplace stress, emergency
services stress, stress management, aid worker stress, humanitarian, stress treatment,
distress, stress coping strategies, recovery, critical incident stress management, and
stress resilience. As a rich body of work exists outside peer-reviewed publications on the
well-being of aid workers, I examined articles published directly by credible
organizations and selected those articles in peer-reviewed publications to develop the
themes presented in this literature review.
Theoretical Framework
The framework for this study was Hobfoll’s conservation of resources. The
conservation of resources theory is an integrated stress model. Hobfoll (1989)
hypothesized that people perceive stress when their resources are threatened or lost.
Resources may be characterized as physical instruments or instruments (such as a home,
clothing, or a vehicle), conditions or social elements (such as being in a relationship,
having a job), personal characteristics (i.e., self-esteem, competencies, or skills), and
energy levels lost or gained (Hobfoll, 2007). According to the conservation of resources
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theory, people strive to acquire and maintain resources, and people thrive when they gain,
maintain, or protect those resources. As such, increased resources imply increased
survival capabilities (Alvaro et al., 2010). Traumatic events deplete resources, the loss of
which increases the level of stress. Conversely, more resources help people to be resilient
to stress and, thus, build defense mechanisms, as those with more resources are less
vulnerable to their loss (Hobfoll, Vinokur, Pierce, & Lewandowski-Romps, 2012).
This study was designed to focus on the stress experienced by humanitarian aid
workers. Physical and psychological stress is a normal reaction to abnormal situations,
and it may not always have a negative impact. Humanitarian aid workers who experience
extreme levels of stress need assistance identifying stress symptoms and impact and
mechanisms to preserve and protect their resources. In this study, I revealed deficits in
the aid workers’ capacity to build and protect their resources to enable them to withstand
the impact of stress. This information was analyzed through the lens of Hobfoll’s
conservation of resources theory. I also explored support networks that can ameliorate the
stress experience and contribute to the literature on how best to support humanitarian aid
workers.
Classical Perspectives on Stress Adaptation
Selye’s Three Phases of Stress Adaptation
Regardless of how stressful a workplace environment can be, humans learn to
adapt. Selye (1938) described three phases of the stress response, which were termed the
general adaptation syndrome (GAS). The first, the alarm phase, is the initial reaction the
body undergoes when experiencing stress. The triphase response is activated as a result of
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the body’s release of adrenaline, noradrenaline, and cortisol (Selye, 1950). These
hormones enable physical activities normally not possible, such as increased physical
strength. The hormones enable an increased blood supply to vital body organs by
reducing blood flow to other areas. Both the blood pressure and heart rate increase to
allow the individual to fight or flee the stressor (Selye, 1938).
The second phase is the resistance stage (Selye, 1950). This phase occurs after the
physiological response to a stressor, usually indicating the resolution of the source of
stress. The body enables recovery and repair, which restores homoeostasis or
physiological equilibrium, over time. The stress hormone levels begin to stabilize and
return to pre-event levels (Selye, 1974). As the body prioritizes energy for recovery and
repair, energy is reduced for other activities, and a person’s defenses lower. Throughout
the resistance stage, the body remains alert for the stressor (Selye, 1950). The third phase
is the exhaustion stage (Selye, 1950). The stress continues, and adaptation ceases. The
body experiences harmful effects of the stress response, and adaptive energy is drained.
Unless addressed, this final stage leads to stress overload or burnout, which is precarious
to an individual’s health, as the elevated stress levels remain heightened (Selye, 1950).
Selye (1982) concluded that all organisms pass through each phase of the GAS response,
as long as the stressor is in place.
Stress, Distress, and Eustress
With time, Selye’s three phases underwent further scrutiny, and not all of the
theories bore fruit. Selye’s contribution remains in the heuristic value of the theory,
which led the development of other theories, such as the work carried out by Lazarus
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(Jackson, 2012). Lazarus (1966) coined the terms eustress to define positive stress and
distress to describe negative stress. Eustress, which helps motivate and focus energy, is
short-lived. Eustress helps individuals cope and improve their performance, and it makes
a person feel excited. Conversely, distress causes anxiety and concern, and it may be
short- or long-lived. People perceive distressing events as outside their ability to cope;
thus, distress feels unpleasant, as it decreases a person’s ability to perform (Lazarus,
1966). The American Psychological Association (2012a) noted the debilitating nature of
stress over time when stress impact is left unaddressed.
Other theories of stress exist, such as Taylor’s tend and befriend theory, which
explains females’ stress response with a tendency to protect her offspring and relates to a
social group for inclusion and social support (Taylor et al., 2000). For the purpose of this
study, Selye’s GAS theory provided the elements to explain how people deal with stress
in a common manner, regardless of gender. The capacity to explain physiological
responses to stress is important as a common denominator for all, rather than in a gender-
defined manner.
Contemporary Research on Occupational Stress
Occupational stress occurs as a result of stress in the workplace. The World
Health Organization (2012) noted how occupational stress results from demands placed
on workers when they have insufficient resources, knowledge, or skills to cope.
Employees can experience occupational stress in any work environment (Heponiemi et
al., 2013). Occupational stress can have a cumulatively negative effect in a number of
measurable ways on the individual (Goodwin et al., 2013). The organization may also
18
suffer with negative impact to productivity and organizational culture (Goodwin et al.,
2013; Lather, Aggarwal, & Samantray, 2011; Meyer et al., 2012). Occupational distress
occurs when stress levels are extreme, prolonged, or unresolved (Marchand, 2012) and is
prevalent as a result of workplace issues.
Stress has a negative effect on efficiency and productivity due to low morale,
absenteeism, substandard production, and resultant health issues (Heponiemi et al.,
2013). Zeller and Levin (2013) noted the large proportion of workplace stressors that
result from workers’ health and safety concerns in their operational environment. Colley
et al. (2013) found that personnel who perceived organizational values in relation to staff
health and safety displayed stronger safety commitments in the workplace. Britain’s
Health and Safety Executive (2009) calculated that 27 million working days between
2011 and 2012 were lost as a direct consequence of stress and related symptoms.
Laschinger, Wong, Regan, Young-Ritchie, and Bushell (2013) provided an estimate of
the cost of workplace distress in the United States as approximately $28.3 billion.
O’Donovan, Doody, and Lyons (2012) described the debilitating effect of distress on
personnel’s capacity to perform and noted problematic effects such as increased
absenteeism and a deterioration in workers’ ability to successfully manage situations
following traumatic events that resulted in the worker experiencing stress. Workers who
experience unresolved stress have a higher rate of sick leave, which results in a reduced
productivity capacity (Lather et al., 2012). Wayne, Casper, Matthews, and Allen (2013)
found that stress related to pressure to perform and tension with colleagues adversely
affects worker performance.
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Chronic stress has been shown to have a long-term impact on individuals’ health.
The effects of occupational stress may be psychological or physical (O’Donovan et al.,
2013; Szeto & Dobson, 2013).
O’Donovan et al. (2013) noted that unresolved stress and
consistently elevated stress hormones can lead to physical repercussions, such as elevated
blood pressure, headaches and backaches, and shortness of breath. The hippocampus
plays a role in the regulation of emotions, and increased stress hormones affect this
regulatory function. McFarlane (2010) noted the longer-term impact of increased stress
hormones may be anxiety, depression, high blood pressure, and heart disease.
Occupational Stress Among Aid Workers
International humanitarian work requires frontline staff to have direct interaction
with individuals who do not share their cultural history. The experience of stress has
cultural interpretations that vary from region to region. Humanitarian aid workers are at
the forefront where suffering is a part of their daily work, with exposure to graphic and
explicit examples of human misery (Roth, 2014). This work environment is inherently
stressful; yet, stress management services are not robust for most of these frontline
employees.
Researchers have depicted the numerous efforts conducted to date in relation to
the stressors that humanitarian aid workers experience and the impact of these stressors in
the short- and long-term. If a region is at peace and no illness has spread among the
people, humanitarian aid workers will not be sent to intervene. Instead, humanitarian aid
workers endure long-term stress due to the nature of the work environment (Pooley,
Cohen, O’Conner, & Taylor, 2013). Aid workers live and work in crisis situations, are
20
confronted by acute suffering, and must attempt to remain physically and mentally
healthy in order to help the affected population (Nilsson, Sjoberg, Kallenberg, & Larsson,
2011).
Researchers have studied the effects of stress on both international and national
humanitarian aid staff and in the context of conflicts and natural disasters. McCormack
and Joseph (2012) found that aid workers experience shame, despair, and self-blame
following traumatic events, such as witnessing genocide, violence, and targeting of
colleagues. Although many organizations have systems in place to support the aid staff,
the support offered is often insufficient to meet aid workers’ needs adequately (Curling &
Simmons, 2013; O’Donovan et al., 2013). As a result, aid workers accumulate stress
impact from different stressors over time.
Aid workers provide humanitarian responses to people who are in need of life
saving support. Cordozo et al. (2012) emphasized the stressful nature of the aid workers’
role and the difficulty in providing appropriate stress management services by aid
organizations. The 2014 Aid Worker Security Report (Stoddard, Harmer, & Kyou, 2014)
confirmed the growing number of incidents of violence against aid workers. In 2013, a
record 251 incidents of attacks were recorded involving 460 aid workers (Stoddard et al.,
2014). Of these, 155 aid workers died, 171 suffered severe injuries, and 134 experienced
kidnaps (Stoddard et al., 2014). The 2013 statistical trend indicates a 66% increase of
violence involving aid worker in comparison to 2012 (Stoddard et al., 2014).
Aid work tends to take place in places where there are security challenges. Roth
(2014) noted how aid workers tend to operate in circumstances where they exert little
21
control over their environment. In their research on security incidents for humanitarian
aid organizations, Willie and Fast (2013) stressed the shifting pattern of violence
experienced by humanitarian aid personnel over the previous 15 years and noted the
numbers of fatalities among aid workers continues to increase. Aid workers must
acknowledge and accept the risk to their safety and security each time they undertake a
mission, as the traditional white flag of humanitarianism is no longer protection against
attack (Roth, 2014).
Often, aid provision is necessary due to the consequences of war. Aid workers
working in front-line humanitarian aid delivery face numerous threats that include
violence, witnessing conflict, vicarious trauma, and safety and security compromises, all
of which may lead to distress (Connorton et al., 2012; Cordozo et al., 2012). Exposure of
this nature may lead to secondary trauma, which should not be discounted in terms of its
potential impact (Elwood, Mott, Lohr, & Galovski, 2011). When members of the aid
team undergo a stressful experience such as a carjacking, other team members not present
may experience stress derived from concerns for their safety and that of their teammates.
As stress is part and parcel of a humanitarian aid worker’s experience, stress
management resources are crucial. Aid organizations acknowledge that operating in
difficult environments contributes to the level of stress that aid workers experience,
leading to distress for which they need help to enable them to cope (Curling & Simmons,
2010). Researchers (Connorton et al., 2012; Ehrenreich & Elliot, 2004; Eriksson et al.,
2012; McCormack, & Joseph, 2012) have found that existing stress management services
are insufficient to deal comprehensively with the distress that aid workers encounter.
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Occupational Stress Management
Occupational stress resulting from employees’ safety concerns is a recognized
worry for organizations seeking to improve worker productivity. Employers and
organizations across different work sectors seeking to achieve optimal productivity have
considered a multitude of factors that influence personnel’s capacity to function
successfully, including stress mitigation, support for workplace safety, and stress
prevention measures (Heponiemi et al., 2013; Loun, Lavin, Riives, & Otto, 2013).
Policies and mechanisms have been initiated to reduce stressors, augment resilience, and
increase the support that employees require when dealing with occupational stress
(O’Donovan et al., 2013) and promote personnel safety (de Baros, Martins, Saitz, Bastos,
& Ronzani, 2012). To provide safer operational environments and thereby reduce stress,
organizations have provided personal protective equipment and response training, such as
fire drills and first aid skill development (Zeller & Levin, 2013). Colley et al. (2013)
reported that as a result of the introduction of safety measures, perceptions improved
among personnel regarding how much an organization valued its staff. Thormar et al.
(2014) found how appropriate use of safety equipment and engagement in safety training
opportunities reduced reported stress levels over time. Zhang and Fang (2013) found
inconsistency in how personnel used and applied safety procedures. For example,
personnel displayed a lack of consistency when using personnel protective equipment.
Zhang and Fang reported some reasons why personnel underuse safety equipment and
safety services, including workers’ ambivalence, insufficient time to don and doff
protective equipment, a limited understanding by personnel as to the nature of the threat,
23
and the personnel’s’ perception about the comfort of the equipment. Williams, Parker,
and Turner (2010) recommended that enforcement of any safety measure requires a
balanced approach that ensures the sustainability of both safety standards and operational
output. Interventions such as the provision of protective equipment and clothing, with
appropriate training, have been shown to help reduce the number of on-site incidents
(Colley et al., 2013; Neal, 2013). Developing an understanding as to the issues personnel
experience in relation to the use of safety equipment and engagement with safety
measures is necessary to overcome the problems, such as compliance challenges wearing
safety goggles (McVicar, Munn-Giddings, & Seebohm, 2013). Understanding these
barriers may enable managers in the emergency services sector and the aid sector to
engage with personnel to enable them to use services appropriately.
Stress Management in the Humanitarian Aid Sector
Although stress management services could provide a robust safety net necessary
to ensure humanitarian aid interventions, the existing measures to support aid workers to
deal with stress appear improvised, inconsistent, and unstandardized. Tol et al. (2012)
recommended that organizations should attempt to deepen their understanding of the
impact of occupational stress aid workers’ experience, both related to prevalence and
impact, to inform the development of stress management services for aid workers.
Nilsson et al. (2011) supported this approach and recommended that a solid
understanding of aid workers’ experiences of their stress is needed to devise stress
management services for aid workers which are inclusive and appropriate. Given the
constant improvements and progress in the stress management services, Tol et al.
24
recommended that stress management practitioner and practices be guided by frequent
reviews of broader stress management services. Continuing the inquiry in other sectors,
such as the emergency services, exploring aid workers’ perspective of their experiences
could provide improved support to aid personnel.
Applying successful stress-buffering efforts among emergency workers may
support emergency personnel of different types who work in front-line critical areas.
Zeller and Levin (2013) found that nurses experienced a reduction in their stress levels
following training in situational awareness. Zeller and Levin further reported the benefits
by the participating nurses who underwent mindfulness training who reported reduced
stress levels by seeking a positive response from stressful situations, which potentially
lowered the risks of the impact of long-term stress among the participating nurses (Zeller
& Levin, 2013). Staff who understood issues that led to stress and their responses to
stressors supported the development of their skills to allow them to deal with stress in a
manner which is timely and predictable. According to O’Donovan et al. (2013), early
identification and mitigation of occupational stressors may limit their long-term effect on
workers. Once a successful strategy has been created, and teams are enabled to increase
their ability to deal with stress effectively, it can provide a community of support to
strengthen systemic engagement with social support mechanisms to use during crisis
events.
Network of Support Systems
Most individuals have a network of support systems that they use in everyday life,
which may include family members, friends, peers, and work colleagues. Kossek,
25
Pichler, Bodner, and Hammer (2011) noted the lack of an accepted singular definition of
social support but offered an explanation that social support is the perception that one is
cared for and appreciated by others. Given the explanation of social support, personnel
want to work in an environment where they feel valued, appreciated, and have access to
support services. Organizations’ approaches to the provision of social support for
personnel lack consistency (Cordozo et al., 2012). For aid workers who are far from
home and away from these organic support networks, social support mechanisms may
vary depending on the staff’s setting (Pooley et al., 2013). In the midst of personal crisis
and distress, people seek additional help, usually from dedicated support systems, such as
a family doctor, a religious leader, or support groups (Cremer et al., 2012). People with
robust social support mechanism appeared to have the impact of long-term stress
mitigated, in comparison to contemporaries with limited social mechanisms, according to
Meyer et al. (2012). Emergency services personnel who perceived limited organizational
support experienced more long-term complications of stress when compared to their
contemporaries (Pooley et al., 2013). Providing a working environment where emergency
personnel work in safety contributes to the effectiveness of their effort and supports well-
being.
Organizations that address workplace stress through robust stress management
services report positive results (Francis, Galappatti, & van der Veer, 2012). Although it is
possible to identify occupational specific stressors, it is difficult to discern the cause of
each stressor to mitigate or prevent it. Not everyone responds negatively to stressful
experiences, and Baron, Franklin, and Hmieleski (2013) found that entrepreneurs
26
appeared to thrive in situations and when faced by issues which others perceived as
stressors. The Baron et al. findings suggest entrepreneurs’ stress responses can be
instructive to help others deal with stress in an effective manner.
As previously explored, organizations struggle to ensure personnel consistently
comply with safety and well-being standards and services, and this is an area which
requires ongoing attention. Understanding the origins of stress is complicated, and
differentiating between stress which originated from the workplace and that from a
worker’s personal life is difficult, noted Newton and Teo (2013). A singular approach
intervention on stress management does not fit all needs recommended by Francis et al.
(2012), and a deeper understanding of different individuals’ needs in evolving contexts is
essential to provide support.
Stress Management Support Systems for Aid Workers
Limited support. Despite the research showing the benefits of managing stress
on an organization and its staff, strong social support mechanisms tend to be limited for
humanitarian aid workers. There is a lack of consistency in stress management support
systems that aid organizations provide for their staff. Findings from a 2004 survey among
nongovernmental organizations (NGOs) about the provision of stress management
support services for aid workers revealed how few of the NGOs who participated had
predictable services in place to support their staff (Ehrenreich & Elliot, 2004).
Interestingly, Ehrenreich and Elliot found of the 100 NGOs approached to participate in
the study, only17 responded. The findings of the study revealed the lack of coherence
amongst these NGOs in the provision of psychosocial support for aid workers and those
27
services in place required development. A decade later, McCormack and Joseph (2013)
observed progress by NGOs on their approach to the well-being of aid workers; however,
further improvement was required. Aid workers need services which are adapted to their
needs and timely in their interventions to support their well-being, recommended Francis
et al. (2012). Health and well-being support systems for aid workers may be in place, but
Francis et al. recommended steps to ensure that psychosocial support services adaptation
are appropriate to the needs of aid workers which commence with a rapid assessment of
their needs. When comparing aid workers to contemporaries, Connerton et al. (2012)
reported the impact of stress resulted in longer-term impact with higher levels of distress.
Eriksson et al. (2012) noted the limited risk posed by predeployment mental health
problems on aid workers’ well-being. Predeployment resiliency factors helped support
the aid workers’ ability to deal with stress. Berger et al. (2015) noted how resilience to
stress enabled people to adapt successfully following a stressful event. There is an
opportunity to support aid workers develop stress resiliency prior to deployment through
an improved understanding of the relevant resiliency factors and areas to optimize these.
Aid workers’ experiences of distress in the working environment may improve with the
use of these measures which would limit the level of distress experienced.
Stress management efforts. Understanding the needs of aid workers, aid
organizations offer a range of psychosocial support services which include stress
management. Curling and Simmons (2010) found the variety of services included regular
breaks out of the operational environment, enabling contact with family and friends,
stress management training, and access to stress counselors. Francis et al. (2012) found
28
other measures such as peer support and managerial level training to support staff formed
part of the support provided by aid organizations.
In recognition of the challenges aid workers face in their work environment, some
aid organizations offer or make mandatory dedicated skills training to support how they
deal with threats such as kidnapping (Connorton et al., 2012). Duffield (2012) found that
singular stress management training was inadequate. Duffield recommended training
which improve aid workers’ resilience to stress to mitigate negative impact rather than
training which focused on how aid workers protect themselves behind physical barriers
such as high walls and razor wire.
The ability to deal effectively with stress improves the capacity to make effective
decisions under duress (Meyer et al., 2012). As workers tend to live immersed in the
areas where they operate, it is difficult to separate personal from professional issues
(Fechter, 2012a). Nilsson et al. noted that additional traumas, such as exposure to chaotic
events such as conflict, massive population displacement, or the impact of a natural
disaster, and the resultant humanitarian needs of the affected population, were further
sources of distress to aid workers. As such, aid organizations must adopt support services
for their personnel that reflect the distinctive nature of the issues aid workers face and the
environment within which they work to effectively support their stress management
needs.
One psychotherapy approach is cognitive behavioral therapy (CBT), of which
there are different types. CBT developed from work evolving from behavioral therapy
and the introduction of cognitivism in the 1960s (Gu, Strauss, Bond, & Cavanagh, 2015).
29
The approach seeks to identify and alter maladaptive thought processes to affect behavior
changes in a positive manner. CBT commences with an assessment where critical
behaviors are assessed with a therapist and identified as excessive or deficient. A baseline
of these critical behaviors helps to identify their frequency, intensity, and duration (Gu et
al., 2015). The therapy supports the patient to lessen excessive behaviors, and where
deficient, increase necessary behavior as part of skill acquisition to reconceptualize their
thinking. The patient must learn to use these skills and maintain their use. Following
treatment, a follow up assessment measures the impact of the training against the baseline
obtained in the initial assessment (Gu et al., 2015). A limitation of CBT is the
requirement to have multiple sessions with the patient to identify the critical behaviors,
and the need to acquire a skill and use it which risks high dropout rates (Imel et al.,
2013). CBT requires an alteration in the pattern of thinking; however, a framework for
what would be considered normal or healthy thinking is absent, and as such, difficult to
prescribe, in particular in the context of aid work. As such, in the realm of an appropriate
approach for use for international aid workers deployed to a variety of contexts, CBT
may not offer the necessary support for immediate use.
A potential model for use in these circumstances is called critical incident stress
management (CISM). The components of CISM are (a) pre-incident planning, which
includes policy development and training; (b) crisis assessment, (c) strategic planning, (d)
individual crisis intervention, (e) large-scale intervention, such as school or community
support programs, (f) small group crisis interventions, including defusings and critical
incident stress debriefings (CISD’s), (g) individual crisis intervention, (h) pastoral crisis
30
intervention, (i) family support services, (j) follow-up and other significant services, (k)
referral services, (l) post-incident education, and (m) links to pre-incident planning, with
preparations for subsequent crises (Mitchell, 2004).
The aim of CISM is to mitigate, and where possible, to prevent distress that
results from a crisis event. The pre-crisis preparation stage allows for training and policy
development. Pre-incident training is intended to prepare populations for likely disasters
and crises by inoculating them from traumatic stress where possible. It also is intended to
train responders as how to best respond to disasters and crises to mitigate the ensuing
stress. For a large-scale incident, this stage includes mechanisms for timely information
sharing, advisories, and demobilization. Defusing refers to a three-phase process, where
within hours of the crisis, small structured group discussions take place with the objective
of assessing, triaging, and mitigating acute symptoms.
CISD refers to structured group discussions and processing of the event, up to 10
days after the event, though often within 72 hours post event. This model of debriefing is
intended to mitigate acute symptoms by processing participants’ reactions to the event.
Debriefing has been criticized by multiple sources (La Greca & Silverman, 2009; Miller,
1998; Raphael & Meldrum, 1995; Stuhlmiller & Dunning, 2000) because of findings that
suggest it can do harm to participants by having them relive the trauma before they have
the necessary resources to cope with what psychological reactions result from this. The
debriefing proposes to mitigate acute symptoms and allow assessment for follow-up
interventions. Debriefing in this manner grew from earlier work that received criticism,
31
and it is worthy of dedicated attention (La Greca & Silverman, 2009; Miller, 1998;
Raphael & Meldrum, 1995; Stuhlmiller & Dunning, 2000).
During World War II, Colonel John C. Flanagan (1954) developed the critical
incident stress reduction technique to gather information from direct observation of
people’s behavior, which informed possible solutions to help solve practical problems.
Everly, Flannery, and Mitchell (2000) further developed Flanagan’s work and devised
critical incident stress debriefing (CISD). Mitchell (2004) explained that CISD aimed to
support those who experienced a traumatic event or critical incident through a focused
discussion on the crisis event to reduce distress and help restore team cohesion and
performance.
Further studies on the efficacy of CISD, however, raised concerns. Although
Tuckey and Scott (2013) argued that critical incident stress debriefing is valuable when
applied as an early intervention and where the debriefing focused on the positive
outcomes of the event not the negative trauma, they noted that there is a risk of harming
participants through the recounting of the traumatic incident before they have the skills
needed to cope with the re-telling. Bisson, Jenkins, Alexander, and Bannister (1997) used
CISD with burn victims and reported the limitations of single incident psychological
debriefing, such as the potential to re-traumatize participants during debriefing. Re-
traumatization of participants during debriefing was a repeated critical issue noted by a
number of practitioners and researchers (Gist, Lubin & Redburn, 1998; La Greca &
Silverman, 2009; Litz, Gray, Bryant, & Adler, 2002; Miller, 1998; Raphael & Meldrum;
1995; Stuhlmiller & Dunning, 2000). Litz et al. (2002) questioned the appropriateness of
32
debriefing as a tool during early intervention following trauma for survivors, and
concluded that psychological first aid is an appropriate initial intervention.
Litz et al. (2002) undertook a meta-analysis of six studies carried out between
1996 and 2000 to understand if sufficient data were available to decide on the benefits or
limitations of psychological debriefing, specifically as described in CISD, and concluded
that psychological first aid is an appropriate initial intervention, as might be cognitive
based therapy (CBT). The Litz et al. findings included a critique of psychological
debriefing as described in the CISD approach, in light of sound scientific evidence. Litz
et al. noted the possible attraction of CISD for emergency services personnel, as it is
focused on psychological debriefing, during which individuals share their responses to
the trauma. The authors were cautious, however, about the efficacy of the intervention.
Litz et al. critiqued psychological debriefing as described under CISD, and called for
further research. Their criticism of CISD was the re-traumatization suffered by some of
those who recounted their experiences as part of the debriefing process but who were not
prepared with coping skills to handle what the recounting brought up for them. Litz et al.
discussed the potential benefits for homogenous groups of trauma survivors as a means to
validate their experience and empower them, however, the authors noted the need for
further research into the appropriate timing of psychological debriefing, as evidence
conflicts regarding when best to intervene. Litz et al. noted how some participants may
benefit from a delay in engagement with psychological debriefing when they have unmet
pain management issues, while they noted that Mitchel and Everly (1995) promoted early
intervention. Based on their meta-analysis, Litz et al. concluded that applying
33
psychological debriefing may add value to some early interventions, but it cannot be used
to prevent issues such as PTSD. Some participants of debriefings are exposed to reliving
the traumatic events prior to having the necessary coping strategies in place, and this
potentially causes them harm. Litz et al. noted the CISD design aims to support
emergency service workers, a group that includes fire and rescue workers, police, and
emergency room personnel. The authors noted the inherent resilience such workers
develop to adjust to their working environments, and how CISD fails to adequately
acknowledge this resilience. As such, Litz et al. questioned the process by which people
or groups are identified as appropriate to undergo CISD. CISD does provide particular
attention to the individual needs of those at risk (Litz et al., 2002). The lack of capacity of
the CISD approach to take into consideration any resilience the worker has developed
may result in the inappropriate inclusion of some staff in CISD.
Raphael and Meldrum (1995) asserted that the timing and appropriate use of
debriefing is essential to participants to avoid re-traumatization when participants who
lack proper coping skills prematurely relive the trauma and become overwhelmed and
unable to cope. An additional and equally important concern is secondary traumatization
of participants. Bisson et al. (1997) also noted the potential for adverse effects of
psychological debriefings, during which participants undergo intense re-exposure to their
trauma through recollection of the events. Kagee (2002) critiqued previous studies of
CISD and stated researchers ignored contrary findings, such as the potential to re-
traumatize participants during the debriefing, in their bid to promote the benefits of
34
CISD. Regal (2010) reported the impact of CISD in some circumstance was neutral at
best and harmful at worst.
In rebuttal of these numerous criticisms, Mitchell (2003) analyzed 64 studies that
used psychological debriefing and critiqued each one. In essence, Mitchell suggested the
technique itself is not harmful, but its practice may be faulty. Some of the common
mistakes Mitchell cited included the lack of inclusion of CISD as part of a broader
support package, debriefings undertaken by untrained personnel, the prolonged duration
of time between the event and the debriefing, and that the debriefing did not always occur
only after basic life-saving needs were addressed, such as the provision of shelter, water,
and food. Everly et al. (2000) also countered some criticisms of the CISD techniques and
cited the lack of appropriate training of debriefing technicians. Hawker et al. (2011)
countered further criticism by noting that some clinicians failed to adhere to the
guidelines related to process, duration, timing, and participants. Currently, CISD is
primarily used with emergency services personnel, however, some sections of the
emergency services use caution when carrying out CISD, and it is rarely used outside this
sector (Hawker et al., 2011).
Individual crisis intervention is not part of CISD but rather would be a referral to
someone who would see the impacted individual privately if all earlier interventions of
CISM failed to adequately help mitigate the traumatic stress. Individual crisis
intervention may include counseling or psychological support depending on the needs of
the person. Family support services are intended to support the family as a unit. Follow-
35
up and other significant services are intended to address any issues identified through the
assessment, such as support to deal with subsequent incidents (Mitchell, 2004).
CISM is intended to support the individual to cope with critical traumatic events,
such as a sudden death or a critical work-related event. Manajan (2010) noted the
importance of learning from critical incidents to improve the individual and
organizational capacity to respond to such events without the emergency service workers
becoming re-traumatized. Mitchell (2004) explained that CISM remains relevant in
multiple settings such as for front line health care staff and emergency services personnel
(Müller-Leonhardt, Mitchell, Vogt, & Schürmann, 2014). The field of crisis intervention
support continues to evolve to meet the needs of personnel. It is important to note,
however, that most people are simply having normal reactions to abnormal events, and do
not require therapy (Mitchell & Everly, 1997).
The different components of CISM allows the relevant elements be selected to
help those who experience a strong response to a traumatic event. Mitchell and Everly
(1995) proposed that this comprehensive approach should include pre-event training to
assist people to deal with the impact of crises and trauma. The various CISM components
should be interlinked to ensure a planned, versatile, and adaptable approach to crisis
management, and Mitchell recommended combining components of CISM for optimal
results in support of the participants. The interlinked components of CISM can be
successfully utilized, with the elimination of the CISD portion (La Greca & Silverman,
2009). Müller-Leonhardt et al. (2014) noted the elimination of the debriefing component
limits the risk of re-traumatizing participants.
36
Psychological first aid (PFA). The intention of PFA, like that of CISM, is to help
reduce the long-term negative impact of traumatic stress. PFA was developed by the
National Center for Post Traumatic Stress Disorder (NC-PTSD) in conjunction with the
United States Department of Veterans Affairs in 2006 (Everly, McCabe, Semon,
Thompson, & Links, 2014). The most senior level global humanitarian group, the
InterAgency Standing Committee (IASC), endorsed PFA as a recommended support
mechanism. PFA is used immediately following critical events, such as a natural disaster,
to help people cope (Lewis, Varker, Phelps, Gavel, & Forbes, 2013). The aim of PFA is
to utilize nonintrusive, pragmatic support, based on one’s assessed needs (Lewis et al.,
2013). Litz et al. (2002) strongly supported the provision of basic comforts and support to
trauma survivors which help to address people’s needs, such as that offered from PFA.
Psychological first aid is a framework for crisis response to support both survivors
and responders to traumatic events (Shultz & Forbes, 2013). The basis for the PFA
framework is the human need in the aftermath of a crisis for basic life-saving services
(such as liquids, food, clothing, and shelter), communication and information, and social
support. Psychological first aid facilitates people impacted by trauma to share
experiences, without requiring the person to relive the event they survived. Skogstad et
al. (2013) noted that being involved in, or witnessing, a traumatic event can challenge a
person’s reality. PFA offers an opportunity to reaffirm the person is having a normal
reaction to an abnormal event. The PFA worker can validate the person’s reported
experiences as those that can be expected subsequent to the critical incident (and are,
37
therefore, “normal”). Such interactions help people to cope with their experience and
commence restoration of their equilibrium.
The components of PFA include protecting the individual from harm, which gives
people the chance to talk, without pressure, with someone who actively listens with
compassion (Allen et al., 2010). Based on the issues identified by the individual, such as
the expressed need to communicate with loved ones, the concerns are acknowledged and
addressed, with access to services and a discussion of coping strategies. Schafer, Snider,
and van Ommeren (2010) highlighted the benefits of social support mechanisms and
noted the empowerment perceived by aid workers involved when PFA was applied for
survivors of the 2010 Haitian earthquake. In the aftermath of a critical incident, normal
people are said to have normal responses to abnormal events (Mitchell & Everly, 1995).
The implication is that people may need brief support to regain their pre-incident level of
functioning, but most people will not require therapy. The above statement attributed to
Mitchell and Everly (1995) with regard to CISM, is also applicable to PFA.
As in critical incident stress management, in PFA appropriate referrals are made
for those needing follow-up. Psychological first aid allows validation of the individual
experience of events as they relate to that person. Someone will actively listen to that
story with compassion (Shultz & Forbes, 2013). Providing practical assistance through
connection with social support mechanisms helps the person to engage with social
support networks. Contact through support networks helps people adjust to their new
reality and promote the ability to seek support from those who care about them, and
enables them to communicate their experience (APA, 2012b).
38
Following endorsement by the IASC, the World Health Organization (WHO) and
several nongovernmental organizations (NGOs) adopted PFA to support survivors of
natural and human-caused crises (WHO, 2011). Shultz and Forbes (2013) noted the
unprecedented uptake in the adoption and application of PFA in the aftermath of the 9/11
attacks. They credited the uptake of PFA in this circumstance to the concurrent
dissemination by mental health experts and international guideline recommendations for
PFA use as a best practice in the early interventions for trauma survivors.
After the 2010 earthquake in Haiti, two NGOs, World Vision International and
War Trauma International, rolled out PFA for survivors of the crisis (Schafer, Snider, &
van Ommeren, 2010). Schafer et al. (2010) reported positive feedback from the NGO
staff who participated. Allen et al. (2010) noted that when PFA was used in support of aid
personnel following Hurricane Gustav, it increased aid workers’ confidence in dealing
with the affected population. PFA utilizes available resources and existing support
mechanisms to facilitate responders’ recovery.
In-house stress management services. Many aid organizations provide in-house
services for their staff. Eriksson et al. (2012) highlighted aid organizations’ responsibility
to provide relevant stress management support to staff, yet stress management service
provision lacks standardization and regulation within the aid sector (Cordozo et al.,
2012). In-house stress management services range from dedicated stress counselors to
stress management training for staff. Duffield (2012) found that current aid worker
training is insufficient to meet the aid workers’ needs to enable them to cope adequately
with the stressors experienced in their operational environment. Duffield recommended
39
providing resiliency training as an additional mental health support mechanism for aid
workers. These findings suggest there is a need to understand how aid workers perceive
existing in-house stress management services and their experiences interacting with these
services to appreciate their relevance.
Unmet Needs
A number of areas continue to require attention to provide support for emergency
services providers. Applying the existing knowledge to establish effective stress
management and support mechanisms is critical because aid workers repeatedly see and
hear of traumatic events that put them at extremely high risk for vicarious traumatization.
PFA may provide a good antidote to this traumatic stress. For some organizations, the
approach to personnel safety is based on litigious concerns or efforts to maximize
productivity, rather than a commitment to staff well-being (Colley et al., 2013). In
countries such as Britain it is used as a response to national legislation of new or
increased health and safety standards (Godwin et al., 2013). Providing support for aid
workers must be enshrined in the organizational commitment to those they serve (Willie
& Fast, 2013). Meyer et al. (2012) called for further research into resilience development
among emergency services personnel to inform emergency personnel training.
Additionally, Skogstad et al. (2013) noted the higher propensity of professionals to
develop posttraumatic stress disorder in the absence of adequate specialty stress
management training. Eriksson et al. (2013) highlighted the potential to maximize staff
capacity through training to develop support mechanisms to help peers during and after
traumatic events. This training would help organizations to enable staff to build stress
40
resilience and devise social support structures to mitigate and prevent the negative impact
of stress. Deepening the understanding of stress, with the development of an appropriate
mechanism within the emergency services, has the potential to inform other sectors’
practices.
Posttraumatic growth. The ideal outcome of surviving a traumatic event would
be to achieve posttraumatic growth. Pooley et al. (2012) defined posttraumatic growth as
an adaptation of positive behaviors and cognitive processes. An example of posttraumatic
growth might be individuals who suffered a traumatic event changing what they perceive
as important following the event, and developing a richer appreciation of life and of
things they previously took for granted. Teodorescu et al. (2012) found that people who
developed posttraumatic growth altered their approach to life. Kashdan and Kane (2011)
noted that personal confidence may increase following a period of posttraumatic growth
as the person pushes boundaries and deals with risk differently. As such, PTSD is not an
inevitable outcome of a traumatic event experience. A small subset of people who
experience trauma have a positive result in the form of posttraumatic growth. Although
outside the parameters of this study, further research is needed into what best contributes
to posttraumatic growth (versus PTSD) as a means to help aid workers and all others
responding to events that may result in traumatic stress.
Summary and Conclusion
Throughout this literature review, several themes emerged pertaining to aid
workers’ perceptions about stress management services available to them, and their
rationale for engaging or not with these services. Although occupational stress affects all
41
workplaces and sectors, humanitarian aid workers may have higher risk factors for
trauma exposure than other job classes (Connerton et al., 2012). Exposure to human
suffering has the potential to lead to long-term impact and distress (McFarlane, 2010).
Enabling stress management systems, services, and resilience among personnel increases
coping capacity and long-term well-being (Bardoel et al., 2014). In the humanitarian aid
sector, additional pressure associated with providing timely life-saving interventions for
crisis-affected populations exacerbates workplace stress. Existing stress management
interventions provided by aid organizations are insufficient to alleviate stress for
humanitarian frontline staff (Connorton et al., 2012). Understanding aid workers’ needs
and relationships with existing stress management services is vital for creating
appropriate interventions to meet their needs. To inform such action, documenting
humanitarian aid worker perceptions of stress management services could inform a
review of the existing services provided.
Emergency service personnel and aid workers encounter comparable workplace
urgency issues (Blake et al., 2013). Improvements in stress management offered to
emergency service personnel may inform improvements to services for aid workers
(Tuckey & Scott, 2014). Optimizing productivity in any operation requires appropriate
measures to enable personnel to work safely. There are a number of techniques
successfully used to support emergency services personnel, such as CISD and PFA.
Further adaptation of these techniques for dedicated use in the aid sector has shown some
success (Schafer, et al., 2010; Vergara, & Gardner, 2011). Gaps in understanding remain
unknown. For example, whether the same problems with CISDs used with emergency
42
services personnel will exist in the aid sector, or whether an adaptation of CISM services
that omits CISDs will be effective in the aid sector. Further, while PFA seems the ideal
intervention approach for many other sectors, its efficacy has yet to be adequately
evaluated in the humanitarian aid sector.
In Chapter 3, I describe the phenomenological, qualitative approach I used to
gather and analyze data through interviews with humanitarian aid workers—more
specifically, the information used to identify and analyze, from the perspective of
international aid workers, the key elements that enable and inhibit them from engaging
with stress management services. Insight from these perceptions are hoped to contribute
to positive social change for international humanitarian aid workers by contributing to the
scholarly literature on traumatic stress response.
In conclusion, in this chapter a wide range of literature (Allen et al,. 2010;
Connorton et al., 2012; Cordozo et al., 2012; Curling & Simmons, 2010; Ehrenreich &
Elliot, 2004; Eriksson et al., 2012; Fechter, 2012b; Nilsson et al., 2011; Tol et al., 2012;
Williams & Greenberg, 2014) was examined that supports the importance of support for
emergency service personnel. Although the impact of stress on aid workers is known,
more research is needed on the elements aid workers perceive as important when
choosing to engage or not with stress management services. Therefore, the gap in the
literature suggested a need for a qualitative study in which aid works are interviewed
about their perceptions of stress management services and what makes them seem worthy
of engaging in or not.
43
The methodology chapter provides details about the proposed process to gather,
analyze, and interpret the data to fill this gap. As an inductive study, the proposed
approach was designed to learn from the real-world experiences of aid workers to
potentially help find better ways to cope with stress. The information was used to identify
and analyze, from the perspective of aid workers, the key elements that enable and inhibit
aid workers from engaging with stress management service. In the next chapter the
sample, data gathering and data analysis plans, ethical concerns, and triangulation plans
are discussed.
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Chapter 3: Research Method
Introduction
Aid workers experience high levels of stress associated with their occupational
experiences. In the first two chapters, I provided details of the evidence gathered to date
surrounding occupational stress, stress management in emergency services personnel, and
stress issues for aid workers. In the literature review, I revealed the wealth of existing
research around stress management for emergency services personnel. The challenges aid
workers face in their working environment are well documented (Blake & Taylor, 2013;
Connorton et al. 2012; Cordozo et al., 2012; Curling & Simmons, 2010; Duffield, 2012;
Ehrenreich & Elliot, 2004; Eriksson et al., 2012; Fechter, 2012b; McCormack & Joseph,
2012; Nilsson et al., 2011; Roth, 2014), and there are some stress management services
provided to aid workers. A gap in the current research relates to aid workers’ relationship
with the stress management services provided for them by the aid organizations for which
they work. In this chapter, I outline the rationale for the research methodology, how the
participants were identified, and measures to ensure trustworthiness of the data.
Research Design and Rationale
The aim of this study was to understand a gap in the literature related to how
international aid workers perceive their work-related stressors and their subsequent
experiences of in-house stress management services. Further, I aimed to describe the
factors that influence aid workers’ decisions to access in-house stress management
services. To gain an understanding from the perspective of the aid worker, a qualitative
method was appropriate following a course of phenomenological inquiry. With this
45
approach, participating aid workers described their lived experiences of stress
management services and the stressors that prompted their use (Tuohy, Cooney, Dowling,
Murphy, & Sixsmith, 2013). The phenomenological inquiry allowed analysis through the
emergence of themes from the information shared by the participants.
The research questions posed for this study follow:
RQ1: How do aid workers perceive their work-related stressors?
RQ2: How do aid workers describe their experiences of in-house stress
management services?
RQ3: How do aid workers describe their decision-making process about whether
to access and use in-house stress management services?
Aid workers operate in challenging environments, and their capacity to deal with
stress has the potential to impact their performance. Those who have unaddressed stress
issues risk psychological, emotional, and health challenges (Eriksson et al., 2013). In the
aid sector, the long-term negative impact of stress may compromise the aid workers’
ability to provide optimal services to populations in need. The central concept of this
study was that aid workers experience stress and have access to stress management
services, yet not all aid workers do access these services (Connorton et al., 2012).
The qualitative approach is an interpretative process that allows a researcher to
understand an experience from the perspective of the participants (Barratt, Choi, & Li,
2011; East, Jackson, O’Brien, & Peters, 2010)—in this case, the aid workers’ shared
experiences, behaviors, and reasons that govern their behavior. The phenomenological
approach best fits a problem based in the past, wherein the participants relate their
46
retrospective experience; thus, the phenomenological approach suited this study (Holt,
2010). To gather sufficient data with thematic prevalence, Guest, Bunce, and Johnson
(2006) recommended researchers interview 12 participants.
To gather the required data, I conducted in-depth, semistructured interviews,
using open-ended questions. Interviews were carried out on a one-to-one basis, in a
location chosen by each participant to conduct his or her interview over Skype, as guided
by Merry et al. (2011). Interviewing multiple persons who met the defined inclusion
criteria allowed me to locate the universal nature of the participants’ experience (East et
al., 2010; Granot, Brashear, & Motta, 2012).
Role of the Student-Researcher
I currently work on the Syria crisis for the UNOCHA and recently worked in
Sierra Leone and Pakistan. The site for data collection was outside of my former and
current humanitarian aid work locations, thus limiting any impingement on my
professional relationships with participants. In addition, targeting workers who did not
work for UNOCHA prevented any risk of inclusion of those for whom I have a
supervisory relationship. I undertook a number of steps to ensure those participating in
the study received timely and relevant information with regard to their rights when
participating in this study. To ensure that the ethical and legal requirements of conducting
this type of study were met, I embarked on this study with a sufficient level of training,
competencies, skills, and understanding of the required information to undertake this
research, as recommended by Bell and Salmon (2012). I ensured appropriate planning
and preparation to minimize any harm, real or potential, to the participants. I designed the
47
instrument, gathered the data, and conducted the data analysis myself. I carried out the
interviews in person and analyzed the data with support from my dissertation supervisors,
ensuring compliance with ethical and instructional guidance.
Critical to this study was the need to identify, acknowledge, and bracket any areas
of judgment or bias to ensure that the analysis of the findings accurately reflects the
participants’ input (Tufford & Newman, 2012). Chenail (2011) recommended that
researchers take the time to identify and reflect on any bias they might hold. As an
operational aid worker who has suffered stressful periods during deployment, I
acknowledged preformed judgments regarding some aid workers’ behaviors and my own
potential conflict of interest. I provided participants with transparent information about
my professional role in UNOCHA as distinct to that of my role as a researcher. I studied
the experience of other aid workers from organizations other than UNOCHA who operate
in a different field location, thus, minimizing the risk of multiple relationship issues
(Holt, 2010).
As I wished to gain a better understanding of aid workers’ stress management
experiences through this research, there was a risk that the participants would become
upset during the interviews. I informed potential participants of the risk and had a plan to
provide them with options to access no-cost or low-cost stress management services if
needed (Boblin, Ireland, Kirkpatrick, & Robertson, 2013) through the United Nation’s
Department of Safety and Security (UNDSS), which provides stress management support
for staff of the United Nations and for NGO staff (UNDSS, 2013).
48
Methodology
Participants and Sample
The sampling technique was purposive to ensure targeting of appropriate
participants from a homogenous sample of international aid workers. International aid
organizations hire national and international staff. For the purpose of this study, only
international staff were targeted as they do not have the social support structures in the
locations where they work such as those that the national staff have. Their homogeneity
arose from their status as international staff. In a purposive sampling method, researcher
seeks to identify participants based on defined characteristics (Stoto et al., 2013). I set up
a Facebook page targeting aid workers solely for the purpose of identifying potential
participants. I shared the link to this page with my existing network of aid worker
Facebook friends and asked them to share the link with their friends. In this way, the
information reached a range of aid workers from the UN, NGO, and international
organizations to target them as potential participants. I posted information to describe the
study, the inclusion criteria, and how interested individuals could contact me for further
information. Potential participants contacted me via e-mail for inclusion.
The inclusion criteria were staff members who had been working with an NGO or
any UN system member, except UNOCHA, and who had 5 or more years of international
aid work experience. Given the number of years of required emergency employment,
participants were at least 23 years of age and under 62 years of age as this is the
retirement age cut off. The duration of time spent as an aid worker was not inclusionary.
International aid organizations recruit international staff at the international level, and as
49
such they come from a variety of backgrounds and nationalities. Their commonality was
as an international aid worker. The participants had to be sufficiently fluent to converse
easily in English and not undergoing mental health treatment at the time of the interview.
Boblin et al. (2013) recommended that the criteria reflect the ethical guidelines of
beneficence, justice, and respect for participants. Thus, the exclusion criteria were those
who were working with UNOCHA and had less than 5 years’ experience as an
international aid worker.
Based on the inclusion and exclusion criteria articulated in the Facebook post,
participants contacted me via e-mail to nominate themselves for participation. Upon
receipt of the contact, I cross-checked each participant’s details against the inclusion
criteria to verify his or her relevance. Once verified, I sent out the requirements for
participants, the provisions for assuring confidentially, and the informed consent process
details. Those not selected received an e-mail of gratitude for their interest, along with an
explanation that their profile did not match the criteria.
Twelve international aid workers met the above stated criteria, with an aim to
reach saturation (Guest et al., 2006). Guest et al. (2006) found that new information
appeared within the first six interviews in a qualitative study and that themes are repeated
in subsequent interviews. As such, I interviewed 12 international aid workers, who were a
homogenous group, and I knew saturation was reached when the participants’
information was repeated and no new information was shared. The participants were not
recruited based on gender definitions to avoid gender stereotyping (Heilman, 2012). The
50
experiences and concerns were weighed equally to strengthen the identified information
(Tomova et al., 2014).
The process of informed consent follows: The participants received a written
consent form that stated the purpose of the study, details of the boundaries of
confidentiality, explanations of the absence of remuneration, and the study parameters
including duration and the chance the process might involve more than one interview
with the participant (Tabor et al., 2012). In the consent form, I stated the potential for
discomfort to the participant. Each participant received a request to read the statement
and e-mail me their statement of consent, while retaining a copy for their record.
Instrumentation
A semistructured interview process was used to collect the data. Although formal
in its structure, I began with some informal greetings and explanation of the process to
allow the participants to be at ease and ask any questions they have. I used a set of
predefined questions to guide the interview; however, if a participant deviated from the
trajectory set to a relevant area of description, then I perused the direction with a relevant
line of inquiry (Irvine, Drew, & Sainsbury, 2013). Once the relevance of the direction
departed from the central themes, I returned to the preset question guide. The interview
was expected to take an hour to an hour and a half, depending on the participants’
responses.
The data collection instruments for this study were audio recordings of each
interview and a sheet to record the participants’ demeanor. Each interview recording was
transcribed to allow me to analyze the data. The transcripts of the interview were
51
reviewed against the documentation of the participants’ demeanor during the interview.
During each interview, in addition to digitally recording the interviews, I took notes
based on my observation of the participant during the interview. Recording this
information helped verify emotions associated with elements of the participant’s narrative
(Fast, 2010). These notes helped capture descriptions of any residual impact on the aid
workers from their experience (e.g., laughing about an exchange they found upsetting at
the time but, in retrospect, they saw in a humorous light).
There are limitations to the use of an online video interview technique to gather
the data. There was a possibility that conducting an online interview versus an interview
in person would limit my capacity to pick up on nuances, as I was not in the room with
them. Although there was a possibility of using the video tool for voice only by turning
off the video component, there is value to seeing the participant’s body language as one
undertakes the interview (Rodham & Gavin, 2006). For example, a participant may have
displayed anxiety pertaining to some point by shaking their leg, which I did not see on
the video. I was aware of this limitation and was vigilant to any nuances. Another
limitation I acknowledge was that an online tool increased the likelihood of the
participant dropping out more readily than in a face-to-face interview. I accepted this
limitation and was prepared with alternative participants to interview should this have
arisen.
Data Collection Techniques
Data collection took place through semistructured, open-ended questions. This
process allowed me to gain the essential meaning of each participant’s experience, in
52
order to build an understanding of the invariant structure of their experience (Granot,
Brashear, & Motta, 2012). I protected the identification of the participants. Each
interview was planned for 1 hour to an hour and a half. I recorded each aid worker’s
interview for accuracy using a voice recording device and then transcribed each
participant’s interview. Where a clarification was required, I contacted the relevant
participant to ensure that I accurately understood the point.
The interview questions were designed to gather information relevant to answer
each research question. I used open-ended interview questions for each research question
to explore the aid workers’ experiences to help understand their behavior. The interview
questions formed part of the institutional review board (IRB) application for approval,
and only the questions approved by the IRB formed the interview approach (Walden
University, n.d.). The interview questions follow:
RQ 1: How do aid workers’ describe their experiences of in-house stress
management services?
• Tell me about your experience interacting with in-house stress management
services.
• Describe your impression of the help the in-house services gave you.
• How does accessing the in-house services compare with your experience on
other methods of dealing with stress?
• How do you view the stress management services within your organization?
• What was your impression of the stress management services? What did you
think of the support they offered?
53
• If you experience distress in the future, how do you think you will deal with
the stress? Would you return to the stress counselor?
RQ 2: How do aid workers perceive their work-related stressors?
• Would you please describe the work-related stressors you experienced?
• What is the impact of work-related stress on your ability to function in your
job?
• Would you please share how work-related stressors compare with stressors
from your personal life?
• Would you please share your perceptions as to the role your gender plays in
terms of the stressors you experienced?
RQ3: How do aid workers describe their decision-making process about whether
to access and use in-house stress management services?
• Tell me about the process you went through to decide to use the in-house
stress management services.
• What other services would did you consider when making your decision?
• Would you prefer to use your organization’s services rather than another
option? If so, would you please share why?
• How did you learn about the in-house stress management services available?
• To what extent do you think that your peers use these services?
The interviews took place using an on-line, free-of-charge video conferencing
tool. Skype is an online tool that requires the person to download the program onto his or
her device and set up an account. Many of the participants had an existing Skype account
54
and choose to use it. A second video conferencing tool option Appear-in was offered, but
none of the participants chose to use it. Merry et al. (2011) recommended ensuring
interview sessions take place in an area where the participant is comfortable. Thus, in
each case, the participant chose a location and timing that suited his or her needs and
privacy. Deakin and Wakefield (2013) noted how an online interview process may enable
the participant to express themselves in a way which a face to face interview setting may
inhibit. Deakin and Wakefield explained how the use of online interviews may place
more control in the hands of the participants. For example, during the interview the
participant may disconnect at any point or choose whether he or she wishes to use the
camera and voice or just the voice element. Deakin and Wakefield noted the need to
continue to explore Skype as an equal interview method choice; however, they noted a
number of positive aspects when undertaking online interviews. For example, online
interviewing is cost effective. It facilitates flexibility for both the participant and the
researcher to set up an interview time that is acceptable. The participant had the option to
set up a Skype account or equivalent just for the interview, which facilitated anonymity,
and as the participant and researcher did not have to travel to participate in the interviews,
there is a reduced health and safety risk. Each participant received a request to share via
e-mail any creative expressions he or she produced that might describe, contribute, or
substantiate an experience. These creative expressions or artifacts might have included
written material, such as journal or diary entries, blogs, artwork, video or voice recording,
or other bodies of work. Participants were asked to share electronic copies, such as
photographs or scanned copies of material, including voice recordings. Such artifacts
55
supported the statements, perceptions, or participants’ experience (East, 2010). I asked
the participant who submitted an artifact to describe the material, significance, and
meaning. Reference to this material, including quotations or paraphrasing, was part of the
informed consent process with the participant. Some participants chose not to share
artifacts and continued to participate in the study.
The participants exited the study through a debriefing process following full
analysis of the information. In addition, they received a summary of the findings,
analysis, and recommendations. Participants were not asked to undergo follow-up
interviews, but as outlined above, clarifications on any ambiguous points of their
interviews were done during the data analysis phase.
Data Analysis Techniques
Data analysis drew from phenomenological methods to manage the data in
defined stages to undertake a phenomenological reduction (Bevan, 2014). I identified and
bracketed any judgment and subjective response to the participants’ answers (Granot,
Brashear, & Motta, 2012). Once I transcribed the interviews, I read each transcript in
detail. I reviewed and evaluated each participant’s responses to build meaning units in a
technique which clusters similar information into categories (Holt, 2010).
Horizonalization describes the second stage. I listed the significant statements gathered
relevant to the topic. I developed a structural description of the experience, which
required me to reflect on any potential different meaning or perspectives (Creswell,
2013). In the next stage, I grouped the statements into thematic or similar meaning unit
clusters and deleted any statements that overlap with others, or appeared repetitive.
56
Finally, I reviewed the categories of the participants’ experiences and their
meaning and refined the meanings into their essential structure (Palmer, Larkin, de
Visser, & Fadden, 2010). Following a comparison of the interview transcripts and the
interview notes made I explained the experiences using the structural meaning. Where
possible, I highlighted aspects of experiences common to participants which contributed
to building invariant structures (Holt, 2010), which exposed the essence of the experience
described. I substantiated the outcomes with existing inquiries related to other groups in
similar job areas, such as emergency responders. I acknowledged there were a number of
dedicated digital tools to assist with organization of the data and which assists with
coding and categorization, such as NVivo and MAXQDA. During the analysis of the
data, I ensured I did not lose the meaning of the data through coding, which is a potential
when using tools such as NVivo (Schönfelder, 2011). Discrepant findings were noted,
reviewed, and explained during the analysis.
Verification of Trustworthiness/Authenticity
Qualitative researchers must ensure data quality and verification. The process
commences during the research planning phase (Tracy, 2010). I documented in a
transparent manner what was done to allow the reader to gauge the trustworthiness of the
data, analysis, and findings. This documentation explained the study’s credibility, based
on its plausibility, and provided sufficient information to allow the research to be reliable
and dependable. External validity factors which enable transferability were addressed and
sufficient information was provided to enable authenticity, thus confirming the findings.
57
Data triangulation was used to ensure the findings are correct and certain and,
therefore, valid. Triangulation is a process where two or more methods help to cross-
check information to validate findings (Palmer et al., 2010). Data triangulation took place
by drawing on different data sources and compared them. In addition, the artifact
optionally provided by the participants, a stress management proposal to managers for an
aid organization, was analyzed to measure the same unit, thus overcoming any
deficiencies in a singular method approach (Abawi, 2012). The proposed methods aimed
to increase finding validity which improved the trustworthiness of the outcomes.
Procedures to Ensure the Quality of the Findings and Verification
This study provided a number of approaches to ensure quality and verification of
the findings. The procedures that I used to ensure rigor and credible data collection are
detailed below. The narrative report allows readers to identify the trustworthiness, in
terms of credibility, dependability, generalization, and confirmability. Engaging with the
participants allowed me to build an understanding of their perceptions of their situation
and context to appropriately interpret and describe as part of the analysis and
documentation.
The notes I took during the interviews provided details noted throughout the
interviews, and provide rich, thick descriptions to add to the data analysis. Information on
the participants’ background and level of experience, the context within which the
phenomenon of aid worker interaction with in-house stress management services
occurred, and the procedures through which the data collection took place added to the
thick descriptions (East et al., 2010). The details provided in this report allow other
58
researchers to validate the findings and the analysis and determine how transferable the
results are to other contexts. I will maintain records for 5 years of all the materials
gathered through this study, including interview recordings, transcript notes, observation
and analysis records, and any optional artifacts. The combined archive of information
contribute to an audit trail, if other researchers choose to interrogate the study results and
test the dependability of the data.
Data Interpretation
The data interpretation process sought to attach meaning to the information
gathered and answer why aid workers interact with stress management services as they
do. The data analysis process produced the essential structure of the participants’
experiences (Palmer et al., 2010). Patton (2002) recommended that the description of the
participants’ points should be separate to the interpretations of the researcher.
The interpretation sought to attach meaning to the data, and I used my experience
as an aid worker to inform this process. The interpretation phase required me to deal with
different perspectives as reported by the participants, and irregularities in the information,
and apparent contradictions in the reports (Patton, 2002). For negative or deviant cases, I
reviewed the interview transcripts and noted different perspectives and irregularities as
they were reported. I provided in Chapter 4 an explanation of the deviant cases which
arose.
With the interpretation, I confirmed what is known about why people interact
with stress management services, as supported by the data; provide sufficient information
to allay any misconceptions; and bring to the surface aspects of the aid workers’
59
perspectives that were previously unknown. “Interpretation means attaching significance
to what was found” which is supported by participants’ quotations or a paraphrase of
their point to ensure representation in the participants’ terms (Patton, 2002, p. 331).
The artifact shared by a participant contributed to supporting the derived meaning.
I provided recommendations drawn from the interpretation of the data (Palmer et al.,
2010). During the data collection, one artifact was provided by a participant. I provided
recommendations in Chapter 5 drawn from the interpretation of the data (Palmer et al.,
2010).
Although the participants were a homogenous group of international aid workers,
some participants provided information that was outside the pattern of the themes found,
known as deviant or negatives cases (Damianakis & Woodford, 2012). There was a
possibility that some of the finding would have a gender aspect. During the interview, I
asked each participant what role they thought their gender played in how they dealt with
the stress they encountered. As part of the analysis strategy, I reviewed each participants’
interview transcript and, if needed, then broadened or revised the emergent patterns
derived from the data analysis. There was one gender-linked finding, which will be
discussed in more depth in Chapters 4 and 5. The revision for negative and deviant cares
helped me explain what may initially appear as contradictions.
Use of Existing Research Evidence to Inform Interpretation
The study drew from existing research to expand and develop findings. Ideas or
proposals presented in existing research enable engagement in explorative speculation on
the data usage and implications (Palmer et al., 2010). Following the analysis of themes
60
from the findings, I revisited the existing research to review the outcomes from previous
studies. I noted the similarities with the findings from this study, and where these studies’
findings contributed to the gap in existing literature with relation to international aid
workers’ perception of their work-related stressors and the issues that informed their
decisions when accessing stress management services provided by their aid
organizations. My research supervisors supported insight development.
Ensuring Participants’ Perspectives
As a student-researcher, I ensured I maintained my responsibility to the
participants’ with an appropriate reproduction of their perspectives in the data
interpretation section. There were a variety of ways to ensure the participants’
perspective is represented and using participants’ words in quotations, or short vignettes
are effective according to Patton, as “each bring his or her assumptions, beliefs, or
perspectives” (2003, p. 174). This approach helps to connect the information provided
with a human perspective (Blodgett, Schinke, Smith, Peltier, & Pheasant, 2011). Before
publication, I shared a summary of the study’s findings with each participant to ensure
the analysis accurately reflects participants’ experiences. I used this method to verify
with participants that I accurately represent their information and allowed them to correct
any misunderstanding I hold (Denham & Onwuegbuzie, 2013). Once their feedback was
received, I reviewed the analysis and further inductive outcomes may evolve (Schensul &
LeCompte, 1999). As an emic inductive study, I connected the findings with my personal
experience as a stressed aid worker who accessed in-house services during the peak
stressor impact. This interpretation has a basis in the knowledge and understanding of the
61
context investigated from my unique perspective. I made every attempt to avoid bias
through an acknowledgement of my personal feelings and emotions related to the issues,
and bracketed these. I remained open to the information and findings which the process
revealed and was open to all possibilities that the analysis revealed. The interview was
conducted in a manner that avoided interview bias; thus, I did not steer the participants’
responses in a manner that I wanted to see as the outcome. Instead, their responses
reflected their honest experience. This required me to choose carefully the wording I used
in the interview and avoid ambiguous or general terms.
Ethical Procedures
I ensured the study’s methodology adhered to the guidance from the Walden
University Institutional Review Board (IRB) for both legal and ethical compliance
(Walden University, n.d.). To this end, I ensured each component of the IRB application
was truthful and within the boundaries of my practice. I submitted the proposed letter of
consent to the IRB for its approval. The Facebook post announced the study, and
interested individuals contacted me and filled out the informed consent form. I am an aid
worker, and I gathered data from aid workers who work with organizations different from
the one for which I work. My role bears the risk of multiple relationships, and I
proactively managed this risk (APA, 2010).
The researcher must aim to ensure beneficence, where the welfare of the
participants was paramount (APA, 2010). I ensured fairness in the selection of
participants and ensured each was treated fairly (APA, 2010). The information provided
about the inclusion and exclusion criteria allows the reader to understand their relevance
62
to the study. All measures feasible were taken to ensure confidentiality of the
participants’ involvement in the study and their privacy and privacy of the participants,
which the informed consent process enhanced.
The documentation in the informed consent process allowed potential participants
to understand their rights as a study participant and related to the study process. The
information provided the potential participant’s information to reassure them they could
withdraw from the study at any point. In addition, there was a clear statement of the lack
of any reimbursement for those included in the study, and an explanation of the measures
planned to ensure the ability to maintain confidentially of the information (Schwartz et
al., 2014). As the interviews took place via an online video tool, the informed consent
reflected this approach.
Included in the informed consent process were details of the criteria and detailed
criteria for inclusion and exclusion of potential candidates (Tracy, 2010). The candidates
were provided with information as to the duration of the interview and the steps I took to
protect their identity and their privacy. I included details of the processes and measures in
the informed consent process. Participants were offered online video tools options,
including Skype or Appear-in. Each option offered privacy, and provision of an option to
allow the participant to choose the option which allows them a comfort level they found
acceptable. The informed consent specified how the interviews were to be recorded, and
the tapes kept for five years by myself in a locked file cabinet and will be for use only by
myself; that is, not to be heard by anyone else. This process allowed the potential
participants to fully understand the process, and pose questions that I could answer.
63
Each participant signed and sent me a consent form (Schensul & LeCompte,
1999). Aid workers affirmed that participation was voluntary, and they were notified they
could withdraw at any time from the study by sending me an email. I ensured the
participants were employed in a location other than the one in which I work to avoid any
risk of multiple relations or coercion (Patton, 2002).
The application to the IRB included the proposed research questions and the
process used to collect and analyze the data (Walden University, n.d.). The application
included details of the study focus and ensured the method of data collection was linked
to the research questions. In this way, the feedback from IRB and the approved method
ensured an ethical approach that protects the participants (Chenail, 2011). Following the
IRB approves the proposed approach, I adhered strictly to the approved methodology.
I designed the instrument, gather the data, and conduct the data analysis in a way
that minimizes the risk to participants. All participants were notified of all their rights to
fulfill all aspects of ethical and legal requirements (Bell & Salmon, 2012). I minimized
any risks, including risks to the privacy of the participants, with particular sensitivity to
the use of an online video tool for data collection. The participants received information
as to the data collection method, and were informed of options provided to them to allow
them choose the relevant online tool which suits their privacy, outlined in the consent
form. I was sensitive to participants’ worries with concerning the possible implications of
the information they provide. As such, I safeguarded the participants’ professional stance
to allay any risk of the information they shared. A remaining risk was that some
participants would experience a stress response based on their involvement in the study.
64
The participates received sufficient information in the informed consent process to allow
each of them to understand the risks of their involvement in the study before they agreed
to participate. I provided information on how and where to access no or low-cost support
should it be required. Holt (2010) noted how the level of risk to the participant must be
reasonable and mitigation measures taken to limit any negative impact.
I ensured the abstract provided sufficient information to allow readers to derive
the importance of this body of work. The narrative allowed the audience to track the
study process, including the analysis process and validation methods which led to the
findings interpretation, as guided by Creswell (2013, p. 179). The narrative included
details of my role and experience, with a full disclosure of my biases, and the efforts I
took to bracket these from any data interpretation. The data analysis process was
explained to allow the reader understand and track the process. Where relevant, examples
provided, with a textured description of the aid workers’ experiences. I provided clear
recommendations based on the study findings and outcomes. All participants received a
two-page summary of the findings to allow them to verify their input.
Each participant’s identity was kept confidential. I used a code to identify each
participant and ensure that any quote or summary point would not be attributable to the
individual participant. All the collected data, voice recordings, interviewer notes,
transcripts, and the artifact were secured in a dually locked file cabinet, accessible only to
myself. The data were retained in electronic form only, saved on a dedicated external
device. All data will be destroyed after 5 years, in compliance with the IRB requirement.
65
As my work requires that I move locations frequently, I will carry the external electronic
device with me, in my hand luggage, as I travel to new postings.
Summary
In summary, the process for this research was a qualitative method with a
phenomenological approach. The participants were drawn from aid organizations based
in hardship duty stations, but not those working with UNOCHA to limit the risk of ethical
impropriety with multiple relationships with the participants. A total of 12 aid workers
participated. The instrument data collection was undertaken using open-ended questions
posed in interviews. Data analysis was done to identify the constant elements of the aid
workers’ experiences. Data interpretation aimed to add meaning to the stories of the
participants, and recommendations were made based on the findings. I ensured the
documentation of the process provides sufficient details to allow the reader to decide the
validity of the process. Chapter 4 documents the findings and analysis drawn from the
data.
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Chapter 4: Results
Introduction
International aid workers operate in a unique environment, usually away from
loved ones and familiar support mechanisms. The nature of their work exposes them to
human suffering, threats to their well-being, and overwhelming work demands
(McCormack & Joseph, 2012). The purpose of this study was to understand the aid
workers’ perspective of their stressors and the decision making they undertake to decide
whether to access the stress management services that their organizations provide. The
purpose of this qualitative study was to contribute to the scholarly literature on the
perspective of aid workers with regard to in-house stress management services, filling in
some current gaps in this knowledgebase. Using the research questions, I explored what
aid workers perceived as their work-related stressors, how they described their
experiences of in-house stress management services, and how aid workers described their
decision-making process about whether to access stress management services as provided
by their organizations.
In this chapter, I will discuss the setting, demographics, data collection, data
analysis, evidence of trustworthiness, results, and summary of the answers to the research
questions.
Setting
To identify participants, I opened a dedicated Facebook page to seek aid workers
(see Appendix D). Those interested to apply contacted me via e-mail or left a message on
the Facebook page, visible only to me. The Facebook page contained information related
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to the criteria for inclusion in the study, several details about the study, and the assurance
that there would be no remuneration for participation. Each participant indicated the time
and date they were available to participate in the interview and chose to use Skype as
their preferred mechanism to participate in the interview. Only the Skype audio mode
was used, as some of the participants had access to limited Internet connection.
Demographics
The participants’ demographics met the inclusion criteria. Each had a minimum of
5 years international aid work experience, and none currently worked for UNOCHA. The
participants’ international aid experience ranged from seven to 27 years. Each participant
had sufficient command of English to easily converse. Of the 12 participants, only two
were native English speakers. To ensure anonymity for the participants, I refer to each
person by an alternate name in the narrative below. Table 1 below provides information
on the demographics of the participants.
Table 1
Participants’ Demographics
Pseudonym Gender Age Years of experience
1 Nadia Female 51 25
2 Maria Female 35 10
3 Rachel Female 47 27
4 Sarah Female 47 15
5 Amanda Female 55 28
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6 Becca Female 43 7
7 Chloe Female 43 12
8 Tom Male 38 6
9 David Male 46 10
10 Jack Male 44 15
11 Sean Male 40 18
12 Harry Male 49 15
After 23 people offered to participate, I requested information related to their
compatibility with the criteria. In a review of their information I found that 13 aid
workers met the criteria. I contacted the first 12 people who volunteered. Each participant
signed and returned the consent form. One person who completed the consent form did
not respond to multiple requests to set up an appointment for the interview; thus, I
approached the next person on the list who met the criteria. Of those who participated,
seven were female, five were male, and all were between 37- and 51-years-old at the time
of the interviews. For the purpose of this study, the female participants were referred to
as Maria, Nadia, Sarah, Rachel, Chloe, Becca, and Amanda. The men were Tom, Harry,
Jack, Sean, and David.
Data Collection
Twelve participants underwent the interview process, and I collected data from
each. Of these, three mentioned artifacts such as a written proposal to the managers on
how to model behavior to support staff in dealing with stress. One person shared a copy
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of this proposal as an artifact, while the other two participants noted that the items that
might be considered as artifacts were internal documents within their respective
organizations.
I arranged an appointment for each interview based on the schedules of the
participants, and the data collection took place over a 2-week period. Each participant
was informed that the process might take up to 90 minutes. Some participants used this
full-time allocation, while others used less. At the outset of each interview, I highlighted
the key elements of the consent form to ensure transparency. Each interview was carried
out only using the audio from Skype, recorded using a digital recording devise. Each
participant was informed when the recording device was turned on and off. I made notes
during each interview of key points and elements as they arose. I stored the digital
recording on a flash drive, which was kept in a double-locked cabinet in my home with
my notes from the interviews.
Data Analysis
I listened to each interview recording and transcribed each verbatim. Upon
completion of transcription of all 12 interviews, I read each interview line by line. I
formatted the transcript of each interview with a wide margin and printed a copy of each
transcript. As I read the interview, I highlighted keywords, phrases, and concepts. I
assigned a code to each unit of information in an open-coding fashion. I listed all of the
codes identified, reviewed the list, and noted codes that were similar and those that were
redundant. This was an iterative process, as I reviewed each transcript repeatedly to
ensure that the codes reflected the data in a constant comparison.
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Once I completed the coding process, I reviewed the open codes with the aim to
identify overarching closed codes or categories. Through this process, 10 closed codes
evolved. Next, I identified themes that reflected the purpose of my study. I reviewed the
data and ensured that all data units fit into the closed code categories. Throughout this
process, I remained open to revision should a unit of data emerge that did not fit the
closed code. The outcome of this process was a range of themes.
Using quotes from the transcripts, I aligned quotes with the different themes. In
this way, I was able to examine the ideas that contributed to each theme. I looked for
relationships between the themes and used the quotes as evidence. Some quotes appear to
fit under more than one theme, and these gave an indication of possible relationships to
explore. On further review of each transcript, I undertook a constant comparison with the
themes and subthemes identified, and when necessary, I revised and adjusted the themes.
Coding of the Data
On primary review of the data, I assigned a term or code to each unit of meaning.
At times, this was a word, a group of words, a phrase, a sentence, or a paragraph. I
applied this strategy to each interview transcript and derived more than 100 codes, such
as demotivation, unproductive, isolated, family, insecurity, workload, stigma, and
recrimination. As the lists of open codes grew, I returned to each transcript to review the
coding and sought to revise possible code allocation to align them. For example, I revised
organizational care and organizational behavior, to organizational environment.
In the second stage, I reviewed the identified codes and the meaning units per
code that supported the development of structural description of the aid workers’
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experiences. I identified the key statements and quotes that described these experiences
and was aware throughout the review to reflect on any potentially different meanings.
Through this process, I identified ten closed codes: role of management, operational
environment, organizational policy, formal stress management services, stress impact,
social support, adaptive behavior, gender differences in stress management, coping
strategies, and the aid worker. I reviewed each open code against the list of closed codes
to ensure that each fit into a category, and I noted those that appeared to have a place
under more than one closed code. I noted these multiple codes for further review to
examine the relationships between elements. Table 2 below provides some examples of
the quotes and coding.
Table 2
Sample of Coding from Interview Excerpts
Raw data Code
One participants said:
“There were constant threats, grenades being
thrown, and people being killed...” Threat to personal safety
Another participant said:
“...it is very important to understand yourself and
to understand how you can contribute, because if
you can’t manage the stress then... all those
people around your become part of the problem.”
Self-awareness
Another participant said:
"I think there can be different levels of [stress
management], but I don't think it has be to
something that is that complicated."
Seeking solutions
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In the third phase, I attempted to take the focus from the detailed to a general
level and developed six themes. These overarching themes were operational environment,
organizational culture, adapting and strategizing, stress management services, social
support, and aid worker responsibility (Table 3). I provide details about each theme and
their relationship in the text below.
Evidence of Trustworthiness
The credibility of the findings was deduced by member checking and data
triangulation. With three participants, I cross-checked whether the analysis of the
findings correlated with their experiences as related during the interview and found these
to be accurate. I requested participants who mentioned products they produced that
supported any of the points to share these artifacts for data triangulation. I used thick
description with direct quotes from the interview transcriptions in the narrative below to
support the points made.
I provide detailed descriptions of the study process and the assumptions central to
the research to allow the reader to define transferability of the findings. As such, the
reader will have sufficient information to decide the degree to which the findings might
be generalized or transferred to other aid workers in other contexts. The detailed
description of the study process, including the analyses and findings, allows the reader to
interpret the consistency of the process and to allow for replication. As an aid worker, I
acknowledged any research bias and worked to ensure bracketing. In the narrative, I
clarified the unique perspective I brought to this study and provided information to allow
the reader to confirm the results.
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Research Results
In the section that follows, I provide a summary of the results framed by the
research questions. The research questions in order of my review below were the
following:
RQ1: How do aid workers perceive their work-related stressors?
RQ2: How do aid workers describe their experiences of in-house stress
management services?
RQ3: How do aid workers describe their decision-making process about whether
to access and use in-house stress management services?
Incorporated under each research question, I organized the results by themes and
subthemes that arose from the participants’ information. The first theme was
organizational culture, with the subthemes of organizational responsibility, policy and
reality, management, perception of staff value, workload, and invisible services. The
second theme was social support, with the subthemes of family commitments and like-
minded peers. The third theme was the operational environment, with subthemes of
human suffering, insecurity and threat to personal safety, living and working
environment, and culture. The fourth theme was the aid worker with subthemes of
exerting control, other aid workers, and gender. The fifth theme was adapting and
strategizing with subthemes of self-care and self-awareness, protected rest, physical
exercises, and motivating solutions. The sixth theme was the stress management services
with subthemes of formal services, informal stress management, and invisible services.
The final theme was services, with subthemes formal services, management, and exerting
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control. The relationship between elements of the research questions is expressed with a
continuation of three of the subthemes under Research Question 3. These subthemes are
formal services, management, and stigma and taboo. The themes, with their subthemes,
in order of my review are below in Table 3. The section ends with a description of the
discrepant findings.
Table 3
Themes and Subthemes by Research Questions
Research Question Themes Subthemes
RQ1. Perceptions of work-
related stressors
Organizational culture Organizational
responsibility
Policy and reality
Management
Perception of staff value
Workload
Social support Commitments to loved
ones
Like-minded peers
Operational environment Human suffering
Insecurity and threat to
personal safety
Living and working
environment
Culture
The aid worker Using experience to cope
Gender
Adapting and strategizing Self-care and self-
awareness
Protected rest
Physical exercises
Motivating solutions
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RQ2. Experiences of in-
house stress
management services
Stress management
services
Formal services
Helping to build
resilience
Invisible services
RQ3. Decision to access
in-house stress
management services
Services Accessible, available
services
Management
Stigma and taboo
Research Questions Results
Research Question 1. Aid workers reported perceiving their work-related
stressors as an accepted reality. All of the participants indicated that their aid
organizations must enable them to work in safe space and provide them with the basic
tools and resources they need to carry out their role in safety. Eleven participants shared
their perception that their aid organizations fell short of this requirement. Given this lack
of care and resourcing, ten participants described their perception that they needed to take
responsibility to manage the issues within their control to maintain their well-being and
safety.
The work-related stressors that the participants related predominantly resulted
from what they described as poor management decisions, unrealistic organizational
policies, overwhelming workloads, pressure to perform, difficult working relationships
with colleagues, and feeling demoralized by how their organization treated them.
Participants described commitments to family and loved ones as contributing the stress
participants experienced through their work. The environment within which aid workers
operate contributes to their stress levels. A surprise in the findings was that eight of the
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participants shared how their working conditions contributed to them leaving at least one
job in the past.
Organizational culture. The most significant stressor that the aid workers
reported experiencing was related to work. “The work-related stressors are always there;
they don’t go away,” noted Maria. Only Sean shared how within his organization he felt
he had space and confidence to share his concerns and access dedicated support. In
contrast, nine participants who spoke of this in detail perceived that, within their
organization, there was no space to be honest with their managers and tell them without
fear of retribution that they needed a break or needed help. Chloe shared how she felt: “It
wasn’t really encouraged to talk about if you had any scare during the day, or if you were
feeling overwhelmed with stress.” Three participants reported how they accessed stress
management services provided by their organizations, and the impact had been less than
positive. Amanda experienced a period of extreme stress and had pursued help.
Amanda. I sought assistance thinking that this was the logical and the right
thing to do . . . and then, really found that it backfired . . . it was used
against me. There were attempts to stop me from coming back to the field.
Organizational responsibility. Participants reported there is an absence of
minimum standards set for staff care among aid organizations, but most international
organizations were reported to have some level of support. The participants noted the
importance of predictable, trusted staff care. Harry experienced with one organization
how “they would just deal with issues and incidents as they arise, and so ad hoc whatever
when someone would burnout.” The predominant perception of the participants was
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described as David said, “There’s a lot that organizations can do to help staff manage
stress that isn’t necessarily stress management.” The organization reportedly plays a key
role that sets the tone for how the conditions of work within the operational environment
are established and maintained.
Jack. After a few weeks [in an emergency response], I was not really
productive… retrospectively I should have left a week earlier, but
there was no process. I was proposing to take days off and they say
“No, no, no, you cannot take days off yet because it is very early, it is
only day number 10.” Remember, there was no places to sleep.
Only Sean shared his sense that his organization cared for his well-being and, in
his opinion, took appropriate and relevant steps to ensure his well-being. The other
participants shared their view that they feel alone in the role to ensure their well-being
and care. All participants acknowledged this role is a joint role with the organization;
however, based on their experiences, they reported no longer trusting aid organizations to
undertake this responsibility.
Policy and reality. Four participants shared their perceptions that international aid
organizations’ staff care policies tend to be flawed. Jack shared that her experience of
trying to work within policies developed at the headquarters level did not provide her the
safety or job security he experienced in the field.
Jack. There was no place to sleep, no food… the agency I went with… it
was not great in planning. You know how some of these [aid
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organizations], they go, they try to be the first so they put their responders
in first to try to get them on CNN, and then the money starts to pour in.
The policies developed must be in place and appropriate to the context within
which aid workers must live and work, recommended David. Chloe reported that when
she was in the field, she cut her hand and on inquiry, found the first aid kits to be lacking.
When she demanded that her organization provide first aid kits, each international staff
reportedly received a kit that was “the size of a kitchen cabinet.” Chloe described that
although she received the first aid kit she requested its size precluding her from taking it
with on mission with her. David expressed concern that the policies developed in
headquarters were primarily devised to meet the needs of headquarters-based staff, but
were inappropriate when applied to the field-based staff given the difference in contexts.
The result was a lack of equity of service provision. A singular policy does not
necessarily indicate an equal approach, he noted.
Becca shared her experience of being required to carry out policy decisions in
challenging contexts, and the difficulty she experienced attempting to communicate this
to her off-site manager. “I am not sure they were even aware of … what we were going
through was really quite stressful. I think they underestimated what was really going on.”
Management. All the participants shared their perceptions of the importance of
the role of managers and management regarding the contribution to stress, in both
positive and negative terms. Rachel explained how working in an environment with
positive management style benefited her performance, in particular with regards to
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managers to facilitate the work of team members by ensuring some level of predictable
work patterns.
Rachel. I think that for a manager to make sure there is predictability in
people’s work is key. To have very clear plans how it is and … to protect
staff quite a bit from too much ad hoc requests, so in that sense
predictability in the deliverables. Still, you can remain flexible, but if you
don’t know what to do and where to go and you only get ad hoc requests,
then I think that is very unhelpful for people.
Management was reported by all participants to play a key role in ensuring the
team dynamic is positive, and that there are the right people in the right jobs. Nadia noted
how in her experience, “Something is going wrong in recruitment.” For teams to work in
an optimal manner, they need management who will enable and facilitate their work and
protect them where necessary, noted three participants. Nadia shared that her
“organization [is] aware that 6 months is too long to stay in the location without a break.”
She noted that to support the team members not becoming too exhausted the managers in
her team encouraged staff to use their annual leave days to take a break.
Management can set the standard of the work expectations and manage how this
environment is maintained, according to Maria. Poor management resulted in a
perception of being unsupported reported Maria.
Maria. Every day the goal posts are being changed… my boss sort of went
off the rails at a certain point and our program officer just like disappeared.
I was alone in the office trying to manage all these things without any of
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the support that I needed … my boss would on one day say one thing, and
then next day say the opposite… that’s stressful.
“I think my management plays a role in some of the stress about the way the
office is run,” noted Chloe and shared “I couldn’t be honest with my manager, she wasn’t
a person who could deal with honesty”. As a result, Chloe stated that she did not share
her experiences or challenges with her manager but instead waited for her exit interview
with a human resource person whom she felt she could speak with in “relative honesty.”
Five participants described how in their experience managers in aid organizations
are overburdened with responsibility and the pressure this brings on the individual staff
member. Sean noted the level of responsibility he shouldered as a senior manager in
multiple crisis responses: “I am accountable for the entire response.” Sean elaborated that
“experience matters” when required to manage the organizations emergency response and
the team of aid workers. At times, managers must make difficult decisions for the well-
being of the team. “Your resilience is the responsibility of two people, one being is
yourself, and to second is your manager”, Sean shared.
Nadia shared her perception that few managers are trained for their management
role, having been hired for their technical competence. This mismatch puts pressure on
others to support and fill the gap these managers leave, according to Nadia.
Eleven participants experienced poor management styles and decisions. Maria
explained that her previous organizations “do not do any training or induction. They just
chuck you into the deep end,” she noted. The impact of such decisions resulted in stress
for Maria, who struggled to find her feet and her confidence in a new operational
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environment. Rachel recommended that organizations must ensure they “always have
experienced staff in the most difficult environments, and not the opposite.” The perceived
delink between senior management and the situation people experienced was repeated by
11 participants. Maria experienced an immediate emotional impact when she learned how
a friend’s compound had been attacked and her colleague was killed. Her manager’s
response was “Just get over it.” Maria reported feeling disempowered by this response
with heightened stress.
Perception of staff value. A sense of just decision making by management within
the working environment was repeated by nine of the participants. Becca noted the level
of stress she experienced when what she perceived as unjust decisions were made by her
management, and how she spoke out when this took place. Nadia noted that within her
current organization “difficult and problematic staff get pampered and seem to be
rewarded.”
Nadia. While others…are just expected to give more and more of their time
and their energy…be more tolerant…Right now I have weekly meetings
with one expat staff. There are weekly meetings anyway, but these are
weekly meetings where everything has to be kept documented and shared
with HR, and it is like record keeping to try to get rid of the staff member,
but not enough has been documented until now to justify termination of
[the] contract.
David offered that staff in field locations and staff in headquarters should be
provided appropriate support and care by the organization. David shared his frustrations
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about how “when you work in the field, and you work in headquarters . . . you are all
under the same rules and regulations.” He explained the vast difference in the contexts
did not allow for the same regulations to offer equal support to staff. In his opinion,
“Organizations put their staff at a similar level of danger” with singular staff care policies
that apply equal standards for staff care and well-being across headquarter and field-
based staff. He noted that there was no adaptation of the policies to allow them to be
flexible to specific needs in the operational environment, such as for a context where
there is a conflict or where cultural differences impact on staff care.
David. I think the system is broken and needs to be fixed … and there has
to be a reform of … the HR systems. The current tools and policies are
inappropriate for our staff to be supported in emergency contexts.
Five participants shared concerns about how their organizations appeared to
deprioritize their staff. Sarah shared how one of the biggest stressors on arrival to a new
location were what appeared to be organizational policies that put her safety at risk. She
noted the frustrations of working in an unsecured environment where no support was
offered to staff to get to work.
Sarah. How do you get to the office? They are telling you there [are] no . . .
vehicles, but then you need to get to the office, and you can’t take a taxi,
you can’t buy a car to bring it in the country, I mean, it is a contradiction!
Workload. By virtue of the work aid workers do, there is a pressure to perform.
Eight participants reported there was never enough time to mitigate the suffering.
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Chloe. I sense that the work is … it is really important, so if you don’t do it
well, or if you don’t do it effectively or efficiently enough, others are really
going to suffer. So, there is a sense of responsibility attached to… to an
overwhelming workload.
Each participant spoke to the impact they experienced working under such circumstances.
This was not always a negative element, and Nadia stated, “If the workload is huge and if
you are with the right team of people, you don’t mind working the long hours.” The sense
of contribution and achievement was described as important, as was the contribution to
alleviate suffering. Nevertheless, Becca noted the stress she experienced when there was
work to undertake, but “typically there is very limited capacity within the office to
deliver quality work.” An imbalance of the perceived prioritization of tasks and
assignment of tasks fed into the stressors the participants shared. Each participant shared
his or her commitment to the work that is necessary for the context within which he or
she worked but also the importance of the contribution they all perceived they made.
Rachel shared her frustration when internal “politics” interfered with planned work
schedules and eroded time allocated for what were priority activities in her estimation.
Modern technology reportedly played a role in workload, according to Amanda.
Amanda shared her frustration around the constant expectation by management that staff
were expected to be contactable via mobile phone and email all the time, and for the staff
to respond to communications during their free time. Amanda shared her experience of
her management’s expectation that she be “on” all the time and expressed “not even the
doctors in . . . are switched on permanently.” When the work had value and contributed to
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alleviating suffering, the participants expressed their willingness to invest the time and
effort to contribute, but expressed frustrations when it was perceived as time-wasting.
“We spend about 90% of our time, we spend it firefighting emails, and responding to
emails rather than actually being creative and actually solving problems,” noted Amanda.
Social support. Each participant noted the role that colleagues, peers, loved ones,
and friends play both contributing to the stress they experienced in the workplace and as
a critical support resource to help them cope with negative stress. Becca noted, “They
help to distract me, they help . . . we can talk about some of the frustrations . . . and, we
can talk about it.” Amanda shared how the space to share with friends who know her
helped her achieve perspective, which she appreciated. “You have some friends present,
you simply go for coffee, and you know, normally you have a talk and after a while if
they think you are saying bullshit, they will say – ‘You are talking shit!’”
Commitments to loved ones. Each participant reported having a family, loved
ones, and friends. The capacity to have regular, effective communication with family and
loved ones was a primary requirement for 10 of the participants. Harry noted how daily
contact with his wife was important to his well-being, and Becca shared the important
role her family played in helping her deal with difficulties, “That’s where family comes
in, that is where they are important.”
Indeed, for the majority of the participants, their primary commitment was
described as to their family. The weight of disappointing these important people lay
heavily on 11 of the participants. “Trauma is not only when you enter [location]. Trauma
is because you have to cancel your family holiday.” Sean shared, “My suffering is with
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the family.” The needs of loved ones “trumps” work commitment, and both Chloe and
Sean shared the impact on their work life as the result of family commitments, such as
the internal conflict they suffered when their child was ill. Amanda noted the pressure her
family placed on her to come home and get a “normal” job. These pressures were
unhelpful for her, and her viewpoint was “You can leave a job . . . you can’t really leave
your family!”
Sean admitted that stress related to family, and disappointing them, impacted him
differently “If an emergency doesn’t happen at the weekend, it is on a holiday.” All
participants noted that international aid workers make personal sacrifices to work in the
aid sector. This implies absence from key family occasions, last-minute changes in plans,
and personal loss which Sean and Chloe stressed as stressful. Sarah shared how “I had a
relationship which fell apart . . . because of my job.”
Like-minded peers. Seven participants shared how they spent time with carefully
chosen individuals or groups. Half of the participants noted the importance they ascribed
to socializing with like-minded peers with whom they were safe to interact to help
mitigate and prevent against the buildup of stress. Four participants noted how part of the
criteria to choose these peers was based on the ability to separate work and personal
life—that is, to associate with non-work colleagues outside of work hours. David
expressed concern about the ability to have a defined personal life, and wondered if part
of the sacrifice that aid workers face is to relinquish a personal life, much like “religious”
communities. Nadia noted how regardless of how one socialized, a stark reality is that the
organizational policies govern one’s movement and freedom.
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Becca, Tom, and Harry noted how they carefully chose their peer group when on
assignment. “All those people around become part of the problem.” Amanda noted the
importance she ascribed to ensuring those with whom she socialized were people she
trusted. Tom shared his realization that people he worked with and socialized with
contributed to his stress. He described how part of his coping mechanism was to have
selected people, specifically those not from the organization with whom he worked, but
like-minded people with whom he could relax, cook, and “talk about normal life, music,
whatever.” Tom used this reflection to change his social group, which he reported
benefited his well-being.
Operational environment. The participants explained the significance of the role
the operational environment played in contributing to their stress in the workplace. The
stressors that originated from the operational environment tended to be outside of the
control of the aid worker and the organization, such as the human suffering resulting
from an
emergency, insecurity and threat to personal safety, the environment within
which they lived and worked, and the cultural elements within that environment. Each
participant shared their impressions of the impact these conditions had upon them as
individuals.
Human suffering. Aid workers are exposed to extreme human suffering. Jack
noted, “It was the first time in my life . . . basically, I saw a dying child.” A lack of
security event was reported by Maria as impacting her: “The attack happened. They
attacked his office and killed one of his colleagues.” Chloe cited the impact of working in
unsafe environments: “There was stress and at times fear, just genuine fear, I mean –
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fear!” Ten of the participants expressed a sense of powerlessness to help when there were
extreme conditions. They described pressure in these extreme conditions to give
everything of themselves to those who suffered, yet they described feeling powerless to
make a substantial difference for those in need. Chloe shared how “It seems . . . you
could work 24 hours a day for 7 days a week, and you would still only scratch the surface
of what actually needs to be done.” Eight participants noted a mismatch between the
pressures they perceived from their organization to work, and the reality of the situation
within which they found themselves. Amanda noted how where she works “has been an
emergency for the last 30 years.”
Insecurity and threat to personal safety. Living in areas where their personal
security is at risk contributed to the stressors that aid workers faced. Maria explained that
“it’s not normal life to have . . . bombs, to hear gun shots,” but for many aid workers this
is the environment within which they work. Sarah explained the stress she experienced
working in a country where she perceived personal threat because of an ethnic conflict in
the area. She expressed how she was “uncomfortable, and sometimes I was abused on the
streets . . . I was physically not welcome.”
The participants worked in operational environments where they had little control.
Eleven of the participants noted how overwhelming their role was and the contribution
this perception has on their stress levels. One person expressed a feeling of
powerlessness. “If you have people coming to you saying, ‘Look, I have my two
daughters who have just been raped,’ and you can’t even go and get them because of
security issues. . . .” This inability to control their environment results in stress that
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impacts on their ability to perform. Chloe said, “Sometimes it’s hard to stay motivated,
sometimes it’s hard to … to stay focused.”
Living and working environment. Stressors from the operational environment
were not limited to insecurity but included basic living arrangements. Harry shared that
during one assignment “there was no place to sleep, no food.” Such experiences were
shared by Chloe, who noted the frustrations when “guest houses weren’t equipped with
water and . . . there weren’t massive supplies so if . . . an angry mob comes again, we
have to hunker down . . . for our safety.”
Culture. As international aid workers, staff moved to different contexts to work. Only
Sean shared how for him a stressor he experienced was working in locations where it was
difficult to publicly practice his faith. His response was to propose to his organization a
mechanism that allowed faith-based support for staff, regardless of what religion the staff
practiced. Sean shared that his faith-based organization had embraced his
recommendation and that plans were underway to provide spiritual support for staff,
regardless of the emergency culture.
The aid worker. The data analysis revealed the dedication and loyalty each of
the participants had to their role in alleviating the suffering of others. Their work-related
stressors were described as multifaceted and often were influenced by stress from their
personal lives. Every participant displayed humor and openly laughed during their
interview. Each admitted the impact stress had on him or her, and some expressed regret
about their actions during previous stressful episodes. During one particular episode,
Harry shared, “I should have left,” and how he learned from this experience to inform
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future actions. Building on experiences and learning from their past experiences, and
from the experiences of others was a critical tool for all the participants and contributed
to their current state of resilience, as noted by Chloe: “I have learned that I am stronger
than I thought.” Two participants shared their experience in terms of their identity as aid
workers, and the impact the loss of this identity had on their self-perception. Amanda
shared that her “family is often thinking of me as Lara Croft.” Conversely, Chloe left aid
work for a time to become a stay at home spouse and mother and struggled with the
impact. “Suddenly, I lost my identity, and it was a very, very hard time for me.”
Using experience to cope. Some participants noted how their perceptions of
stressors had developed over time. Sean admitted, “There are some things that affect me
less now than they did at the beginning.” Three participants shared how they had
developed strategies that allowed them to exert control over the things that were within
their grasp. Sean noted how “stress related to work has a context,” and therefore, for him,
was easier to rationalize.
The findings indicated that all the participants considered their capacity to cope
with their stress levels when deciding to engage with formal stress management services.
All the participants shared how they review the options available to them, in terms of
strategies, skills, and copying capacity, when in the past they considered accessing
services. Tom noted during one period of extreme stress how he weighed up his options,
including accessing the on-site stress management counsellor, before he decided to leave
the job and return home to seek care there.
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Sometimes, the role aid workers are sent to perform is “mission impossible,” Jack
noted, and the aid worker has little control over the context. In the absence of supportive
and realistic organizational care, the participants perceived themselves to be alone in their
responsibility of self-care. Maria shared that she now realized, “You have to be prepared.
You have to arm yourself—sort of equip yourself with the tool that you need, that you
can’t expect anybody to look after you.” This sentiment was echoed by David, who said,
“In this sector, you have to rely on yourself.” Both Rachel and Jack shared how they
developed their self-awareness and their stress management resources internally, which
allowed them to exert control over what stress they experience. Jack noted that “the
opportunities for stress are diminishing” when he made decisions about how he chose to
engage or not in challenges. “You also have to say, ‘I don’t need to deal with this’ and let
it go.”
Gender. There were few gender differences noted by the participants about their
personal experiences, but some noted concerns about how the other sex experienced
stress. Maria share that “in this compound full of dudes . . . they were so happy to just
drink away their stress, smoke away their stress . . . and just be like . . . dudes!” She
postulated what the reaction might have been had she challenged her males colleagues by
suggesting “Guys, six o’clock on the roof – Yoga!” Both David and Jack noted how as
males, they had access to stress management strategies that given the operational
environment were not afforded to their female colleagues, “It was easy for me. I had
female colleagues who could not do this.” For example, Jack shared that he could go
jogging in public, while his female colleagues were unable to jog in public in some
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cultures. There was a strong indication from the participants’ feedback that the machismo
attitude among aid workers continues. Harry shared that in his perception the attitude he
experienced when he faced challenges was “You are a man—you can do it.”
Adapting and strategizing. To survive in the operational context, each
participant shared how they adapted to their environment. Self-awareness was described
as key for the participants to understand what they were going through, the effects stress
had on them, and to inform how they adapted to the environment. Each participant
explained the strategies they employed to help them manage stress. Tom described a
period of reflection and realization where he realized his behavior indicated he was
stressed. He used a simple checklist tool that allowed him to tick off the behaviors he was
employing at that time. Based on this list, he proactively addressed his stress. Each
participant identified strategies they defined as part of the coping. The adaptations and
strategies defined provided the participants with some control over their well-being, and
therefore, over the issues that resulted in stress: “I am able more and more to control
those stressors.”
The behavior of other aid workers was reported to be a stress for most of the
participants. Working, living, and socializing with the same people were reported as a
burden for 11 of the participants. Self-awareness was a key tool for all the participants to
build their understanding to help them avoid and overcome stress. “It is very important to
understand yourself and to understand how you can contribute,” noted Chloe.
Aid workers learn from each other. David noted, “I definitely have had some
excellent role models in terms of how you deal with professional stresses.” For Chloe,
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she reflected how, “When I am stressed, I don’t always handle the situation in a way that
I wish I would. I don’t model the values that I want to.” Chloe aspired to improve how
she deals with stress, and acknowledged some of the efforts she made to achieve this,
such as with the use of yoga.
Self-care and self-awareness. Adaptation began with recognition. Self-care and
self-awareness were elements that each participant emphasized as important. Maria noted
how she thought “for regular, everyday stress, it is more about taking care of yourself.”
The participants shared a range of coping strategies, such as physical exercise, protected
personal space, and, as Harry pointed out, “careful selection of people to hang around.”
The participants shared the signs that they display when they are stressed, from
overeating, disturbed sleeping, to becoming irritated and short with others. Chloe
explained that when she noticed this in her behavior, she dealt with it by putting herself
in “timeout.”
Despite the negative experiences described by the participants, each shared a
reflection of their personal growth as a result of their learning. Maria described her
learning as a result of some of her experiences that taught her a “great lesson.” David
pointed out how in one prolonged period of acute stress, “I did not save myself first. I
allowed myself to be extended because those around me . . . collapsed.” Despite the
trauma he experienced, he stated that is he “better equipped now because of the
experience.”
Protected rest. Each participant has over time developed coping mechanisms that
they reported bringing with them location to location. To the greater extent, these
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mechanisms are those that might be used in any operational context, such as for Amanda,
who shared: “I tend to spend Saturdays and Sundays on my own . . . just peace and quiet .
. . You have to hit the ‘off button.’” Nine of the participants spoke of the importance of
protected rest, either in terms of time off, or the importance of sleep. Eight participants
spoke of the efforts they made to ensure they were able to rest, such as Harry, who
shared, “I am much more cautious. I make sure I have a place to sleep, and there are
supplies and other things.” Both Amanda and Nadia shared their strategies for protecting
their personal space during out of work hours, and the importance that this protected time
allowed them in their rest. Nadia shared how “at least one weekend day . . . I try not to
open work emails.”
Physical exercise. Common to seven of the participants were practices of yoga
and meditation as strategies to mitigate and prevent stress. Rachel said, “Yoga and
meditation . . . are tools to help me focus this stress . . . support tools for everyday life.”
Stress management tools of this nature do not require any particular resources and can be
carried out in the confines of small spaces. Jack shared how, for him, his “beloved
jogging” was key to his well-being, while Rachel shared that the ability to be able to
exercise would influence her decision to accept deployments to some locations.
Motivating solutions. Four of the participants shared how they had offered some
mechanism to their peers or organization to help support the well-being of the team. Jack
reflected on the confinements of the context where they lived, then offered to the stress
management teams some proposals to have arranged social gatherings to help staff deal
with boredom. Nadia shared her misgivings around mandatory efforts labeled as stress
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management services. Instead she offered to her organization to introduce to the regular
staff induction package “sessions on stress management”, in a bid to both normalize
stress as a common experience and provide staff with tools to support their efforts to deal
with the impact. Her recommendation was reportedly accepted. Based on the challenges
he experienced when trying to practice his faith on deployment, Sean developed a
proposal to have within their teams staff with a chaplaincy type role. These staff could
offer “spiritual support” to a variety of colleagues in real time, and in particular, when
staff experienced stress.
Each participant shared his or her perception of how stress management might be
enabled. “It could be quite simple. It is not that complex and sophisticated to do
something basic about it.” There was a relationship between access to formal stress
management services and the perception of risk that engagement might bring. Informal
stress management plays a significant role in helping the participants to cope. Sean
shared that the most effective tools he experienced were not “super sophisticated” but
allowed him to understand the strategies that worked for him and provided positive
reinforcement for him to devise his strategies. He explained that he had learned
“techniques in managing stress” during dedicated stress management sessions that
allowed him to understand how he could proactively manage his stress. This knowledge
reportedly empowered him and provided him with confidence in how he approached his
stress, “The way you manage your stress is by telling stories.”
Finally, Chloe explained her commitment to take what she learned from her
experience and ensured that the team she managed benefits from this. She reported
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drafting a policy to develop a “system” to support staff to manage stress. In her draft, she
proposed that to ensure that staff feel comfortable to share their experiences and feelings,
the managers must lead by example, and talk openly in a protected environment about the
impact the work has on them, and encourage others to do the same.
Research Question 2: The aid workers interviewed described their experiences
when accessing in-house stress management services as variable. Seven participants
described finding the services accessible, positive, and uplifting. Six participants
described being met by unprofessional, inexperienced counselors, and two participants
reported facing retribution by their organization for accessing the services. Fear of stigma
around accessing stress management services was described by some participants who
shared their concerns about how they would be treated if their organizations were aware
they accessed stress management services.
Stress management services. All the participants shared how perception of stress
management services is manifold. For all of the participants, stress management was
more about the normal, everyday element to help them cope rather than the formal stress
management services that counselors provide during specific times when they sought
help. This point was made by Maria, who expressed that “you can go to a counselor for
an hour, but on a day-to-day basis if there isn’t a culture of taking care of yourself” then
you are alone.
Formal services. Accessibility to formal in-house stress management services
was critical for timely proactive engagement, according to the participants. Eight of the
participants shared their varied experiences accessing services through their
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organizations. When professional, these services were reported as useful, empowering,
and reinforcing. The predominance of the credible, professional services experienced by
half of the participants were those external to their organization, where there was a
formal relationship between the organization and the counselling service. When
compromised, five of the participants expressed anger and frustrations about the absence
of professionalism, and the impact this would have on future decisions to engage or not
with in-house stress management services. Sarah, Jack, Nadia, and Amanda had positive
experiences when accessing services, where the counselors were described as
professional and provided structured support and guidance, “because you should develop
a relationship of trust with the counselor.” Amanda explained the impact she experienced
when accessing a professional service and how “It was useful to explain how you felt . . .
put the thing into perspective.”
Accessing formal stress management services should be straightforward and
predictable noted nine of the participants. For some organizations, such as that for which
Sean works, “We go to the debriefing, and there will be a slot, you just need to . . . fill the
slot.” In David’s experience, “I asked for help and those requests were not responded to.”
Approaches such as inductions and debriefing, when done well, were described as being
appreciated and viewed positively. David noted, “The predeployment training . . . was
particularly good.” These approaches helped to provide the participants with the
knowledge, and, for some, with tools that enabled them to cope with the operational
environment and the workload they faced. Chloe and Maria noted the value of inductions
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and debriefings but how in their experiences such approaches were not standard, and they
had experienced the absence of each on different deployments.
On another occasion, Nadia met with a counselor who she reported appeared
inexperienced and used the session to talk about herself and pursued what Nadia referred
to as an inappropriate line of questioning. Maria experienced a counselor who “related
what I was telling her to own personal life and told me . . . about her faith-based
practices.” Rachel described how in one natural disaster response context, the
organization deployed a staff counselor to the field to support the staff. “But I am not
sure how helpful he was. He was more stressed himself than anything else.”
The presence of a dedicated stress management staff member was perceived
positively by 10 of the participants. Both Becca and Jack explained how the mere
presence of a person of this nature supported the team and encouraged interaction. Jack
explained how informal interactions with this person enabled him to gauge the level of
accessibility “I talked to the person, socially, out of curiosity.”
Helping to build resilience. Most participants shared how stress management in
their experience was less about access to formal stress management services, and more
related to a working environment that allowed them to thrive. Nine participants expressed
how in their opinion their experiences have made them more robust to deal with their
challenges. Nadia explained how over the years “we build on our resilience” to deal with
the issues faced in the aid sector. Jack shared that he learned from a previous bad
experience and that he has built confidence based on what he learned from his response
to this experience. He explained how he is more resilient now by ensuring he understands
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the working conditions. Prior to accepting future deployments he ensured he queried to
“make sure I have a place to sleep, and that there were supplies… and make sure it is
clear what the role [would be].”
Four participants shared how they learned techniques during engagement with in-
house stress management and then used what they learned to inform their on-going stress
management. Harry shared that he thought “he learned something” based on his initial
engagement with in-house stress managers, and that “this was already helpful for the
remaining time there.” Nadia explained that she has learned overtime to use the
techniques she learned to allow her deal with stress in a proactive manner.
Nadia. It doesn’t matter to me how harsh, how basic, or how advanced
conditions are within the country. I guess nowadays organizations are
much better with making sure everyone has a job description, there is some
element of induction in the new job, the new role, and over the years you
get familiar with what to do and how to do and the expectations.
Some participants noted the benefits they experienced when enabled to deal proactively
with their experiences by appropriate stress management. Maria noted that she can “kind
of … separate out what is actually stressful and what isn’t,” and how helpful and
empowering such techniques are “I definitely feel stronger for having been through it.”
Tom shared that in his experience when “we put services in place… we no longer have to
worry about people’s capacity to cope.”
Invisible services. All participants noted how their current or previous
organizations had stress management services; however, during some of the participants’
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deployments, the services appeared to be invisible. The participants knew of their
existence because of other experiences, but during some deployments had not received
any information on how to access them. David said, “I don’t know where to begin
seeking qualified, competent formal stress management.” Rachel had recently joined a
new organization and reported she had not received any orientation on the stress
management support provided by the organization. She noted she had access to an on-line
training center and, “if I am digging into it,” she thought she might find some information
related to stress management.
Research Question 3: All participants noted the importance of trust in the system
and that assurances of confidentiality underpinned their decisions to access stress
management services. Each aid worker shared the strategies he or she used for coping,
and four participants shared initiatives they had introduced to help other colleagues cope.
There was a relationship between the previous experience the participants had with
accessing stress management services and their decision to engage in future.
Services. Seven participants stated that their perception of how their organization
would view or use staff accessing stress management services influenced their decision to
access in-house stress management services or not. Chloe noted her fear that she risked
being thrown on the “scrapheap” by her organization if she accessed stress management
services. Harry and Amanda noted that there appears to be no organizational retribution
for displaying negative behavior, and each gave examples of witnessing colleagues’
abuse of alcohol.
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Accessible, available services. The defining features that would influence 11 of
the participants’ decision to engage in the future with in-house stress management
services were their accessibility and availability, the professionalism of the services, and
an assurance of confidentiality. A key finding was that all the participants were less
focused on the formal in-houses stress management service provision that they associated
with counselors, and more weighted on the “normal” things organizations could and
should provide to reduce the work-related stressors they experienced. Five participants
stated their preference for future engagement with any formal services were to access
those external to their aid organization to ensure confidentiality.
The decision-making pathway that the participants explained when they were
deciding to engage or not with formal in-house stress management services were
complex. Becca noted, “Admitting that there is a problem that you would rather not deal
with . . . it’s a little bit . . . confrontational that you have to admit to yourself in the first
place.” That initial first step was difficult, and five of the participants expressed
suspicions about the how confidential was their engagement, based on their previous
experiences and the experiences and feedback of others. Once they decided they would
engage, the participants noted they had expectations with relation to the services. For
example, David noted, “Stress management for me is not one meeting . . . Stress
management for me is facilitating the things I need to do to get through a period.”
Meeting the array of expectations informed the perception of each of the participants of
the value of engagement that they experienced and their likelihood to engage again in the
future.
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Stigma and Taboo. Ten participants shared their concerns about accessing in-
house stress management services as they feared some negative repercussions. Four
participants spoke of the continued stigma and taboo around seeking help, and the risk
they faced of being “branded” by colleagues and their organizations if they were seen not
to cope. Jack expressed how there “is still taboo and stigma . . . around” engaging with
formal in-house stress management services. Amanda shared how she “sought assistance
thinking that this was the logical and right thing to do and then really found that it
backfired” when, in her opinion, her managers attempted to use her accessing support to
prevent her from returning to her job. This experience for Amanda influenced her future
decisions for engagement of stress management services, she stated that if in future she
required support she “might not do it through the organization anymore.” Sarah shared
how when she was referred to staff welfare support during one difficult episode. Rumors
of the lack of confidentially related to any interaction with the staff welfare team
influenced her decision about what to share with them “I was reluctant”.
Sarah. I was talking to them, but obviously, I didn’t share anything that I
wanted to share, even though … they shared went through the list of “Oh
yes, this is confidential,” but I knew, I mean, I knew I had hear horrible
stories.
Chloe expressed her concerns based on her experience of in-house stress
management. Despite a previous bad experience with in-house stress management, she
remained willing to engage in the future. She expressed the conditions she would look
from prior to any engagement, including assurances of anonymity.
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Chloe. [If] I had the confidence that this was going to … wasn’t going to
impact on the performance appraisal, or advancement within the
organization, then I would be happy to use organizational services. But if I
don’t have confidence in those things, then I would go to other services.
Discrepant findings. A significant part of the learning and adapting was the realization
for some that not all stress had a negative effect. Rachel and Chloe noted how they
responded to working under pressure with tight deadlines. Rachel shared, “I like kind of
having tight schedules and deadlines, and I am enjoying when it is positive stress.”
Not all participants reported being comfortable with some coping mechanisms as
suggested by stress managers, such as physical exercise. Tom shared how for him and his
friends, social gathering where they smoked cigars and drank alcohol helped them to
relax “because you come up with some techniques, and you ignore certain things, and
you don’t let them stress you.” Jack found an absence of things to fill his off-time and
noted that this was an issue that his colleagues shared. He was proactive in approaching
the stress counselors to make suggestions about what he thought would help him and his
colleagues to cope, “My issue was boredom, and there was not much going on.” He
recommended that the stress counselors organize “parties, watching sports events
together, or movies.”
Summary
International aid workers reported their beliefs that their jobs were more than
jobs; it was reported as a commitment. All participants reportedly accepted stress as part
of the aid work package. The participants described their experience with in-house stress
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management services as both positive and negative. This experience was based on the
level of accessibility to the services and the professionalism displayed by the counselor.
The participants described perceiving their work-related stressors as an expected part of
any deployment, and 10 participants expressed their concern around the perceived stigma
of accessing stress management services by their management and organizations. Each
participant described the adaptation he or she underwent and the strategies he or she
devised to deal with these stressors. Two participants noted how he and she experienced
some stress as positive and motivating. Each participant described his or her decision-
making process about whether to engage or not with in-house stress management based
on their perception of trust in the system, the level of professionalism they could expect,
and, most critically, trust in the confidentiality they required.
Chapter 5 will provide a discussion of the findings, with the implications for
contribution to social change, recommendations based on the findings, and the
conclusions drawn.
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Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
The purpose of this study was to understand the issues and challenges that
international aid workers encounter that lead to stress, their relationship with stress
management services as provided by their organizations, and the choices they make
whether to access these stress management services. A qualitative approach using
semistructured interviews provided the perspectives of 12 international aid workers about
their experiences.
The key finding was the importance of relief organizations providing a safe and
predictable working environment to benefit the international aid workers’ mental health.
The participants shared the stress that they suffered when dealing with poor management
decisions, the lack of basic logistical support to allow them to work in a predictable
manner, and the sense that their organizations deprioritized their well-being. Although
international aid workers accessed in-house stress management services when dealing
with both work-related and personal stress, their experiences with this form of mental
health assistance varied. Some experienced professional, helpful services; others
encountered unprofessional, inappropriate services and faced a real or perceived risk of
disclosure. Trust in the professional level of services, including assurances of
confidentiality, the level of accessibility, and appropriateness of services influenced aid
workers’ decisions to engage with formal stress management services.
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Interpretation of the Findings
The findings were used to confirm and extend knowledge of the issues that aid
workers encounter that lead to stress and the elements that aid workers consider when
deciding whether to access in-house stress management services. The key themes
identified in this study of the operational environment, organizational environment,
coping and adapting, formal stress management services, social support, and the aid
worker are intertwined. The participants offered possible areas where aid organizations
might do more to improve basic working conditions. The following analysis is structured
under each of the research questions.
Research Questions
Research Question 1. The participants described their experience of in-house
stress management services as inconsistent. They described how some professional
services were supportive and helpful and contributed to their recovery from the distress
they were experiencing. Other services were perceived as unprofessional, with counselors
who appeared unable to deal with the circumstances facing international aid workers, and
therefore, resorted to talking about themselves. Other aid workers encountered
professional and helpful services. Of those who had a positive experience accessing the
services, two participants reported that their managers or organizations attempted to
exploit the staff’s engagement for other purposes. Through different job experiences, the
participants noted that they were aware of some stress management services within their
organization; however, they had not received an orientation about what these services
were nor how to access them.
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The inconsistent standard and experience with in-house stress management
services informed how the international aid workers perceived these services, and thus,
their willingness to engage. The formal services that were professional, accessible, and
appropriate were reported to be helpful, motivating, and healing. The participants who
encountered these services reported being more likely to reengage in these services. From
the perspective of the participants, the services that they experienced as unprofessional or
incompetent were perceived to do more harm than good. Despite the recognition of aid
organizations that aid workers require stress management support (Curling & Simmons,
2010), their efforts to support workers were reported to be inadequate. The systems in
place appeared inconsistent and insufficient to meet the needs of the international aid
workers, thus supported previous studies’ findings (Curling & Simmons, 2013;
O’Donovan et al., 2013). Existing in-house services are insufficient to support aid
workers to deal adequately with their stress management needs (Connerton et al., 2012;
Ehrenreich & Elliot, 2004; Eriksson et al., 2012, McCormack & Joseph, 2012).
The most effective in-house stress management services are accessible,
predictable, and normalized. Aid workers feel isolated when attempting to deal with
stress, and the fear of stigma about suffering from stress is real and continues. The
participant aid workers reported how they continue to fight to have time for and protect
their rest periods. Many described their managers’ expectation for them to remain
available during out-of-office hours. Some participants described the pressures of
working in an emergency, which led to in an internal conflict for the aid worker when
they know they need to rest and sleep, yet remain available to deal with the workload.
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Understanding the issues that contribute to their stress is important and may contribute to
the mitigation of long-term effects of stress (O’Donovan et al., 2013). Organizations must
develop systems that allow staff to rest, yet perform the organizational mandates.
Research Question 2. The majority of the work-related stressors that
international aid workers perceived are preventable conditions within the working
environment. Poor management, unrealistic workload expectations, and unrealistic
organizational policies in comparison to the reality of the working environment led to the
distress of aid workers, they reported. The shortcomings within the organizational culture
caused the most significant level of stress for aid workers, and as a result, some aid
workers left their jobs. The lack of control that aid workers had over their operational
environment was reported to be stressful (Roth, 2014). The aid worker role is stressful,
and organizations have responsibilities to their staff to help them cope (Cordozo et al.,
2012). According to the findings, the informal stress management offered to international
aid workers by organizations that provided appropriate working environments appears
beneficial. According to the participants, the most significant contribution aid
organizations can make to mitigate and prevent stress of aid workers is to provide a
healthy, predictable working environment, where aid workers are encouraged to openly
express anxiety and stress. Organizations in which managers model appropriate,
supportive behavior and in which polices support aid workers will fare best according to
the findings.
Organizational policies tend to be developed to serve the organization rather than
the aid work staff. The one-size-fits all approach, where a singular policy for a whole
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organizational structure that has operations in a variety of contexts including
headquarters, regional offices, and field posting, was reported as inadequate. The
variance of contexts affects the ability to provide equal levels of services and support to
staff. Aid organizations must develop their understanding of aid workers’ needs in the
variety of contexts within which they work to ensure appropriate support and standards of
care (Tol et al., 2012).
Living and working in difficult, and often unsafe, environments takes a toll and
leads to distress (Connorton et al., 2012; Cordozo et al., 2012). Many of the issues that
contributed to participating international aid workers’ stress were related to the
operational environment. To cope, the participants sought to adapt and exert whatever
control they could over their well-being by employing strategies that they developed over
time. In an environment where they have little control (Roth, 2014), participating aid
workers developed strategies to allow them to deal with stress within their operational
environment. For example, they modified the desire for physical exercise from jogging in
public, which is taboo is some cultures, to adopting a yoga routine, which aid workers
can undertake in private. Helping aid workers develop a proactive mechanism to deal
with stress enables physical and mental health in difficult living and working
environments (Nilsson et al., 2011).
When faced with human suffering and an overwhelming workload, aid workers
perceived a scene of inadequacy, and despair in their inability to help more. McCormack
and Joseph (2012) reported the shame that aid workers described when they witnessed
war and genocide. This shame arose as the aid workers described their inability to protect
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the affected populations from the impact of war and genocide. Roth (2014) noted the
impact on aid workers when exposed to human suffering, and how it was a significant
contributor to the stress experienced by participants in this study.
International aid workers reported that they learned from their traumatic
experiences. The posttraumatic growth they experienced tended to be self-directed and
the potential to adapt positive behavior may be limited unless appropriately guided by a
mentor. Support to help grow after posttraumatic experiences is essential to help develop
positive behaviors (Pooley et al., 2012). International aid workers acknowledged their aid
organizations’ responsibilities to provide them with appropriate, safe, and predictable
working environments, but as this falls short, the aid workers attempted to take control of
their safety and well-being. Supportive initiatives, such as inductions, orientation to the
available stress management service, and debriefings were not consistently done for aid
workers, they reported. As such, the training and facilitation of aid workers’ training were
insufficient to help them cope (Duffield, 2012). Aid organizations have a responsibility to
ensure that support for their staff is central to their organizational policy (Willie & Fast,
2013).
A mitigating factor to the work-related stress international aid workers face was
the support they receive from their social support group. For many aid workers, such
groups comprised loved ones and like-minded peers who they proactively sought out.
Many chose to distance themselves socially from the people with whom they work. The
social support mechanism was dependent on the setting in which the aid worker lives
(Pooley, et al., 2013). The ability to communicate in a predictable manner with loved
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ones was critical for the well-being of aid workers the participants reported and helped to
offset distress when there were limited like-minded peers available to support them.
Research Question 3. Aid workers reported basing their decisions to access in-
house stress management services on a variety of factors. They reported accessing formal
in-house stress management services only during infrequent periods of acute stress.
Those who previously accessed services reported using past experience as a yardstick to
gauge future engagement. Those new to the services based their decisions on the
perception of the level of professionalism of the services available, the degree of trust
they had in the process and engagement, and the level of confidentiality they expected,
balanced against the rumors of others’ experiences and the perceived or real stigma they
might face by accessing services.
Many of the international aid workers described their experience accessing in-
house stress management services as ad hoc. The aid workers reported that they
considered the possibility of encountering unreliable or unprofessional formal services
when making their decision to engage with in-house stress management services. The aid
workers reported their individual experience and the known or rumored experience of
others also played a direct role in how the aid workers engage. Aid workers reported
perceiving that although their aid organizations acknowledge that their staff experience
stress in the workplace, the services provided are insufficient to meet their needs
(Cordozo et al., 2012). Reported concerns about accessing services and receiving
appropriate professional care, in particular, related to confidentially pushed the
participants to try to cope without formal support or care.
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The culture of stigma and taboo reportedly continues in the perception of aid
workers who reported accessing stress management services. Aid workers reported
carefully weighing the options when deciding to access formal stress management
services. For some, the risk was too high to engage, and they chose alternative options. In
this study, eight participants shared that they had left a job as the result of being unhappy
in a previous role. In other words, the risk perceived by these aid workers was such that
leaving a job poses a lesser risk than seeking a formal mechanism to seek support.
Addressing this stigma and lifting the taboo can be accomplished only through
organizational engagement and a change in organizational culture to make engagement
with stress management services acceptable (Cordozo et al., 2012). Organizations that
promote initiatives such as appropriate managerial training for staff and peer support
mechanisms contribute to the support that aid workers perceive (Francis et al., 2012).
Initiatives such as these are cost effective when balanced with the impact of staff who are
unproductive due to stress or due to the loss of staff (Francis et al., 2012).
Theoretical Framework
Hobfoll’s (1989) conservation of resources theory proposes that people’s
perception of stress comes about when their resources are at risk. As described by the
theory, resources may include physical items, such as a home, one’s condition or social
status, or personal characteristics, such as one’s energy level or skill. When viewed
through the lens of the conservation of resources theory, the current findings inform
processes and mechanisms that can strengthen international aid workers’ capacity to
cope. International aid organizations should invest in ensuring that the working
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environment must provide an optional and appropriate level of safety and security to
allow aid workers to operate. Many of the elements of the operational environment are
outside the control of the aid organizations. Physical elements however, such as a safe,
functional working space within an organization for aid workers, contribute to aid worker
teams’ perception of safety and would help increase personal characteristics resources. In
this way, physical resources help to support and build other resources, which in turn
would allow aid workers to build their resilience to stress.
The resources that contribute to conditions or social elements are important for
aid workers. A majority of the participants mentioned the ability to have predictable,
frequent communication with loved ones as key to their ability to cope with their stress.
Thus, organizations should provide technical support, such as phones and access to the
Internet, to help aid workers to develop their communications with those with whom they
choose to communicate. Interactions with like-minded peers, specifically, those sought
out by the aid worker, appear to be another key way for aid workers to build and maintain
resources. Stress management training that promotes these strategies help to build the aid
workers’ toolkit of strategies and may ameliorate stress and build resources. Strategies
such as these are empowering and are within the capacity of the aid worker to explore as
necessary to help control their resources.
Another area of support is to help aid workers develop their skills and
competencies to cope with stress. Building aid workers’ capacity to reflect on what
stressors they experience and their impact, would help workers develop their self-
awareness and the resultant adaptation that is necessary to survive. Under the
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conservation of resources theory, developing personal characteristics increases the
resources a person has, and thus, contributes to building resilience to stress (Hobfoll,
2007). Augmenting support for aid workers by providing healthy and safe working
environments can help to limit the depletion of resources, and thus, help aid workers to
maintain an equilibrium of resources to cope.
Limitations of the Study
Several limitations are associated with this study. Although the participants had
experience across a variety of different organizations and contexts, the transferability of
these findings to all aid workers is not appropriate. In addition, I gathered data using an
online audio conferencing tool. Thus, I may have I missed nuances displayed through
body language. Finally, several aid workers participated in the interviews from remote
locations and used limited Internet connections. Given these conditions, these participants
may have chosen to summarize the information they shared in an effort to expedite the
interview.
Recommendations
Further research is necessary to continue to explore the optimal level of formal,
stress management support for aid workers. Elements such as formal, structured
inductions and debriefing for international aid workers could be explored to understand
the benefits that international staff perceive. This may help aid workers mitigate and cope
with stress. Other opportunities for research arise from this study. Aid workers noted the
value of informal stress management, such as informal access to professional mental
health staff. Future researchers might explore what informal services offer value for aid
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workers for their stress management. Further research is needed on how discontent with
the working environment leads aid workers’ to decide to leave their jobs.
Implications
The potential for positive social change based on the findings of this study are
manifold. The proposals outlined below are based on the recommendations from the
participants of this study, and, thus the voices of international aid workers. Support for
international workers to enable them to deal with stress in a positive, proactive manner
through training, support, and appropriate organizational culture has positive
implications. The potential impact of social change is possible at the organizational level,
the individual aid worker level, and ultimately at the level of those in need of essential
life-saving when they are at their most vulnerable.
Based on the findings, aid workers expect to encounter stress in their work. When
aid workers are supported and trained to recognize the signs of stress, techniques to deal
with stress, and are afforded the time and space to engage in positive techniques to deal
with stress, their capacity to build resilience to stress improves. Some aid workers have
the capacity to undergo posttraumatic growth and develop positive adaptive behaviors
that can mitigate against stress. Posttraumatic growth allows aid workers to maintain
physical and mental health, and thus, to support their capacity to work in an optimal
manner. Changes are needed in aid organizations. They must address the shortcomings of
their existing staff welfare policies to ensure parity of care for aid workers, appropriate to
the context within which they work. Developing an organizational culture that
destigmatizes those who seek stress management is critical to the timely support stress
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aid workers receive. These combined efforts have the potential to enable an optimal
working environment in which aid workers can be as productive as possible in their
support of people who require humanitarian live-saving assistance.
Resilience to stress develops through reflection, self-awareness, and an attempt
toward staff care. The findings indicated that international aid workers seek to adapt
following stressful experiences, and they identify strategies that allow them to cope. The
adaptation builds resilience to stress (Berger et al., 2015). The existing mechanisms that
aid organizations employ to support aid workers to build resilience are inadequate. As a
result, aid workers seek to identify strategies such as doing yoga and meditation and
protecting their rest periods. Still, such strategies may not be appropriate for all aid
workers. Other coping strategies such as substance abuse may, in fact, have negative
consequences.
Recommendations for Practice
From these results several recommendations for practice arise for improving aid
workers’ capacity to deal with stress.
Organizations. Organizational policies for staff care must be appropriate to the
context within which aid workers operate, and allow for dynamic usage depending on the
individual aid worker and his or her needs. Aid organizations should consider flexible
policies that encourage equal standards of care and support, regardless of the operational
environment. Staff must be urged to engage in stress management and never be penalized
for engagement with stress management services.
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Organizations have a responsibility to educate their staff about the available
services and the mechanisms to access them. Organizations should ideally foster a culture
that normalizes access to such services. Formal and structured inductions and debriefings
with stress management mainstreamed into the process per assignment should be
standard.
Organizations must also ensure that the working environment for aid workers is
healthy and safe. Aid workers access formal stress management services only on an
irregular basis during periods of acute stress. Other informal mechanisms can aid stress
management, such as team activities, peer support, and organizations and managers
helping staff to partake of protected rest periods. Furthermore, aid workers must receive
training on how to identify and understand their experiences with stress and deal with it
in a positive manner. They must also be trained on how to build resilience to stress.
Aid workers. Individuals can do a variety of things to help themselves. Although
organizations have a responsibility to train staff in appropriate techniques for the context
within which aid workers operate, aid workers must engage actively in the training
opportunities and use the tools developed to address the stress they encounter.
Furthermore, workers must develop the skills and competencies to reflect, adapt, and
build coping strategies and control their experiences. Some practices require skill, but all
require the confidence to make the changes needed to help aid workers cope. For
example, bringing a yoga mat on deployments could be a useful way to encourage a self-
care practice. Aid workers could be supported to learn and develop skills which allow
them to mitigate and prevent the negative impact of stress. For such techniques to work,
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aid workers must be allowed predictable, protected rest periods, both during deployment
and when on a leave break, to allow them to engage in such practices.
Stress Management Framework
Stress management framework. In an ideal world, holistic support for aid workers
to allow them to deal with stress need not be costly or sophisticated, as indicated by the
participants in this study. Many organizations currently provide stress management
support of various degrees, but there is limited standardization between organizational
approaches (Cordozo, et al., 2012). BI propose a potential stress management framework
with broad categories recommended based on the combined experience of aid workers,
and that complies with previous studies’ findings around the benefits of staff support to
counteract the negative impact of stress (Cordozo et al., 2012; Ehrenreich & Elliot, 2004;
Vergara & Gardner, 2011). I acknowledge that many organizations provide a package of
support to aid workers; however, the systematic provision of support to all aid workers
remains a gap.
The support should be considered in three phases: predeployment, deployment,
and post-deployment. The support across these phases should be harmonized,
standardized, and complementary. Table 2 provides an outline of a stress management
framework of support based on the combined experiences of the participants of this
study, with details of each phase provided in the narrative below.
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Table 4
Stress Management Framework
Deployment Phase Support Purpose
Predeployment Induction
Mainstream stress
management training
Predeployment training
Training managers
Prepare aid workers for the working
and living environment during
upcoming assignment. Aid workers
should be facilitated to undergo these
services with each deployment.
During deployment Orientation
Event management
Extreme cases
Ongoing support to aid workers to
allow them to work to their full
potential, while dealing in real time
with issues as they arise.
Postdeployment Exit debriefing
Follow-up with stress
management services
Facilitating a smooth exit for each
aid worker as they leave each
deployment. This service should be
offered for staff who leave the
organization and for those moving to
other locations of deployments with
the same organization.
Phase 1: Predeployment. Before staff deploy on any assignment there should be
some process where they receive foundational information to enable them to prepare for
the mission ahead.
Induction. All aid workers should receive an induction before their deployment.
An induction that helps aid workers understand the context where they were going and
the organizational expectations of the staff member’s role is key to help the aid worker
prepare. The induction could include information that orients the staff member to the
standards of living, the items available to buy for basic resupply, and the absence of any
critical supplies for personal or professional use. Aid workers require preparation to
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enable them to be ready to undertake their assignment. David spoke of the value of an
induction package that allowed him to be prepared for his deployment.
Mainstream stress management training. During the induction period, all aid
workers should undergo stress management training that is mainstreamed into the
induction process. Aid organizations could help staff to improve their preparations and
manage expectations through the provision of standardized inductions. Nadia shared her
recommendation to streamline stress management training into the standard induction
that aid workers receive. Normalizing stress management through mainstreaming
initiatives helps to break down stigmatization and the potential of taboo around stress
management.
Predeployment training. Training international aid workers during the
predeployment period helps them develop skills to use during their deployments. David
and Tom reported the benefits they experienced from predeployment training that
included situational awareness, recognizing their symptoms of stress, and security
management techniques. Training should take place throughout any career, but this
foundational level training that allows aid workers to build a skill base increases
resilience to stress.
Predeployment training for managers. All managers should receive training
appropriate to the required role, that includes elements of how managers should deal with
stress. Maria shared the distress she experienced when her manager was unsupportive
during a stressful experience. Amanda, Rachel, and Becca reported their frustrations what
they considered poor management decisions. Nadia recommended that all managers
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receive dedicated training to allow them to manage staff in a manner that enabled
productivity.
Phase 2: Deployment. Support to aid workers throughout their deployment
enables them to manage their workload, productivity levels, and mitigate against the
impact of long term unresolved stress.
Orientation. All aid workers should receive an orientation to a new role and
location on arrival at a new location, regardless of the number of deployments the aid
worker had to date. The orientation could include an overview of the decision-making
pathway within the context, basic information to allow the aid worker to become
established in the location to live, work, and commute, and information pertinent to the
context that has the potential to impact the aid workers’ stress levels. Nadia and Chloe
recommended that all aid workers receive an orientation on arrival to new job placement
locations.
Proactive management. Organizations are comprised of people, and the people
involved in decision making for the organization are responsible for ensuring there is
consistent and proactive management of all elements of the environment within which
staff works to mitigate and prevent stress. The proactive management should include
support that enables aid workers set up their living and transport arrangements, support
and training to managers to facilitate good decision-making mechanisms, and agreed
upon arrangements that respect staff off time. All the participants reported the real or
potential benefits such interventions would have to mitigate and prevent their stress as aid
workers.
