Self Care for Health Care Professionals Working with Refugees

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Introduction

Working with people with refugee experience is often rewarding meaningful work, but it can also be challenging, especially to the physical and psychological health of the individual working in this field.

Physiotherapists treating refugee populations are exposed to possible negative reactions related to several challenging aspectsthey face in this work. They are confronted daily by suffering and grief and the situation of generalized loss in which refugees often find themselves. [1] In particular, histories of survivors trauma can be highly demanding for the untrained physiotherapist to deal with, due to their extreme nature often involving torture and/or violence. [2] Additionally, there can be difficulties related to cultural competency required when working with this population. [3]

All these aspects can combine and result in challenging problems to face, that can make the health care professional feel inadequately trained or unskilled, putting her/him at risk for serious distress reactions. [4] Health workers in this field talk of how their work can sometimes leave them feeling numb, disconnected, isolated, overwhelmed, and depressed. For these reasons, the Importance of Self-Care is crucial. [5]  Studies on physiotherapists as a profession alone are limited are limited, but have shown that they are also subject serious distress reactions, with one study showing 45.8% of the physiotherapists were affected by burnout or at a high risk of developing the syndrome. [6] 

What is Self-Care

Self-care is any activity that we do deliberately, in order to take care of our own mental, emotional and physical health. It’s “something that refuels us, rather than takes from us”. [4]

It is a broad concept encompassing hygiene (general and personal), nutrition (type and quality of food eaten), lifestyle (sporting activities, leisure etc), environmental factors (living conditions, social habits, etc.) socio-economic factors (income level, cultural beliefs, etc.) and self-medication. [7]

Why Self-Care is Important

  • Working with people with refugee experience can be emotionally difficult for individuals working in this field. 
  • Embedding self- care activities in daily life helps in identifying, managing, and reducing stress and anxiety. It helps maintain and enhance short and longer-term health and well-being.
  • It can help prevent negative reactions (explained below) such as secondary trauma, compassion fatigue or burnout.
  • It helps improve the quality of life, and support achieving a healthy balance between life and work.
  • Taking care of yourself will allow you to continue providing care to those you support in your work and at home. 

Understanding Stress

At the most basic level, stress is our body’s response to pressures from a situation or life event. Stress can be viewed in two ways; as eustress and distress. Eustress is positive stress in our lives and distress is negative stress in our lives. Usually when we talk about stress, we are talking about distress. 

Eustress differs from distress with the following characteristics: [8]

  • It only lasts in the short term
  • It energizes and motivates
  • It is perceived as something within our coping ability
  • It feels exciting
  • It increases focus and performance

On the other hand, distress, or negative stress, is characterized by:

  • Lasting in the short as well as in the long term
  • Triggering anxiety and concern
  • Surpassing our coping abilities
  • Generating unpleasant feelings
  • Decreasing focus and performance
  • Contributing to mental and physical problems

What contributes to stress can vary hugely from person to person and differs according to our social and economic circumstances, the environment we live in and our genetic makeup. Some common features of things that can make us feel stress include experiencing something new or unexpected, something that threatens your feeling of self, or feeling you have little control over a situation.  

Common Sources of Stress as a Health Professional 

Sources of stress can be divided into external and internal

External Stress Sources

Examples of External Stressors are: [9][10]

  • A chaotic work environment
  • Work overload
  • Tight deadlines and stressed coworkers
  • Feeling overwhelmed by unmet needs
  • Overload of administrative work
  • Little possibility of promotion at work
  • Communication difficulties due to personality and cultural differences 
  • Facing moral and ethical dilemmas
  • Inadequate working space
  • Unrealistic expectations of patients and their families
  • Daily unforeseen and unplanned situations

Other non-work specific factors could include;

  • Travel difficulties and delays;
  • Lack of social support;
  • Major life changes; such as a new marriage, a planned pregnancy, the death of a loved one or a divorce;
  • Environment; things that overwhelm our natural senses such as building work next door to you, sunlight in your eyes while at work in your office;
  • Social: negative family dynamics, new interactions.

Internal Stress Sources

Examples of Internal Stressor are: 

  • Fears; such as fear of failure or public speaking or of flying.
  • Uncertainty and lack of control; Job uncertainty or waiting for the results or a test.
  • Beliefs; These might be attitudes, opinions or expectations such as the anticipation of a perfect holiday or differing political beliefs with family or friends.
  • Negativity and pessimism
  • Previous experience with trauma or very stressful event. [11]

Stress Physiology  

Our bodies judge a situation and decide whether or not it is stressful. This decision is made based on sensory input and processing (i.e. the things we see and hear in the situation) and also on stored memories (i.e. what happened the last time we were in a similar situation) [12] 

When we perceive an event that is stressful or frightening to us, our body is stimulated to produce stress hormones that trigger a ‘flight or fight’ response (also known as the acute stress response). These responses are evolutionary adaptations and help us to respond quickly and increase our chances of survival in threatening situations. [12]

  • Information from the senses is sent to the amygdala, an area of the brain that contributes to emotional processing. 
  • The amygdala interprets the images and sounds. If danger is perceived, it instantly sends a distress signal to the hypothalamus.
  • The hypothalamus communicates with the rest of the body through the autonomic nervous system, which controls such involuntary body functions as breathing, blood pressure, and heartbeat.
  • The autonomic nervous system has two components, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system functions like a gas pedal in a car, providing the body with a burst of energy so that it can respond to perceived stresses/dangers. The parasympathetic nervous system acts like a brake. It promotes the "rest and digest" response that calms the body down after the danger has passed.
  • The hypothalamus activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping the hormone epinephrine, also known as adrenaline, into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes. 
Table.1 Fight or Flight - Physiological Responses [13]
Body System Physiological Effect Consequence
Heart Increased heart rate

Dilation of coronary blood vessels

Increase in blood flow

Increased availability of oxygen and energy to the heart

Circulation Dilation of blood vessels serving muscles

Constriction of blood vessels serving digestion

Increased availability of oxygen to skeletal muscles

Blood shunted to skeletal muscles and brain

Lungs Dilation of bronchi

Increased respiration rate

Increased availability of oxygen in blood
Liver Increased conversion of glycogen to glucose Increased availability of glucose in skeletal muscle and brain cells
Skin Skin becomes pale or flushed as blood flow is reduced Increased blood flow to muscles and away from non-essential parts of the body such as the periphery
Eyes Dilation of the pupils Allows in more light so that visual acuity is improved to scan nearby surroundings

Chronic Stress

Long term stress is regulated by the Hypothalamic Pituitary-Adrenal (HPA) system which allows an  adaptive response to any stressor. The hypothalamus, signals the pituitary gland to produce a hormone, which in turn signals the adrenal glands, located above the kidneys, to increase the production of cortisol. Cortisol increases the level of energy fuel available by mobilizing glucose and fatty acids from the liver. During a stressful event, an increase in cortisol can provide the energy required to deal with prolonged or extreme challenge. [14] However, chronically, if our stress response is activated repeatedly, or it persists over time, the effects can result in wear and tear on the body and can cause us to feel permanently in a state of ‘fight or flight’. Rather than helping us push through, this pressure can make us feel overwhelmed or unable to cope. 

Impact of Chronic Stress becomes Pathological Affecting Multiple Body Systems

Table.2 Impact of Chronic Stress on Body Ststems
Body System Consequence
Nervous System
  • Overdrive of ANS causing changes to multiple body systems
Musculoskeletal System
  • Mechanical pain related to altered motor control/myofascial restriction
  • Decreased Core Stability
Respiratory System
  • Altered Breathing Mechanics:
  • Decreased Diaphragmatic Breathing
  • Increased Accessory Breathing
Cardiovascular System
  • Increased risk of heart disease
  • Decreased circulatory efficiency
Endocrine System
  • Increases in cortisol can affect the activity of insulin leading to metabolic disorders such as diabetes and obesity.
  • The immune system is also compromised. Studies have shown that people under chronic stress are more susceptible to viral illnesses like flu and common cold as well as other infections. 
Gastrointestinal System
  • Appetite Changes
  • Acid Reflux
  • Diarrhea or Constipation
  • Stomach Pain
  • IBS (Irritable Bowel Syndrome)
  • IBD (Irritable Bowel Disease; Ulcerative Colitis & Crohn’s disease) are the common symptoms seen, 
Reproductive System
  • Menstruation, Sexual Desire, Pregnancy, Worse Pre-menstrual Symptoms or Menopausal Symptoms
  • Increased Risk of Gastrointestinal Disease
Sensory System
  • Light Sensitivity
  • Sensory Exclusion
Mental Health
  • Depression
  • Anxiety
 

Stress affects the whole body. It can have several physical or psychological symptoms, which can make functioning on a daily basis more challenging. The type and severity of symptoms vary considerably from person to person. Signs and symptoms of stress can include: 

Table.3 Signs and Symptoms of Stress
Emotional
  • Mood Swings
  • Feeling “Over Emotional”
  • Irritability
  • Anxiety
  • Depression
  • Anger
  • Emotional Numbness
Mental
  • Poor Concentration
  • Confusion and Disorganised Thoughts
  • Forgetfulness
  • Difficulty Making Decisions
  • Dreams or Nightmares
  • Intrusive Thoughts
Existential
  • Feelings of Emptiness
  • Loss of Meaning
  • Discouragement & Loss of Hope
  • Cynicism
  • Doubt
  • Religious Crisis
  • Alienation & Loss of Sense of Connection
Behavioural
  • Risk Taking e.g. Driving Recklessly
  • Over-eating or Under-eating
  • Increased Smoking
  • Listlessness
  • Hyper-arousal
  • Aggression  
Physical
  • Low Energy
  • Upset Stomach, including Diarrhoea, Constipation, and Nausea
  • Aches, Pains, and Tense Muscles
  • Rapid Heartbeat and Breathing
  • Insomnia
  • Frequent Colds and Infections
  • Loss of Sexual Desire and/or Ability

High Levels of Stress and Associated Reactions 

Self-care is essential and we all need it as we can all suffer from stress at work, but working with people with refugee experience has its unique challenges. There are a number of conditions that health care professionals develop when they are exposed to high levels of stress. The diagram below demonstrates the conditions health care workers may develop, both positive and negative.

Compassion Fatigue

Compassion fatigue refers to an inability to empathise with beneficiaries as they share their experiences, or an unwillingness to bear the pain of difficult stories or provide support. Professionals regularly exposed to the traumatic experiences of the people they service, such as healthcare, emergency and community service workers, are particularly susceptible to developing compassion fatigue. Compassion fatigue is characterised by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to make decisions and care for patients and/or clients. [15] It focuses oncognitive, emotional and behavioral changes occurring when working with victims of trauma. [16]

Compassion fatigue can be the result of a high workload in a clinical setting, especially when the clinician experiences a feeling of helplessness or inability to meet the needs of beneficiaries.
Figure.1 Figleys Compassion Fatigue Process [17]

Vicarious/ Secondary Trauma 

This refers to symptoms of trauma which health care workers can begin experiencing as a result of being exposed to stories of traumatic events from survivors. Secondary Traumatization may happen to a worker after a single exposure to a traumatized patient. Symptoms experienced can be the same or similar to those who have suffered the trauma, such as  fatigue, hyper vigilance, avoidance, numbness and Post Traumatic Stress Disorder type symptoms. Vicarious traumatisation occurs due to cumulative exposure to traumatised patients. This produces mental and cognitive signs and symptoms in regards to the oneself, others, the surrounding world Symptoms include;

  1. Changes in Spirituality;
    • For example changes in beliefs, causality, and faith, questioning prior beliefs and the meaning and the purpose of life, hopelessness.
  2. Changes in Identity;
    • For example, changes in the way you think about, friend, or family member, or practice important identities as a professional.
  3. Changes in Beliefs Related to Major Psychological Needs; 
    • For example;  beliefs regarding safety, control, trust, esteem, and intimacy. These beliefs can influence your thoughts (e.g. worrying about safety issues, mistrust of strangers) and actions (e.g. being more protective of your children) [18]

Most commonly the onset is gradual as the worker hears more and more stories in a context where they lack support or good self-care practices, Both secondary traumatization and vicarious traumatization result in a reduction in, motivation to work, work productivity, empathy and an increase in work avoidance. [15]

Burnout

Burn-out is defined by the WHO (2018) as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:  

  1. Feelings of energy depletion or exhaustion;  
  2. Increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and  
  3. Reduced professional efficacy [19] 

Burnout is characterized by emotional exhaustion, lack of energy or demotivation, apathy, feelings of hopelessness, rapid exhaustion, disillusionment, melancholy, forgetfulness, irritability, experiencing work as a heavy burden, an alienated, impersonal, uncaring and cynical attitude toward clients, a tendency to blame oneself coupled with a feeling of failure. [20] 

The table below shows the many symptoms of Burnout. 

Table.4 Symptoms of Burnout
Psychological
  • Depression
  • Anxiety 
  • Hopelessness
  • Emotional Numbness 
  • Cynicism
  • Difficulty concentrating
  • Lack of motivation 
  • Negative attitudes 
  • Intrusive thoughts 
  • Low morale
  • Forgetfulness 
  • Guilt
Physiological
  • Headaches
  • Sleep Disturbances
  • Body Pain and Aches
  • Tiredness
  • Chronic Health Issues e.g. High blood Pressure, Ulcer, etc.
  • Stomach Complaints
  • Changes in Appetite
  • Rapid Heartbeat
  • Breathing Difficulty
  • Muscle Tension 
  • Inability to Relax
  • Low Energy 
Behavioural
  • Withdrawal from Others 
  • Indifference and Boredom
  • Procrastinating, and Missing Deadlines
  • Lack of Boundaries
  • Irritability 
  • Blaming Others 
  • Relationship Difficulties 
  • Communication Difficulties 
  • Increased Addictions or Dependencies
  • Distrust in Colleagues
  • Increases Errors
  • Difficulty Coping with Tasks

Causes of Burnout in the Workplace

In a workplace context it can be the result of a high workload, inadequate support or resources, organizational and personal conflicts, [21] Interpersonal conflicts, inequality, lack of job satisfaction or recognition can also be contributing factors. Working with the refugee population can be challenging, but it’s also rewarding, inspiring, and energizing, you witness their resilience, strength, hope, and their growth during therapy, which fuels you to continue providing support and doing the work of helping.

There are also positive reactions that are associated with working with this population. 

Compassion Satisfaction

This is the pleasure you derive from being able to do your work, and includes the parts that you experience as being ‘life-giving ‘, for example, you may feel like it is a pleasure to help others through your work, or you may feel positive about your ability to contribute to the work setting (ProQOL)

Vicarious Resilience (VR)

This is the positive impact on personal growth of therapists that results from exposure to both traumatic material and resilience witnessed in survivors results from exposure. [22] VR manifest itself as personal growth in the areas of self-perception and worldview, spirituality, self-care, trauma work and connection with clients. [23]

The ABC's of Self-Care

Understanding how to create self-care is based upon three main principles. [24]

Awareness

Awareness is an essential first step in figuring out your responses to what’s happening in your work and your life (the potential risk factors and your own warning signs) and what you can do to take care of yourself in those times. It’s important to check in with yourself on regular bases:

  1. How You Are Feeling (Emotionally, Physically and Spiritually)? 
    • Spend some time reflecting on how you’re feeling (physically, emotionally, and spiritually)
    • Ask yourself how did you feel when you woke up this morning? How do you feel now? try exercise like Body scan and self-attunemen
  2. Identify The Sources Of Your Stress and How You Are Responding?
    • Identify what sort of problems or people do you find it especially easy to empathize with? 
    • Identify some of the ways that caring about people who have been hurt affects you?
    • Identify sources of stress r in your life, and which areas of your life need improvement. ( A helpful tool here is Wheel of Strife or the Wheel of Life
  3. Stay Connected And Present
    • When you are working with people with refugee experience it is important to stay connected and present, it will help you observe your body and mind, and be more aware of your actions ad reaction. 
    • List any signs or symptoms that you are experiencing in the Physical, Psychological, Behavior and relationships, and Worldview or frame of reference (spirituality, identity, and beliefs) areas.( See the table above under sign of stress) 
    • Think back over the last couple of years. What are your early warning signs? (i.e. the first signals that warn you that you’re struggling in this area)
  4. Recogniae Early The Need To Make the Needed Adjustments To Your Work And Personal Life
    • Do you know what you’re doing in your work, and why? (Knowing that your work is making a difference in other people’s lives, will reminds you that your work have a purpose, a meaning, and a positive impact on people lives)
    • How do you measure success in your work? (For example; Do you need to accomplish everything on your to do list to feel the success? Or do you feel the success when you do your best at any task?)
    • What can you control in your work?  (Can you make a choice about your work schedule? Structure?) Knowing what can you control and what you can’t, will prevent you from putting up energy and focusing on things you can’t change, a helpful tool here is the Circle of Influence
    • What are the costs and rewards of this work, and how are you personally changing? (When you work in a hematuria field changes by the work is inevitable, what is rewarding about the work you do? What are the risks? Think about why did you choose to work in this field? Highlight the differences between then and now.)
    • List the ways that you have changed over time because of your work?

Balance

It is important to balance your personal needs with the demands of your work; making sure that each work day includes some breaks for meals and physical activity, and that you are taking sometimes away from work for rest and relaxation, for friends and family, for spiritual renewal, it is also important that you find a balance between caring for others and being cared for. Balance is also about finding a balance within work that will allow you to work in a sustainable way.

List the things that you do to cope with these symptoms? In the Physical, Mental and emotional, Behavior and relationships, and at work. What are the activities you do regularly or enjoy doing that can help you cope? Which do you find most helpful to you? And which strategies do you wish you used more regularly? (See self-care strategies table above), a helpful tool also here is the Self-Care Wheel:

Connection

It is important to keep the connection with other people whom you like and care about. It is about keeping the connection with other people, and with our spiritual selves. It is also important to connect with the community, connect to a group of people who know each other, share experiences and values, and reach out to one another in good times or in times of need or distress. It is advisable to connect with different communities, for they often provide different types of support.

Self- Care Strategies

Table.5 Self Care Strategies
Emotional
  • Reflection: Journaling, Writing, Meditating
  • Ongoing Support Group
  • Counselling 
  • Expressive Therapies
  • Drawing 
  • Movies, Books, Music
Physical
  • Regular Exercise
  • Healthy Eating 
  • Drinking Water 
  • Limiting Consumption of Alcohol
  • Relaxation Techniques
  • Therapeutic Massage 
  • Repetitive Activities such as walking, drawing and cooking.
  • Getting Enough Sleep 
Interpersonal
  • Regular Contact with Friends and Family
  • Healthy Boundaries 
  • Use of Humour 
  • Building and Maintaining Positive Relationships 
  • Takes Some Time Off 
Spiritual
  • Knowing your Values: Where do you tend to find meaning in your life?
  • Participating in a community of meaning and purpose
  • Regular time of Prayer, Reading, Meditation 
  • Spiritually Meaningful Conversations 
  • Listening to Spiritual Music
  • Contact with Religious / Spiritual Leaders 

Assessment Tools

The Professional Quality of Life Measure (ProQOL)

The ProQOL is the most commonly used measure of the negative and positive effects of helping others who experience suffering and trauma. The ProQOL has sub-scales for compassion satisfaction; burnout and compassion fatigue. The measure has been in use since 1995. Is available in a wide range of translations.

Self-Care Assessment Tool (SCAT)

The SCAT is a tool developed by Karen W. Saakvitne and Laurie Anne Pearlman (1996) to provide an overview of effective strategies to maintain self-care in 5 major domains; Physical, Psychological, Emotional, Spiritual, and workplace and professional. After completing the full assessment, you can move on to developing a full self-care plan.

Maslach Burnout Toolkit and Maslach Burnout Inventory (MBI)

The Original form of the MBI was constructed by Christina Maslach and Susan E. Jackson with the goal to assess an individual’s experience of burnout. The MBI takes between 10-15 min to complete and can be administered to individuals or groups. It consists of 22 items pertaining to occupational burnout, and explores three dimensions; Exhaustion, Depersonalization, and Personal Achievement.

The Work Stress Questionnaire (WSQ)

The Work Stress Questionnaire (WSQ) has been developed with the purpose of early identification of individuals at risk of being sick-listed due to work-related stress, and has been used in medical research like the systemic review study on stress among health care professionals. [25] 

Tips

  1. Identify Your Own Sources of Stress
  2. Learn Your Own Stress Signals, your Early Warning Signs 
    • Recognize how you deal with stress
    • Find Healthy Ways to Manage Stress;
    • Practice Self-care Strategies Regularly e.g.
  3. Take Care of Yourself
    • Eat a Healthy Diet
    • Live an Active Life
    • Sleep Well
    • Set Work/Life Boundaries
    • Make time for Hobbies and Leisure Activities
    • Make time for Family and Friends.
  4. Connect with or Disconnect From
    • People e.g if you work mostly with a team try to set some time out as a small break, if you work alone try to connect with other people
    • Reach out for support if needed e.g. family member, friends, work colleagues, direct supervisors, counsellors
  5. Change Some of the Things that Bother You 
    • Change things you can control e.g. cleaning and organising your desk
  6. Try Something Different at Work 
    • Avoid the routine and try to do something in a different way e.g. work on a project with a  colleague, conduct a small workshop, learn something new
  7. Write About Your experiences at Work  
  8. Find Ways to Retain or Regain Perspective During the Day 
    • Practice some exercise to calm your body and ground your mind
    • Try some breathing and meditation exercises
  9. Invest in Professional Networks and Relationships with Colleagues 
    • Share your Work Experience e.g. case study, or some resources, or some non-work experiences with your colleagues.

Resources

Signs of Stress

More information on signs of stress can be found at; 

Organisations

References

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