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Risk and resilience factors affecting thepsychological wellbeing of individuals deployed inhumanitarian relief roles after a disaster

Samantha K. Brooks, Rebecca Dunn, Clara A. M. Sage, Richard Amlôt, NeilGreenberg & G. James Rubin

To cite this article: Samantha K. Brooks, Rebecca Dunn, Clara A. M. Sage, Richard Amlôt, NeilGreenberg & G. James Rubin (2015) Risk and resilience factors affecting the psychologicalwellbeing of individuals deployed in humanitarian relief roles after a disaster, Journal of MentalHealth, 24:6, 385-413, DOI: 10.3109/09638237.2015.1057334

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J Ment Health, 2015; 24(6): 385–413! 2015 Taylor & Francis, LLC. DOI: 10.3109/09638237.2015.1057334

REVIEW ARTICLE

Risk and resilience factors affecting the psychological wellbeing ofindividuals deployed in humanitarian relief roles after a disaster

Samantha K. Brooks1, Rebecca Dunn1, Clara A. M. Sage1, Richard Amlot2, Neil Greenberg1, and G. James Rubin1

1Department of Psychological Medicine, King’s College London, London, UK and 2Emergency Response Department, Health Protection Directorate,

Public Health England, Microbial Risk Assessment and Behavioural Science, Porton Down, Salisbury, Wilts, UK

Abstract

Background: When disasters occur, humanitarian relief workers frequently deploy to assist inrescue/recovery efforts.Aims: To conduct a systematic review of factors affecting the psychological wellbeing ofdisaster relief workers and identify recommendations for interventions.Method: We searched MEDLINE� , Embase, PsycINFO� and Web of Science for relevant studies,supplemented by hand searches. We performed thematic analysis on their results to identifyfactors predicting wellbeing.Results: Sixty-one publications were included. Key themes were: pre-deployment factors(preparedness/training); peri-deployment factors (deployment length/timing; traumatic expos-ure; emotional involvement; leadership; inter-agency cooperation; support; role; demands andworkload; safety/equipment; self-doubt/guilt; coping strategies) and post-deployment factors(support; media; personal and professional growth).Conclusions: As well as role-specific stressors, many occupational stressors not specific tohumanitarian relief (e.g. poor leadership, poor support) present a significant health hazard torelief workers. Humanitarian organisations should prioritise strengthening relationshipsbetween team members and supervisors, and dealing effectively with non-role-specificstressors, to improve the psychological resilience of their workforce.

Keywords

Disaster, humanitarian relief, mental health,psychological impact, relief work

History

Received 25 March 2015Revised 12 May 2015Accepted 24 May 2015Published online 8 October 2015

Introduction

Humanitarian staff deployed overseas in crisis response roles

provide essential support for local populations. While many

emergency responders view work overseas positively

(Hibberd & Greenberg, 2011; Thoresen et al., 2009) some

return with psychological problems (Shah et al., 2007). The

Health and Safety Executive (2007) identified six primary

workplace stressors: work demands; control over work;

support; relationships; role and responsibilities and organisa-

tional change. These stressors can affect employees’ general

and psychological wellbeing. Similar factors may impact on

humanitarian relief workers, although their psychological

wellbeing may well be affected by a combination of

‘‘everyday’’ and role-specific stressors related to performing

challenging tasks in austere environments.

Research on military and civilian deployment following

conflict and civil emergencies has shown a typology of

stressors which have the potential to affect wellbeing (NATO/

EAPC, 2009). While deployment stressors, including threats

to safety and not feeling in control, are difficult to eliminate,

organisations can ensure that staff are properly informed

about them, so they can prepare accordingly. Stressors not

inherent to deployment, but equally detrimental to wellbeing,

may include an absence of role-specific training and poor

leadership/management practices (Williams & Greenberg,

2014). Strong evidence exists of the impact of leader

behaviours upon the mental health of military troops deploy-

ing on high-threat operations (Greenberg & Jones, 2011).

National Institute of Health and Care Excellence guide-

lines (NICE, 2009) for the mental wellbeing of employees

emphasises the importance of promoting a culture of partici-

pation, equality and fairness; flexible working; and a man-

agement style encompassing an open communication style

and provision of regular feedback. These guidelines may

equally apply to the field of humanitarian relief work.

Understanding which factors are most important in promoting

or impairing psychological wellbeing in humanitarian

responders is essential to prepare responders adequately for

the challenges they will face and to help where possible, avoid

exposure to major stressors and to develop interventions to

meet their needs during and after deployment.

In this systematic review we identify risk and resilience

factors which may predict psychological outcomes in

humanitarian relief workers, in order to identify recommen-

dations for interventions for reducing risk and fostering

resilience in disaster relief workers.

Correspondence: Dr. Samantha K. Brooks, Department of PsychologicalMedicine, King’s College London, Cutcombe Road, London SE5 9RJ,UK. E-mail: [email protected]

Regarding the terminology used in this review, it should be

noted that ‘‘resilience’’ – generally used to describe the

ability to recover from difficulties – is a term used in varying

ways by different authors, not all of whom describe how they

define the term. What does seem to be agreed upon is that

psychological resilience relates to the adaption of individuals

after trauma, and that certain ‘‘protective’’ factors may

influence the extent to which individuals adapt. Similarly,

‘‘wellbeing’’ may be variably defined in the literature. We

present the term simply as it has been used in the papers

themselves, but it must be considered that different authors

may have defined and measured it in different ways. We hope

that our description of ‘‘measures used’’ for each paper in

Appendix III gives an idea of how resilience and wellbeing

were defined for each paper.

Method

Selection of studies

We limited our search to the following inclusion criteria:

� primary research papers;

� published in peer-reviewed journals;

� English language and

� reporting on factors determining any psychological

outcomes (e.g. stress, wellbeing, mental health disorders,

resilience and personal growth) in humanitarian aid

workers or similar professions deployed to help with the

aftermath of a disaster.

No date restriction was employed.

Conducting the review

We composed a list of terms relevant to wellbeing, covering

both negative and positive health effects (Search 1). We used

the Emergency Events Database (EM-DAT) (Centre for

Research on the Epidemiology of Disasters, 2009) to assem-

ble a list of extreme events, which became Search 2. Our third

search included terms relating to relief work. The full strategy

can be seen in Appendix I.

One author (S.K.B.) conducted a free text literature search

using the databases MEDLINE�, Embase, PsycINFO� and

Web of Science. Resulting citations were downloaded to

EndNote� software version X7 (Thomson Reuters, New

York, New York, USA) and duplicate citations removed.

Based on the inclusion criteria, three reviewers (S.K.B., R.D.,

C.A.M.S.) evaluated the titles of citations for an initial

decision on inclusion or exclusion; irrelevant papers were

removed. Reviewers then screened abstracts for the remaining

citations to evaluate their relevance; any clearly not meeting

the inclusion criteria were excluded. Full-text copies of all

remaining citations were then obtained. Reviewers then read

these papers in their entirety and decided which to include.

We also searched reference lists of key papers for any which

may have been missed in initial searches.

Data extraction and quality appraisal

A standardised process was followed by extracting details

from relevant studies into pre-designed spreadsheets, includ-

ing: year of publication; country participants originated from;

study design; participants (‘‘n’’ and demographic data); type

of disaster and country deployed to; wellbeing outcomes and

how they were measured; predictive factors and how they

were measured; key results; conclusions and limitations.

Following repeated readings of the ‘‘key results’’ column of

our spreadsheet, we used thematic analysis to group predictive

factors into a typology. We accepted as ‘‘themes’’ topics

which had been identified by at least two studies.

We used the Qualitative Research Checklist developed by

the Critical Appraisal Skills Programme (2013) to appraise

qualitative studies’ quality. We assessed quantitative studies’

quality in three different areas: study design; data collection

and methodology and analysis and interpretation of results.

Quality assessment forms for quantitative studies were

designed for the purpose of this review, but informed by

existing quality appraisal tools (Drummond & Jefferson,

1996; Effective Public Health Practice Project, 2009; National

Institute for Health, 2014). Each study was given an overall

score as a percentage, based on the number of ‘‘yes’’

responses to the quality questions.

Results

A total of 5926 citations were identified. After screening,

61 papers remained appropriate for inclusion (see flow chart,

Appendix II). Methodological details for each included paper

are given in Appendix III.

Quality appraisal

The purpose of this review was to identify risk and resilience

factors in order to make recommendations for interventions,

rather than to evaluate the current state of the literature;

therefore, the results focus on the themes emerging from the

literature rather than on the methodological rigour and quality

of studies. However, we did carry out appraisal of the studies

to give an overview of the quality of existing literature.

Individual quality scores for each paper can be seen in

Appendix III.

Though the majority of studies were of high-quality, most

did not explore factors affecting psychological and personal

growth following disaster work in great depth, and the

majority of studies focused on negative outcomes.

Quantitative papers were generally of fairly high quality.

The data presented in Figure 1. show the results of the quality

appraisal.

The majority of papers scored highly, particularly for

methodology. No papers scored below 41% overall. The

median overall percentage was 85.7% (IQR¼ 71.4–93.3).

Figure 2 shows the number of qualitative papers scoring in

different percentage intervals for quality.

Quality of qualitative papers was more inconsistent. The

median score was 76.4% (IQR¼ 55.5–88.9); there were seven

lower-quality papers which scored below 60%. Although the

quality of papers included in the review was fairly high

overall, we found a lack of high-quality quantitative studies

specifically exploring the association between risk and

resilience factors and outcomes. Much of the available

research was qualitative, and many of the survey studies

included open-ended questions and so analysis became

thematic and qualitative in nature. Many quantitative studies

did not explore the association of variables with outcomes,

386 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413

instead reporting for example the percentages of respondents

who reported various factors as ‘‘stressors’’. More in-depth

statistical analysis is needed, looking at the relationship

between potentially influential factors and psychological

outcomes. Further research on the themes identified in this

report is needed.

Themes

Table 1 presents an overview of the themes that emerged from

the literature, showing first author and year of publication for

each qualitative and quantitative study which looked at each

theme.

Our results have been grouped into three core themes: pre-,

peri- and post-deployment, with further sub-themes. The key

themes presented below were mentioned by at least two of the

papers included in the review. Appendix IV provides a full

description of which papers explored which themes, and what

they found. Socio-demographic factors are not focused on in

the report, though these are also detailed in Appendix IV.

Pre-deployment

Preparedness and training

Evidence suggested that appropriate training was needed to

equip all DRWs with the skills, knowledge and confidence to

operate under challenging conditions, particularly when they

are required to take control, make decisions and take up

positions of responsibility (Bjerneld et al., 2004; Yang et al.,

2010). Training individuals in how to work as a team in crisis

response environments and having teams train together pre-

deployment appeared to help facilitate collaborative

functioning (Wyche et al., 2011). Ensuring that team mem-

bers were provided with sufficient training and information to

enable them to be emotionally and cognitively ready for the

realities of their work was found to be protective and viewed

as valuable by disaster response workers (DRWs) (Hearns &

Deeny, 2007; Johnson et al., 2005; Wilson & Gielissen,

2004).

Peri-deployment

Deployment length and timing

Findings from Cardozo et al. (2005) indicated a strong

association for international DRWs between the number of

deployments and depression; the risk of depression was

highest on the first mission, decreased for the second and

reached a peak with five or more missions. However,

deployment length was inconsistently related to mental

health: a quantitative study by Perrin et al. (2007) found

that the risk of PTSD increased with the length of time spent

at the disaster site while qualitative reports suggested that

DRWs found shorter deployments more stressful because

workers lacked time to adapt to their surroundings (Bjerneld

et al., 2004).

Traumatic exposure

Unsurprisingly, many papers reported that traumatic exposure

was significantly linked to the mental health of disaster

workers. DRWs in an incident’s epicentre had significantly

higher rates of acute stress disorder, anxiety and depression

(Fullerton et al., 2004). Yokoyama et al. (2014) found that

nurses who witnessed more destruction and death during an

Figure 1. Results of quality appraisal:quantitative studies.

Figure 2. Results of quality appraisal:qualitative studies.

DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 387

Table 1. Themes.a

Theme Qualitative evidence Quantitative evidence

Preparedness and training: Preparednessfor the multiple roles and tasks takenon by relief workers/Importance ofboth prior experience and pre-disastertraining

Bjerneld et al. (2004), Hearns & Deeny(2007), Johnson et al. (2005), Norris et al.(2005), Pulido (2012), Stuhlmiller (1994),Weber & Messias (2012), Wilson &Gielissen (2004), Wyche et al. (2011) andYang et al. (2010)

Hagh-Shenas et al. (2005), Lundin &Bodegard (1993), Paton (1994), Perrinet al. (2007), Thoresen et al. (2009),Thormar et al. (2013), Witteveen et al.(2007), and Wyche et al. (2011)

Deployment length and timing: Lengthand frequency of deployments/Whenthey were deployed

Bjerneld et al. (2004) Cardozo et al., (2005), Ehring et al. (2011),Eriksson et al. (2001), Holtz et al. (2002),Perrin et al. (2007), and Yokoyama et al.(2014)

Traumatic exposure: Exposure to death,destruction and grief, as well as toharassment, anger, aggression andassault from victims

Brandt et al. (1995), Putman et al. (2009),Stuhlmiller (1994), Ursano & McCarroll(1990), Wang et al. (2011) and Yang et al.(2010)

Alexander (1993), Cardozo et al., (2005),Chang et al. (2008), Dobashi et al. (2014),Durham et al. (1985), Fullerton et al.(2004), Holtz et al. (2002), Karanci &Acarturk (2005), Marmar et al. (1996),Paton (1994), Thoresen et al. (2009),Thormar et al. (2013), West et al. (2008)and Yokoyama et al. (2014)

Becoming emotionally involved:Secondary traumatisation/Over-identi-fication with victims/Emotionaldistancing

Berah et al. (1984), Brandt et al. (1995),Clukey (2010), Norris et al. (2005), Pulido(2012), Stuhlmiller (1994), Ursano &McCarroll (1990), Wang et al., (2011,2013) and Wyche et al. (2011)

Cetin et al. (2005), Chang & Taormina,(2011), Hodgkinson & Shepherd (1994),Paton (1994), Soliman et al. (1998),Thormar et al. (2013), Wyche et al. (2011)and Zhen et al. (2012)

Leadership: Relationships with super-visors, professional support from lea-ders and organisations/Importance of‘‘reward’’ and recognition in terms ofgood feedback

Bakhshi et al. (2014), Bjerneld et al. (2004),Cox (1997), Hearns & Deeny (2007),Johnson et al. (2005), Stuhlmiller (1994),Wang et al. (2011), Weber & Messias(2012), Wilson & Gielissen (2004), andWyche et al. (2011)

Alexander (1993), Biggs et al. (2014),Cardozo et al. (2005, 2012), Curling &Simmons (2010), Eriksson et al. (2009),Soliman et al. (1998), Thormar et al.(2013), Van der Velden et al. (2012) andWyche et al. (2011)

Inter-agency cooperation: Cultural differ-ences/‘‘Insider vs. outsider’’ dynamics

Berah et al. (1984), Cox (1997), Norris et al.(2005), Wyche et al. (2011) and Yanget al. (2010)

Hodgkinson & Shepherd (1994), Soliman &Gillespie (2011), and Wyche et al. (2011)

Social support: Organisational support/Support from co-workers and peersduring operation/Communication withhome

Bakhshi et al. (2014), Bjerneld et al. (2004),Hearns & Deeny (2007), Moynihan et al.(2005), Norris et al. (2005), Wang et al.(2011) and Wyche et al. (2011)

Biggs et al. (2014), Cardozo et al. (2012),Ehring et al. (2011), Eriksson et al. (2001,2009), Huang et al. (2013), Karanci &Acarturk (2005), Kasperen et al. (2003),Miles et al. (1984), Paton (1994), Van derVelden et al. (2012), West et al. (2008) andWyche et al. (2011)

Formal during- disaster support: Peersupport/Professional support/Counselling

Johnson et al. (2005), Moynihan et al. (2005)and Yang et al. (2010)

Curling & Simmons (2010)

Role: Role clarity, adapting one’s role andresponsibilities in a chaotic situation/Tasks

Bakhshi et al. (2014), Bjerneld et al. (2004),Moynihan et al. (2005), Norris et al.(2005), Pulido (2012), Wyche et al. (2011)and Yang et al. (2010)

Paton (1994) and Soliman et al. (1998)

Demands, workload and long hours:Workload, demands and exhaustion/Resources/Long hours

Bakhshi et al. (2014), Bjerneld et al. (2004),Cox (1997), Hearns & Deeny (2007),Norris et al. (2005), Putman et al. (2009),Stuhlmiller (1994), and Wang et al. (2011)

Biggs et al. (2014), Curling & Simmons(2010), Paton (1994), Putman et al.(2009), Soliman & Gillespie (2011),Thormar et al. (2013), and Yokoyamaet al. (2014)

Safety and equipment: Sense of personalvulnerability/Safety concerns/Concerns over equipment and facilities

Bakhshi et al. (2014), Clukey (2010), Hearns& Deeny (2007), Johnson et al. (2005),and Yang et al. (2010)

Huang et al. (2013), Karanci & Acarturk(2005), Kenardy et al. (1996), Marmaret al. (1996), Miles et al. (1984), Paton(1994), Perrin et al. (2007), and Thormaret al. (2013)

Self-doubt and guilt: Doubting one’s selfand actions/Guilt and blame

Bakhshi et al. (2014), Brandt et al. (1995),McCormack & Joseph (2013), Pulido(2012), and Stuhlmiller (1994)

Ehring et al. (2011), Marmar et al. (1996),Miles et al. (1984), and Wilkinson (1983)

Coping strategies: Negative coping/Talking and writing/Relaxation/Redefining experience in positive ways

McCormack & Joseph (2013), Norris et al.(2005), Stuhlmiller (1994), Wang et al.(2011, 2013), and Wyche et al. (2011)

Chang et al. (2008), Curling & Simmons(2010), Huang et al. (2013), Karanci &Acarturk (2005), Miles et al. (1984), Paton(1994), Wilkinson (1983), and Wycheet al. (2011)

Formal post-disaster support: Peer sup-port/Professional support/Counselling/Debriefing

Bakhshi et al. (2014), Bjerneld et al. (2004),Hearns & Deeny (2007), McCormack &Joseph (2013) and Stuhlmiller (1994)

Durham et al. (1985), Kenardy et al. (1996),Van der Velden et al. (2012) and Wu et al.(2012)

Media: Media coverage of disaster/Publicity

Bakhshi et al. (2014), Norris et al. (2005) Miles et al. (1984), Nishi et al. (2012), andPaton (1994)

(continued )


incident had lower mood, worse sleep and more intense

fatigue than nurses who had less traumatic exposure. Dealing

with dead bodies either as a primary role, or encountering

them in another way, appeared be a strong significant risk

factor for psychological distress and post-traumatic stress

responses (Dobashi et al., 2014). Exposure to local and

survivor hostility, lack of gratitude and aggression were

sources of stress in DRWs (Thormar et al., 2013; Wang et al.,

2011).

Becoming emotionally involved

Many studies reported participants becoming ‘‘emotionally

involved’’ (often over-involved) in the disaster, and secondary

or vicarious traumatisation (generally defined as experiencing

similar symptoms to trauma victims as a result of indirect

traumatic exposure via close contact with the survivors;

Figley, 1995) was common. Hodgkinson & Shepherd (1994)

found that workers with a high level of identification with

survivors had significantly more intrusive thoughts and scored

higher on an obsessive/compulsive scale. Many studies

reported DRWs repeatedly re-living the disaster experience,

feeling a sense of ‘‘knowing the victim’’ and imagining their

loved ones in such situations (Cetin et al., 2005; Paton, 1994;

Pulido, 2012; Soliman et al., 1998; Thormar et al., 2013;

Ursano & McCarroll, 1990).

Several studies’ results emphasised the need to keep

professional and psychological distance (Brandt et al., 1995;

Norris et al., 2005) and suppress grief (Wang et al., 2013).

Indeed several studies found that emotional distancing and

repression were used as coping strategies by relief workers

(Stuhlmiller, 1994; Wang et al., 2011). However, one

quantitative study (Zhen et al., 2012) showed that avoidance

of traumatic thoughts during a disaster was predictive of

traumatic stress, perhaps suggesting a need for acceptance

rather than avoidance.

Leadership

Poor leadership was described as including ad hoc planning

(Hearns & Deeny, 2007); poorly planned work and schedules

(Bjerneld et al., 2004); lack of guidance in terms of roles and

boundaries (Soliman et al., 1998) and a lack of concern for

staff’s welfare needs (Johnson et al., 2005). Poor organisa-

tional support was significantly associated with increased

likelihood of depression post-deployment in international

DRWs (Bjerneld et al., 2004; Cardozo et al., 2005), while

good organisational support and sensitive staff management

practices were demonstrated to contribute to the positive

occupational health of body handlers (Alexander, 1993).

Leaders who gave good feedback and were perceived as

recognising workers’ efforts were viewed more positively;

lack of recognition in efforts and feeling undervalued were

considered stressors (Cox, 1997; Curling & Simmons, 2010),

particularly for those working in small organisations (Weber

& Messias, 2012).

The effects of involvement and support from all levels of

management were also felt. Lack of coordination and

communication among government officials, employees and

volunteers led to frustration, job overload and stress (Bakhshi

et al., 2014; Wang et al., 2011; Weber & Messias, 2012),

while for some DRWs organisational headquarters were

perceived as not fully understanding the reality of the

worker’s environments (Hearns & Deeny, 2007) and were

viewed as being only involved superficially and for bureau-

cratic procedures (Wilson & Gielissen, 2004).

Inter-agency cooperation

Lack of inter-agency cooperation was also a stressor; several

studies noted tension and rivalry between agencies, secrecy of

information, cultural differences and ‘‘insider vs. outsider’’

dynamics (Berah et al., 1984; Hodgkinson & Shepherd, 1994;

Yang et al., 2010). Norris et al. (2005) reported local

professionals appearing to have a sense of ‘‘ownership’’

over the disaster; the involvement of ‘‘outsiders’’ was seen to

imply a lack of ability of the local community to self-manage

the situation leading to resentment unless they were seen as

playing a supporting role to local leadership.

Social support

Social support was predictive of wellbeing. After adjusting for

all other study variables, Cardozo et al. (2012) found that

social support was significantly associated with lower levels

of depression, psychological distress, burnout and lack of

Table 1. Continued

Theme Qualitative evidence Quantitative evidence

Personal and professional growth:Rewarding experience/Feeling ofhaving made a contribution/accom-plishment/Re-evaluation of self and themeaning of life/Increased understand-ing/Feeling more educated and able toassist in future relief work

Bakhshi et al. (2014), Berah et al. (1984),Moynihan et al. (2005), Putman et al.(2009), Shih et al. (2002), Wang et al.(2013), Yang et al. (2010) and Zinsli &Smythe (2009)

Alexander (1993), Cardozo et al. (2012),Chang & Taormina, (2011), Miles et al.(1984), Putman et al. (2009), Solimanet al. (1998), and Thoresen et al. (2009)

Socio-demographic characteristics andpre-/post-disaster experiences:Gender/Age/Ethnicity/Family andrelationships/Educational background/Pre-deployment mental health/Previous experience and exposure/Having a family member injured/Post-disaster life events

Putman et al. (2009) Cardozo et al. (2005, 2012), Dobashi et al.(2014), Ehring et al. (2011), Eriksson et al.(2001), Fullerton et al. (2004),Hodgkinson & Shepherd (1994), Holtzet al. (2002), Musa & Hamid (2008),Putman et al. (2009), Soliman et al.(1998), Thormar et al. (2013), West et al.(2008), Wilkinson (1983), Witteveen et al.(2007) and Zhen et al. (2012)

aSome studies used mixed-methods and therefore may appear in both columns.


personal accomplishment and greater life satisfaction.

Perceived social support from colleagues appeared to mitigate

the effect of traumatic exposure on symptoms of stress (Biggs

et al., 2014; Kasperen et al., 2003) and correlate with post-

traumatic growth (Karanci & Acarturk, 2005). Qualitative

studies showed that on return from their missions, DRWs

recommended that the pre-departure team building would

usefully foster resilience when in the disaster area (Norris

et al., 2005; Paton, 1994).

There were mixed findings regarding the impact of social

support from friends and family via communication with

home. Infrequent contact with family and perception of

communication facilities as poor were associated with stress,

depression and isolation (Bjerneld et al., 2004; Cardozo et al.,

2005; Hearns & Deeny, 2007; West et al., 2008). However,

another study (Bakhshi et al., 2014) found that contact with

friends and family could be stressful, as home-based loved

ones worried when they became aware of incidents through

media reporting.

Formal during-disaster support

During-disaster support (including support from peers and

professionals/counsellors) was generally viewed as desirable,

though often lacking. Many participants felt that there was a

lack of appropriate clinical and other supportive services

(Moynihan et al., 2005); one study found that occupational

health support and policies for non-uniformed workers were

not seen as equal to those provided for first responders/

uniformed services (Johnson et al., 2005). The availability of

on-site professional psychological counsellors or stress man-

agement workshops was generally seen as helpful (Curling &

Simmons, 2010; Yang et al., 2010).

Role

Although disaster workers may be assigned to specific roles

within the disaster response, lack of clarity around tasks and

role expectation was a considerable source of stress. Notably

role ambiguity appeared to be more problematic in the early

stages of disaster work due to the chaotic aftermath of

traumatic events; roles and tasks often appeared to ‘‘fall into

place’’ with time (Bakhshi et al., 2014). Employer and role

flexibility are considered essential in order to accommodate

for changing needs and to foster resilience (Paton, 1994;

Pulido, 2012; Wyche et al., 2011). A strong ‘‘chain of

command’’/line management structure was believed to reduce

confusion in such situations (Norris et al., 2005).

Demands, workload and long hours

The high demands of the job, in terms of workload,

complicated tasks and long hours were associated with

stress and poor wellbeing. Putman et al. (2009) found that

emotional exhaustion was a significant predictor of PTSD.

Soliman & Gillespie (2011) found that complicated tasks,

high expectations and excessive demands led to stress,

particularly when associated with inadequate resources.

Biggs et al. (2014) also reported that job resources played a

role in the stressor-strain process after unpredictable and

emotionally challenging work demands. Many papers

reported that time off while deployed was essential for

maintaining emotional stability and being able to distance

oneself from the work (Bakhshi et al., 2014; Stuhlmiller,

1994), limiting daily working hours and a need for adequate

staff-to-work ratios (Norris et al., 2005).

Safety and equipment

Many study participants felt concerned about personal safety,

poor living conditions and inadequate equipment: all could

induce a sense of vulnerability (Clukey, 2010; Hearns &

Deeny, 2007; Paton, 1994; Thormar et al., 2013; Yang et al.,

2010). Anxiety and PTSD symptoms were found to increase

in relation to not feeling enough safety measures were in place

and fearing for one’s own safety (Miles et al., 1984; Thormar

et al., 2013); however, contact with and reassurance from

seniors could be helpful in alleviating these fears (Bakhshi

et al., 2014). DRWs with PTSD were more likely to report

near-death experiences, severe injury or severe mental trauma

(Huang et al., 2013).

Self-doubt and guilt

Several studies found that DRWs commonly experienced

feelings of self-doubt, self-blame and guilt. Many participants

reported wanting to have done more to relieve suffering and

felt helpless, frustrated and reported themselves ‘‘failing’’

victims as they could not meet all of their needs (Miles et al.,

1984; Pulido, 2012; Wilkinson, 1983); blaming oneself for

not being able to help more was significantly associated with

increased psychological distress (Ehring et al., 2011).

McCormack & Joseph (2013) reported that workers doubted

their own actions, especially when having to prioritise their

own safety over others, which led to shame and fear of being

judged.

Coping strategies

Many studies reported on a range of coping behaviours

employed by DRWs. Negative coping strategies included

increased use of tobacco, alcohol, caffeine, tranquilisers and

medication (Curling & Simmons, 2010; Miles et al., 1984),

while positive strategies included talking, writing, massage

and deep breathing (Miles et al., 1984; Norris et al., 2005).

Other positive strategies included returning to work, finding

meaning and purpose in their life and work, and compart-

mentalising things outside of one’s control (McCormack &

Joseph, 2013; Wang et al., 2011; Wilkinson, 1983). Chang

et al. (2008) found that the strategies mentioned above

positively modified the effect of disaster related exposures on

psychiatric morbidity.

Post-deployment

Formal post-deployment support

Several studies reported poor re-adjustment into home,

society and work environments and a need for support

programmes (Bakhshi et al., 2014; Hearns & Deeny, 2007).

Lack of support, criticism, indifference, disinterest or

being told to ‘‘get on with life’’ by colleagues and family

members once home led to feelings of anger, betrayal,

disconnection and lack of validation, often leading to poor


reintegration (McCormack & Joseph, 2013). Some partici-

pants felt that their organisation should automatically pro-

vide debriefing, not only when requested (Bjerneld et al.,

2004). Group debriefings, however, were seen as stressful

(Stuhlmiller, 1994). Training in Trauma Risk Management

(TRiM; Greenberg et al., 2008) was reported by participants

as helpful post-disaster in one study (Bakhshi et al., 2014).

Media

Publicity and media coverage of the disaster were often

perceived as being stressful and post-disaster was reported to

be a significant stressor and trigger of disaster recall (Miles

et al., 1984; Paton, 1994). Criticism from the media was often

taken personally and participants suggested that training how

to deal with the media would be helpful (Bakhshi et al., 2014;

Norris et al., 2005).

Personal and professional growth

Several studies reported evidence of psychological growth,

with participants feeling they had, personally and profession-

ally, benefited from the experience. Many participants viewed

the experience as rewarding, in terms of feeling they had made

a contribution; personal accomplishment; and consequent

improved confidence and self-esteem, increased compassion,

and re-evaluation of the self and meaning of life (Bakhshi et al.,

2014; Soliman et al., 1998; Wang et al., 2013; Yang et al.,

2010). Humanitarian concern, work satisfaction and the feeling

of ‘‘giving back’’ were motivators. Levels of perceived

personal accomplishment were inversely related to PTSD

(Putman et al., 2009), and associated with higher levels of

resilience and lower levels of secondary trauma and burnout

(Chang & Taormina, 2011). However, one quantitative paper

(Cardozo et al., 2012) found that a reportedly ‘‘better’’

experience and more positive evaluation of work was signifi-

cantly associated with higher anxiety and burnout possible

from participants being overinvolved by working as a DRW.

Socio-demographic characteristics and pre-/post-deployment experiences

Several quantitative studies examined various socio-

demographic characteristics and experiences both pre- and

post-deployment as predictors of psychological outcomes.

The literature yielded mixed results on the effects of

demographic variables on psychological outcomes.

Generally, younger age was associated with poorer outcomes,

though there was more ambiguity surrounding other charac-

teristics. Details can be seen in Appendix IV.

Discussion

The results of this review suggest that factors before, during

and after deployment affect DRWs’ mental health. An

understanding of these factors is likely to be useful to

organisations that deploy DRWs in order to ensure they are

appropriately prepared for and supported on deployment as

well as cared for post-deployment to ameliorate the negative

impact of disaster work.

Pre-deployment DRWs are likely to benefit from being

prepared for the tasks they will undertake in the aftermath of a

crisis. Such training should be backed up by relevant

handbooks and guidelines for DRWs to refer to. An emotional

preparation component may be useful as part of this pre-

disaster training to develop resilience, possibly including

specific training to cope with exposure to tragedy. Workers

should also be prepared for potential hostility and lack of

gratitude from survivors. Training should also be evidence-

based and cover the range of psychological responses to

trauma and vicarious trauma management.

Evidence regarding the impact of the length and frequency

of deployments on workers’ mental health was inconsistent.

While some studies suggest longer deployments increased the

risk of adverse psychological health effects (Ames et al.,

2007; Hibberd & Greenberg, 2011; McCarroll et al., 2000),

possibly as a result of increased exposure to an accumulation

of highly challenging exposures, other findings on this topic

have been less consistent. Thus further research on the impact

of deployment length and frequency is required. However,

studies have shown that initial deployments are the most

challenging, and that first time deployees are particularly

vulnerable (Adler et al., 2005; Huffman et al., 1999). Being

deployed with a supportive and experienced team may

be a particularly important protective factor in these

circumstances.

Several studies report that DRWs can potentially become

‘‘emotionally involved’’ with their work placing them at risk

of over-identification with survivors and secondary trauma-

tisation. While distancing was often cited as a useful coping

strategy in the immediate aftermath, this is often difficult to

do and may lead to suppressed feelings surfacing at a later

time. Time to discuss and ‘‘make sense’’ of emotions after the

event would be useful. Wilson & Gielissen (2004) recom-

mended that a degree of secondary traumatisation is a

‘‘normal reaction to an abnormal situation’’. Thus becoming

emotionally involved should perhaps be something workers

learn to accept as ‘‘normal’’ and manage, rather than avoid.

Organisations could consider implementing this into training

programmes, perhaps drawing from the type of training and

supervision that therapists and counsellors have to help them

cope with potential secondary traumatisation (Wesson et al.,

2013).

Poor leadership was reported as a stressor in several

studies suggesting a need for leaders to be supportive, clear in

their directions and feedback and have good relationships with

their subordinates. DRW supervisors should be especially

adept at leading in challenging environments and be able cater

for their staff’s mental health needs. We suggest that

organisations establish training programs to enhance leader-

ship skills, ensuring supervisors are trained in management as

well as leadership. It is also important that leaders should be

appropriately experienced; similarly at least some members of

the team should be able to provide support and advice to

inexperienced workers. Lack of recognition of efforts was a

stressor; this provides some support for the effort-reward

imbalance model of occupational stress (Siegrist, 1996) which

suggests that a reciprocal relationship is needed between

effort (required to meet job demands) and rewards (in terms

of money, esteem, career opportunities, positive feedback or

feeling valued) at work. It may be that more focus on

‘‘reward’’ in terms of positive feedback from leaders could

bolster the wellbeing of employees.


Inter-agency cooperation was a frequent stressor, with

‘‘insider versus outsider’’ dynamics prevalent. Our findings

suggest that ‘‘outsiders’’ (i.e. those non-local deployed

DRWs) need to be seen as supporting local agencies rather

than competing with them. Efforts to minimise rivalries,

perhaps by encouraging different agencies to focus on joint

goals, may be helpful. Future research might consider

exploring various different groups of relief workers and

their relationships with local agencies; those with more

positive relationships could be examined in more detail to

ascertain exactly what constitutes a ‘‘good’’ inter-agency

relationship and how to best foster one.

We found that poor intra-team support was a risk factor for

poor mental health. This supports previous literature relating

to the psychosocial impact of individuals’ exposure to

adversity, conflict, violence and hardship, which suggests

strong social networks and support are important in fostering

resilience (Williams & Greenberg, 2014). Future studies

should investigate how best to build and maintain cohesion

between team members. There may be utility in ensuring that

pre-deployment skills and procedural training may also

provide opportunities for DRWs to learn effective ways of

helping and supporting their peers. Leaders should also be

aware of the benefits of fostering social support by

encouraging teamwork among workers.

Poor facilities to communicate with home can lead to

stress; however, communication with home can also be

stressful in itself due to family and friends being worried after

having seen dramatic media reports, and putting pressure on

workers to return home. This supports previous research such

as a study by Mulligan et al. (2012) of British military

personnel serving in Iraq and Afghanistan, who found that

difficulties communicating with home were associated with

PTSD symptoms and common mental disorders. Overall, it

appears that it would be helpful for adequate facilities for

communicating with home to be in place for those who do

wish to use them, and personnel could be taught specific

strategies for dealing with various mediums of communicat-

ing with friends and family.

Due to the unpredictable and ever-changing nature of

disaster roles, workers often reported lack of role clarity and

being put in positions of responsibility when they were not

expecting to be. Due to the nature of disaster relief work, it

may not be possible to ensure that roles are consistent and

clarified at all times, but managers and organisations can

ensure that personnel are helped to set, and reset, their

objectives as a deployment develops and to set as clear goals

for DRWs as possible.

We found evidence that the high demands of the job such

as workload and long hours, particularly when coupled with

lack of resources, had a negative psychological impact. The

job demands–resources model (Demerouti et al., 2001), which

categorises working conditions as demands (aspects requiring

effort or skills) or resources (aspects which may help to

achieve goals or lessen demands), may offer a useful

framework for identifying aspects of the work environment

needing to be better managed. The literature reviewed here

suggests that appropriate training and preparedness and

support from colleagues and management are particularly

valuable resources. Shift rotations and sharing of workload to

enable shorter exposure time would be beneficial where

possible. DRWs should be encouraged to take breaks without

feeling guilty, and to engage in recreation during breaks.

While shortening working hours may be challenging with

limited available manpower, if long hours are essential,

promoting camaraderie between team members so the risks

of work overload and long hours are minimised is especially

important.

Concerns about safety and equipment were also prominent

issues, with poor living conditions, inadequate equipment and

a sense of being in personal danger leading to feelings of

vulnerability. While DRWs cannot be guaranteed an entirely

safe working environment, our results suggest that organisa-

tions are likely to help their staff by taking steps to ensure that

their safety is being taken as seriously as it can be. Provision

of adequate supplies and equipment is essential for both

physical and psychological health. Ensuring that senior staff

are available to talk to and reassure workers about the steps

taken to ensure their personal safety may be helpful. The

safety of deployed workers can also be threatened by

harassment and violence from survivors. The current

‘‘Health Care in Danger’’ project (International Committee

of the Red Cross International Committee of the Red Cross,

2015) concerning the protection of deployed humanitarian

and healthcare personnel, aims to address this, proposing

development of a domestic legal framework to monitor and

protect the safety of deployed workers.

Feelings of self-doubt, guilt and blame were common:

doubting one’s self and actions can lead to self-blame, and

learning to view the experience as meaningful and drawing

from the positives are important. This often happens naturally

with time and distance from an incident but can be delayed

due to lack of support from colleagues, family members and

peers on return home; it is therefore essential that support

networks are in place when DRWs return home.

Provision of during, and post-disaster, support was viewed

as desirable though often lacking. There was, however, some

evidence which suggested immediate psychological debrief-

ing was unhelpful. This fits with National Institute for Health

and Care Excellence (NICE) guidelines for PTSD which state

that individual debriefing sessions focusing on the traumatic

incident should not be part of routine practice (NICE, 2005).

However, our findings suggest that most DRWs desired some

kind of post-disaster support. On return home, many partici-

pants reported needing time to adjust and re-integrate and felt

that support throughout this process would be helpful.

Participants of several studies noted a lack of validation and

support from peers on returning home, which could be

distressing: while organisations cannot wholly determine the

response of family members, friends and colleagues, they

could provide education or support to the family members

themselves or compensate for potential lack of support in this

area by ensuring that validation and support are provided by

managers. Post-mission support should encourage workers to

redefine their experience in positive ways, for example, using

it to find meaning and purpose in their life, re-evaluate one’s

self and goals or focus on the positives such as professional

growth. Thus, instead of non-evidence based psychological

debriefing, we suggest that DRWs who desire, or need,

support access it from organisationally aware psychological


support from line managers or possibly from in-house

counselling/therapists. TRiM (Greenberg et al., 2008), a

trauma-focused peer support system originating in the mili-

tary and since adopted by many organisations including

media companies, emergency services and the National

Health Service may also be a useful support mechanism.

TRiM has been found to be associated with reduced

sickness absence after a traumatic event and may lessen

some of the negative effects of high trauma exposure (Hunt

et al., 2013).

Finally, publicity and the media are often perceived as

being stressful, especially in terms of media criticism and

demands for information; over-exposure to the media may

also worsen the feeling of being emotionally involved. Over-

exposure to disaster media coverage should be avoided to

foster relaxation and allow workers to keep ‘‘distance’’ from

their work.

Results on the effect of socio-demographic or pre-disaster

factors on wellbeing were inconsistent, and do not appear to

imply that any particular screening processes would be useful.

This supports previous literature that there is little value in

pre-deployment screening processes based upon psychometric

testing or profiling. Brewin et al. (2000) suggest that the

extent to which traumatic exposure impacts on wellbeing

depends more on the availability of good social networks than

it does on the personal histories, attitudes and capacities of the

individuals, while Rona et al. (2006) suggest that screening in

the Armed Forces is not only ineffective but has the potential

to exclude perfectly capable and resilient candidates and

provide false reassurance that individuals will remain resilient

no matter what they are exposed to.

In summary, we found many non-disaster-specific occu-

pational stressors (such as overwhelming demands, limited

resources, lack of training, poor leadership and poor support

networks) that were relevant and amenable to modification.

While direct exposure to traumatic events is impossible to

prevent, training, preparedness and the support received

during and after the mission can be improved. Taken together,

the results of the review suggest that preparedness and support

are of particular importance, both of which can be improved

through good leadership.

Limitations

This review yielded mainly studies from North America.

Future reviews could consider translating foreign-language

papers to explore whether similar stressors are discussed.

The majority of the papers included in this review, which

were qualitative or cross-sectional. Concepts (such as ‘‘resili-

ence’’ and ‘‘wellbeing’’) may be defined differently by

different authors, and this should be kept in mind when

considering the overall findings.

Implications for researchers

More prospective and longitudinal studies are needed to

consider directionality of effects and clarify the influence of

stressors or protective factors. Further in-depth quantitative

considering the relationships between variables rather than

merely the numbers of participants citing certain events as

stressors would be useful.

Implications for DRWs

The results of this review demonstrate that the potential for

stress prevention measures to be incorporated into disaster

relief work. We have used the findings to develop a guideline

of recommendations for reducing risk and fostering resilience

in DRWs. Interventions which appear the most likely to make

a difference include:

� Systematic, educational training programmes pre-

deployment, emphasising both psychological and phys-

ical preparedness.

� Making appropriate guidelines, handbooks and policy

documents available, particularly for workers going on

their first deployment.

� Dedicated training programmes and management courses

for those in supervisory roles.

� Regular manager–employee feedback, ensuring that good

work is ‘‘rewarded’’ with positive feedback and

encouragement.

� Training to build and maintain cohesion between team

members, incorporating awareness of the psychological

challenges of humanitarian work.

� Establish and emphasise joint goals to encourage

teamwork.

� Training in effective ways of supporting other team

members.

� Other, perhaps less important but still potentially helpful

interventions might include:

� Increased communication with other agencies; encour-

agement to focus on a joint goal.

� Identification of personnel with poor support networks at

home; ensure this vulnerable group have good support

from professionals, both during and post-disaster.

� Additional training in skills for dealing with the media.

� Encouraging talking, sharing and other relaxing or

expressive outlets.

� Ongoing non-judgmental support groups allowing for the

sharing of experiences and opportunities for discussion

and education about emotional responses to disasters.

� Interventions to promote positive thinking and teach

appropriate coping strategies such as acceptance or

redefining the experience in positive ways.

� Education about the potential risks of the job and

training in relaxation, problem-solving and self-care

behaviours.

� Interventions aimed at improving psychosocial skills, e.g.

skills in supporting colleagues.

� Interventions aimed at improving self esteem and self

efficacy.

While certain disaster-related stressors cannot easily be

changed, such as exposure to traumatic events and developing

a degree of emotional attachment to victims/survivors,

organisations can work with their employees to ensure that

they are properly supported, their concerns are listened to and

they are taught evidence-based approaches to cope with their

anxieties.

Acknowledgements

The authors gratefully acknowledge Professor Til Wykes and

Dr. Alison Beck for their guidance on the search strategy.


Declaration of interest

Financial support from Service User Research Enterprise,

Institute of Psychiatry, King’s College London/National

Institute for Health Research Health Protection Research

Unit National Institute for Health Research Health Protection

Research Unit. N.G. runs a small company providing

psychological support to trauma-exposed organisations and

is President of the UK Psychological Trauma Society. The

research was funded by the National Institute for Health

Research Health Protection Research Unit (NIHR HPRU) in

Emergency Preparedness and Response at King’s College

London in partnership with Public Health England (PHE).

The views expressed are those of the author(s) and not

necessarily those of the NHS, the NIHR, the Department of

Health or Public Health England.

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Appendix I. Search strategy

Search: EMBASE 1980–2015; EMBASE 1974–1979; EMBASE Classic 1947–1973; Ovid Medline 1946–2015; PsycINFO 1806–2015; Web ofScience.

Search 1 (psychological wellbeing)

Well?being; anxiety; panic; post?traumatic stress; PTSD; stress; ‘‘mental health’’; depress*; neurosis; adjustment disorder*; distress; psychological;resilience; coping; ‘‘mental disorder*’’; ‘‘positive psychology’’; ‘‘satisfactory life’’; mindfulness; flourish; pleasure; flow; growth¼COMBINE WITH OR

Search 2 (disasters)

Anthrax; avalanche; avian influenza; bioterrorism; bird flu; blizzard; bomb*; chemical spill; Chernobyl; cyclone; drought; disaster*; earthquake;Ebola; emergenc*; explosion; fire; Fukushima; H1N1; H5N1; hurricane; industrial accident; landslide; massacre; mass killing; MERs; Middle Eastrespiratory syndrome; pandemic; nuclear radiation; radiological; SARs; severe acute respiratory syndrome; September 11th; shooting*; storm; swineflu; terroris*; Three Mile Island; tidal wave; tornado; tsunami; typhoon; volcanic eruption; volcano; World Trade Center.¼COMBINE WITH OR

Search 3 (humanitarian work)

Humanitarian; relief work*; ‘‘disaster aid’’; ‘‘disaster planning’’; ‘‘aid agencies’’; ‘‘aid agency’’; ‘‘emergency relief’’; ‘‘disaster relief’’; ‘‘disasterrecovery’’; ‘‘aid work’’*¼COMBINE WITH ORCombine Search 1 AND Search 2 AND Search 3LIMIT TO: Human studies, English language

Appendix II. Flow diagram

Records iden�fied through database searching

n = 5895

Addi�onal records iden�fied through other sources

n = 31

Total records foundn = 5926

Duplicates removedn = 2609

Titles screenedn = 3317

Abstracts screenedn = 1433

Full-text ar�cles assessed for eligibility

n = 162

Studies included in review n = 61

Excluded a�er �tle screening n =1884

Excluded a�er abstract screening n = 1271

Excluded a�er full-text screening

n = 91; Full text unavailable

n = 10


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ers

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erA

lph

aN

ort

hS

eaO

ilE

xp

losi

on

&C

lap

ham

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lC

rash

–U

K

So

cial

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dju

stm

ent

Rat

ing

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le;

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pk

ins

Sy

mp

tom

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eck

list

;P

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olo

gic

alW

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gS

cale

;m

od

ifie

dP

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nal

Har

din

ess

Sca

le;

Th

efo

llow

ing

wer

eas

ked

ina

stu

dy

spec

ific

ques

tio

nn

aire

wit

hso

me

qu

es-

tio

ns

form

edfr

om

lite

ratu

rere

sear

ch–

exp

erie

nce

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selo

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stre

ss&

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pin

g;

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cial

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pp

ort

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Em

plo

ym

ent

Ro

leIs

sues

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erA

lph

aS

eaO

ilE

xp

losi

on

-9

mo

nth

s&

12

mo

nth

sC

lap

ham

Rai

lC

rash

–4

mo

nth

s&

12

mo

nth

s

73

.3


Ho

ltz

etal

.(2

002)

Cro

ss-s

ecti

on

al7

0H

um

anR

igh

tsW

ork

ers

Hu

man

Rig

hts

Dat

aC

oll

ecti

on

–K

oso

vo

Gen

eral

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lth

Qu

esti

on

nai

re-2

8;

Ho

pk

ins

Sy

mp

tom

Ch

eck

list

-25

;H

arv

ard

Tra

um

aQ

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tio

nn

aire

(ad

apte

dfo

rtr

aum

aev

ents

inK

oso

vo

)

No

tre

po

rted

92

.9

Hu

ang

etal

.(2

013)

Cro

ss-s

ecti

on

al9

23

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5w

ith

PT

SD

&8

68

wit

ho

ut

wh

oac

tas

con

tro

lg

rou

p

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itar

yre

scu

ew

ork

ers

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chu

anE

arth

qu

ake

–C

hin

aC

lin

icia

nA

dm

inis

tere

dP

TS

DS

cale

du

rin

gst

ruct

ure

din

terv

iew

s;E

yse

nck

Per

son

alit

yq

ues

-ti

on

nai

re;

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itC

op

ing

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leq

ues

tio

nn

aire

;S

oci

alS

up

po

rtq

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tio

nn

aire

;&

self

-rep

ort

dem

o-

gra

ph

ics

ques

tio

nn

aire

18

mo

nth

s8

5.7

Joh

nso

net

al.

(2005)

Cro

ss-s

ecti

on

alw

ith

qual

ita-

tive

dat

aan

dan

alysi

s

11

14

retu

rned

surv

ey&

33

2fi

lled

inth

eo

pen

-en

ded

ques

tio

nin

the

surv

ey

Rec

over

yw

ork

ers

(reh

abil

itat

ion

&re

con

stru

ctio

n)

9/1

1W

orl

dT

rad

eC

entr

ed

isas

ter

US

AS

tud

ysp

ecif

icqu

es-

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nn

aire

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orl

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rad

eC

entr

eC

lean

-Up

&R

ecover

yW

ork

erH

ealt

hS

urv

ey

18

–3

6m

on

ths

62

.5

Kar

anci

&A

cart

urk

(2005)

Cro

ss-s

ecti

on

al2

00

10

0m

emb

ers

of

Ko

cael

iN

eig

hb

orh

oo

dD

isas

ter

Vo

lun

teer

sO

rgan

izat

ion

vs.

10

0co

ntr

ols

19

99

Mar

mar

a,T

urk

eyea

rth

qu

ake

Sy

mp

tom

Ch

eck

list

-4

0(S

CL

-40

);W

ays

of

Co

pin

gQ

ues

tio

nn

aire

;S

tres

sR

elat

edG

row

thS

cale

(SR

GS

)

4.5

yea

rs1

00

Kas

per

enet

al.

(2003)

Cro

ss-s

ecti

on

al2

13

UN

So

ldie

rs&

Rel

ief

Wo

rker

sA

idse

rvic

es&

mil

itar

yse

rvic

esin

Yu

go

slav

ia1

99

2–

19

96

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um

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xp

osu

reQ

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tio

nn

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bas

edo

nU

nit

edN

atio

ns

Inte

rim

Fo

rce

InL

eban

on

stu

dy

;P

ost

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rau

mat

icS

tres

sS

cale

;Im

pac

to

fE

ven

tsS

cale

;S

tud

ysp

ecif

icS

oci

alN

etw

ork

Su

pp

ort

Qu

esti

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nai

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No

tre

po

rted

71

.4

(co

nti

nu

ed)


Co

nti

nu

ed

Ref

eren

ceD

esig

nP

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cip

ants

(n)

Occ

up

atio

nal

gro

up

Dis

aste

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isis

Mea

sure

sT

ime

of

mea

sure

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ent

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ter

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alit

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pra

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re(%

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Ken

ard

yet

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(19

96

)L

on

git

ud

inal

19

5R

elie

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ork

ers

(in

clu

din

gem

er-

gen

cyse

rvic

esp

erso

nn

el,

dis

as-

ter

wo

rker

s)

19

89

New

cast

leea

rth

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ake,

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stra

lia

Imp

act

of

Even

tS

cale

;G

ener

alH

ealt

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nn

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27

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0,

86

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14

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ks

93

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Lu

nd

in&

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deg

ard

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93

)

Lo

ng

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ers

19

88

Arm

enia

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qu

ake

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esti

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nai

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gG

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alH

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hQ

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nn

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pac

to

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cale

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edia

tely

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mo

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ter

60

Mar

mar

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.(1

99

6)

Cro

ss-s

ecti

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98

resc

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aco

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01

San

Die

go

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Res

cue

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of

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igh

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sed

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estr

uct

ion

19

89

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ma

Pri

eta

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80

free

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apse

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oti

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le;

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itra

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atic

Dis

soci

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eE

xp

erie

nce

sQ

ues

tio

nn

aire

;S

tres

s-sp

ecif

ic&

gen

eral

sym

pto

mm

easu

res

No

tre

po

rted

86

.7

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orm

ack

&Jo

sep

h(2

01

3)

Qu

alit

ativ

e2

Hu

man

itar

ian

Aid

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sM

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on

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and

a,S

ud

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rra

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ne,

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tT

imo

r,B

urm

a,L

iber

ia,

Pak

ista

n,

and

the

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lom

on

Isla

nd

s.

Inte

rvie

wN

ot

rep

ort

ed1

00

Mil

eset

al.

(19

84

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ross

-sec

tio

nal

54

Res

cue

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rker

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refi

gh

ters

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urs

es,

emer

gen

cym

ed-

ical

tech

nic

ian

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ort

icia

ns,

phys-

icia

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ther

no

n-h

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late

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cyH

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y1

98

1

Ho

pk

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mp

tom

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ealt

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ter

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son

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esti

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aste

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2–

6m

on

ths

85

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anet

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(20

05

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ual

itat

ive

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rld

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de

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tre

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aste

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SA

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cus

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mo

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5.5

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id(2

00

8)

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on

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3H

um

anit

aria

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dw

ork

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re-

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tin

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1re

lief

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anis

atio

ns

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edco

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ict

inD

arfu

rP

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ssio

nal

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alit

yo

fL

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esti

on

nai

re;

Rel

ief

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rker

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rno

ut

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esti

on

nai

re;

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eral

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lth

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esti

on

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re(G

HQ

-28

)

No

tre

po

rted

64

.3


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hi

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012)

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ng

itu

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act

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cale

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erit

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tory

1m

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than

d4

mo

nth

s9

3.3

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rris

etal

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005)

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alit

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e3

4A

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ith

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vid

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mb

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ild

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ma

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in1

99

5

Inte

rvie

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77

.7

Pat

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(19

94

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ross

-sec

tio

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37

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efi

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ters

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&re

scue

char

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lun

teer

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nea

rth

qu

ake

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act

of

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tssc

ale

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her

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hsh

ort

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8in

terv

iew

s

3m

on

ths

78

.6

Pu

lid

o(2

01

2)

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alit

ativ

e2

6M

enta

lH

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lin

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ns

9/1

1W

orl

dT

rad

eC

entr

ed

isas

ter

US

AIn

terv

iew

s2

4m

on

ths

77

.7

Pu

tman

etal

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009)

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edM

eth

od

s:st

ud

y1

cro

ss-

sect

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alit

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e

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dy

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tud

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6A

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ork

ers

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mis

sio

nin

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atem

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cus

gro

up

s;L

os

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gel

esS

ym

pto

mC

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kli

st;

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lach

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rno

ut

Inven

tory

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urv

eyo

fC

hil

dre

n’s

Ex

po

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om

mu

nit

yV

iole

nce

No

tre

po

rted

78

.6

Sh

ihet

al.

(20

02

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ual

itat

ive

46

Nu

rse

vo

lun

teer

s9

–2

1T

aiw

anes

eea

rth

qu

ake

Inte

rvie

ws

No

tre

po

rted

88

.9

So

lim

anet

al.

(1998)

Cro

ss-s

ecti

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al6

4O

utr

each

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rker

s1

99

3Il

lin

ois

flo

od

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rker

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cep

tio

nS

cale

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pen

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ded

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esti

on

sto

enco

ura

ge

com

men

ts

No

tre

po

rted

75

So

lim

an&

Gil

lesp

ie(2

011)

Cro

ss-s

ecti

on

al2

74

Rel

ief

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cial

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rker

sR

efu

gee

cam

ps

infi

ve

reg

ion

so

fth

eM

idd

leE

ast

(Jo

rdan

,L

eban

on

,S

yri

a,th

eG

aza

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ipan

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eW

est

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k)

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rvey

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ot

stat

edN

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rep

ort

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alit

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a-re

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spo

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ron

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ves

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ob

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88

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ore

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her

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ful,

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wo

uld

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ern

ot

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on

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10

0

(co

nti

nu

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and

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erie

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13

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teer

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00

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nes

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to

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ven

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ale;

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spit

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iety

and

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le;

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bje

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ity

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surv

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ned

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0

Bo

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s-p

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cp

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itar

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od

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and

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son

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s1

0m

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ths

88

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13

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ual

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ive

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Dis

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20

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ake

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terv

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0m

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2F

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66

.7


Appendix IV

Themes and results: all studies

Theme Evidence

Pre-deploymentPreparedness and training DRWs need to prepare for the complex social, economic, mental and physical needs of

survivors and victims (Paton, 1994; Pulido, 2012; Stuhlmiller, 1994; Witteveen et al., 2007).Participants cited poor non-medical training and felt out of their depth when put in positions of

responsibility and asked to make decisions, lead projects and teach skills. Participantsworking outside of their main profession reported poor training and lack of handbooks,guidelines and policies to read. Deploying solely with inexperienced staff led to anxiety,stress, frustration and failure to execute the role adequately (Bjerneld et al., 2004).

Performing tasks atypical of the intended role predicted PTSD (Perrin et al., 2007).Training together as a team helped build a network and function collaboratively (Wyche et al.,

2011).Inexperienced volunteers scored more highly on intrusive thoughts, inability to control

emotions, depression and anxiety scales than experienced workers (Hagh-Shenas et al.,2005).

75% of workers felt that they needed more training and skills, and those who felt preparedmanaged better psychologically (Lundin & Bodegard, 1993).

Sufficient training and information to ensure emotional and cognitive readiness for the realitiesof disaster work was found to be protective and viewed as valuable by DRWs (Hearns &Deeny, 2007; Johnson et al., 2005; Wilson & Gielissen, 2004).

Films and speakers as part of training helped to adapt and prepare (Paton, 1994).More realistic rescue and recovery expectations, training on work tasks and specific

preparation for the mission were significantly associated with lower levels of stress(Thoresen et al., 2009).

Training and preparation is an inconsistently managed area across many organisations withinadequate preparation for what to expect, leading to anxiety and dissatisfaction(Norris et al., 2005; Thormar et al., 2013; Weber & Messias, 2012).

Peri-deploymentDeployment length and timing There was a strong association for international DRWs between the number of deployment

missions and depression; the risk of depression was highest on the first mission, decreasedfor the second and reached a peak with five or more missions, though the time period inwhich these occurred was unclear in the paper (Cardozo et al., 2005).

Probability of PTSD increased with longer duration of time worked at the disaster site (Perrinet al., 2007). Another study found no significant relationship between length of deploymentand PTSD severity (Eriksson et al., 2001).

Shorter deployments were more stressful as it took time for workers to ‘‘find their feet’’ andadapt to their surroundings (Bjerneld et al., 2004).

Staff working in a human rights organisation for more than six months were found to havehigher rates of non-specific psychiatric morbidity, anxiety and depression than those whohad worked with the organisation for less than six months (Holtz et al., 2002).

Longer deployments were strongly associated with lower anxiety and depression symptomlevels (Ehring et al., 2011).

Nurses who were dispatched within the first three weeks of the disaster experienced greaterpsychological suffering than those dispatched later (Yokoyama et al., 2014).

Traumatic exposure Workers directly exposed to the disaster itself had significantly higher rates of acute stressdisorder in the aftermath, significantly higher rates of depression at seven and 13 monthspost-disaster, and higher levels of PTSD 13 months post-disaster, compared to thoseworking off-site (Durham et al., 1985; Fullerton et al., 2004).

Workers experienced stress, anxiety and intrusive thoughts caused by the magnitude of deathand grotesqueness witnessed including recovering body parts, smelling burnt flesh and notknowing how to reply to victims asking if they were going to die (Brandt et al., 1995; Paton,1994; Putman et al., 2009; Thormar et al., 2013; West et al., 2008; Yang et al., 2010).

Local and victim hostility in the form of misunderstandings, displaced anger and lack ofgratitude were sources of general stress in DRWs (Thormar et al., 2013; Wang et al., 2011).

Although victim and local population contact could be very stressful, finding ways to comfortfamilies was viewed as making the work worthwhile (Stuhlmiller, 1994; Thoresen et al.,2009).

The prevalence of elevated anxiety was significantly greater in DRWs who witnessed torture(OR 3.0, 95% CI 1.1–81) or general hostility (OR 4.4, 95% CI 1.8–11.0) while being injureddue to an assault was a significant risk factor for PTSD and depression (Holtz et al., 2002).

There was more than a threefold significant increase in depression for DRWs who experiencedthreats to their life, as well as significant differences in non-specific psychiatric morbiditybetween DRWs who experienced threats to their life and those who did not (Cardozo et al.,2005).

At step one of a multivariate model, two exposure variables were uniquely associated withstress reactions for direct disaster exposure; witnessing traumatic experiences and having toreject victims in need of help. At step two, with ‘‘training’’ added to the model (a measure

(continued )


Continued

Theme Evidence

of preparation), they were no longer significant (Thoresen et al., 2009).Dealing with dead bodies either as a primary role, or encountering them in another way,

appeared be a strong significant (p50.01) risk factor for psychological distress and post-traumatic stress responses when compared to workers without such exposure (Dobashi et al.,2014).

Exposure to dead bodies was significantly associated with post-traumatic morbidity (Changet al., 2008); elevated anxiety and intrusive flashbacks, although in most individuals thissignificantly decreased over time (Alexander, 1993); greater psychological distress (Marmaret al., 1996); and remained significant even after adjusting for age, gender and previousPTSD (West et al., 2008).

Bodies of children (Ursano & McCarroll, 1990) and taking family members to identifymutilated bodies of loved ones were found to be particularly stressful experiences (Brandtet al., 1995).

Magnitude of death and destruction was reported as a stressor by 10 (48%) non-emergencyservice volunteers and 12 (75%) fire fighters. Death of young children was reported asstressor by 43% volunteers, 38% fire fighters (Paton, 1994).

Among disaster-area personnel, witnessed experiences most likely to be reported as ‘‘verystrainful’’ were seeing victims searching for next of kin (n¼ 48/23%) and seeing childrenwho were separated from family (n¼ 33/32%). In the disaster-area group, approximately 1in 3 (n¼ 57) rated personal contact with disaster victims who had suffered loss as ‘‘verystrainful’’ compared to approximately 1 in 5 (n¼ 29) of home-base personnel (Thoresenet al., 2009).

Becoming emotionally involved Secondary stress reactions included fatigue, sleep disturbance, grief and anger (Clukey, 2010).Workers with a high level of identification with survivors had significantly more intrusive

thoughts and scored higher on an obsessive/compulsive scale (Hodgkinson & Shepherd,1994).

Identification (sense of kinship) or emotional involvement with the deceased produced distress;working with the personal effects of the dead was particularly stressful as it tended to createa sense of ‘‘knowing’’ the victim (Cetin et al., 2005; Ursano & McCarroll, 1990).

Repeatedly hearing stories of trauma often led to re-living of the incident, over-identificationwith victims and an inability to separate oneself from those they were there to help, andinternalisation of their pain and suffering, leaving workers feeling emotionally affected(Paton, 1994; Pulido, 2012, Soliman et al., 1998; Thormar et al., 2013). This often led tofeelings of helplessness (Berah et al., 1984; Wyche et al., 2011).

Workers involved in certain tasks which may evoke emotional reactions to the victims, namelyproviding psychosocial support and food aid to affected communities, were more vulnerableto PTSD and depression (Thormar et al., 2013).

Workers found it stressful if they thought of family members and friends when seeing victimsand imagined seeing their loved ones in that situation (Berah et al., 1984).

Several authors emphasised the need to keep professional and psychological distance (Brandtet al., 1995; Norris et al., 2005) and to suppress grief (Wang et al., 2013).

Emotional distancing and repression were used as coping strategies (Stuhlmiller, 1994; Wanget al., 2011).

However, suppression and avoidance of traumatic thoughts was also predictive of traumaticstress (Zhen et al., 2012).

One study found that rescue workers were at low risk for secondary trauma, though those whodid experience this were also more likely to report burnout (Chang et al., 2011).

Leadership Poor leadership was described as including ad hoc planning (Hearns & Deeny, 2007); poorlyplanned and badly anchored work and schedules (Bjerneld et al., 2004); lack of guidance interms of roles and boundaries (Soliman et al., 1998) and an overall lack of concern forstaff’s welfare needs (Johnson et al., 2005).

Poor leadership acted as a stressor (Stuhlmiller, 1994; Wyche et al., 2011) particularly toinexperienced staff (Cox, 1997).

Lack of perceived support from leaders was related to greater psychopathology 18 monthspost-disaster; lack of support from the organisation in the aftermath was the strongestcontributor to depression (Thormar et al., 2013).

‘‘Poor or good’’ organisational support, rather than ‘‘excellent’’ support had a strongsignificant association with increased likelihood of depression post-deployment ininternational DRWs (Bjerneld et al., 2004; Cardozo et al., 2005).

Poor organisational support was associated with increased emotional exhaustion anddepersonalisation (Eriksson et al., 2009).

Perceived lack of organisational support pre-, mid- and post-deployment led to disappointment,reduced self-worth, anger and a sense of failed achievement. Despite the lack of support,many participants felt that a sense of loyalty and wanted to continue to work for them(Hearns & Deeny, 2007).

Supervisory support had a strong positive association with intrinsic job satisfaction,engagement, and work culture support, and a strong negative association with psychologicalstrain and turnover intentions (Biggs et al., 2014).

Field leader team cohesion was associated with lower risk for burnout in personal

(continued )


Continued

Theme Evidence

accomplishment (Cardozo et al., 2012).Participants felt frustrated with inexperienced leaders who were not used to being in a position

of such power and did not know how to handle it; they wanted experienced leaders (Clukey,2010).

Lack of coordination and communication among government officials, employees andvolunteers led to frustration, job overload and stress (Bakhshi et al., 2014; Wang et al.,2011; Weber & Messias, 2012).

Organisational headquarters were perceived as not fully understanding the reality of thesituation that workers were dealing with (Hearns & Deeny, 2007) and being only involvedsuperficially and for bureaucratic procedures (Wilson & Gielissen, 2004).

Good organisational support and sensitive staff management practices were shown tocontribute to positive occupational health (Alexander, 1993).

Organisational social support provision was largely reported to be positive, although someworkers felt that their supervisors were too busy to provide emotional support or they wouldfeel uncomfortable opening up to them (Bakhshi et al., 2014).

79% reported that they could rely on their superiors when they returned home and resumedtheir normal work. 98% also reported that they received a lot of appreciation and recognitionfor their work (Van der Velden et al., 2012).

Lack of recognition in efforts and feeling undervalued were considered stressors, particularlyfor those working in small organisations (Weber & Messias, 2012).

Feeling undervalued was reported to be in the top five stressors (Curling & Simmons, 2010).Workers sometimes reported a sense of invisibility and did not feel valued (Cox, 1997).

Inter-agency cooperation Local professionals appeared to have a sense of ‘‘ownership’’ over the disaster; ‘‘outsiders’’were seen as implying the local community was not able to manage the situation themselvesand tended to be resented unless they were seen as playing a supporting role to localleadership (Norris et al., 2005).

Lack of cooperation between agencies often meant different services operating in their ownareas on their own time schedules, and workers reported conflicts with other aid workersand having disparaging opinions of each other (Cox, 1997).

There were often tensions between local first responders and ‘‘outsiders’’, with differences inopinion between agencies hindering the provision of a quick and appropriate response(Wyche et al., 2011).

Moderate to considerable difficulties with other relief teams were attributed to two majorfactors: differing philosophies/frameworks and professional rivalry/jealousy (Berah et al.,1984). Inter-agency rivalry and secrecy of information was also noted by Hodgkinson &Shepherd (1994).

Cultural differences and communication difficulties were blamed for an inability to buildcollaborations with local responders, which became a barrier to productive work (Yanget al., 2010).

Even when agencies collaborated, this was of minimal help in reducing stress, suggesting thatthe intense nature of the role can make it distracting to engage with other agencies (Soliman& Gillespie, 2011).

Social support Social support was significantly associated with lower levels of depression (AOR 0.9; 95% CI0.84–0.95), psychological distress (AOR 0.9; 95% CI 0.85–0.97), burnout in lack ofpersonal accomplishment (AOR 0.95; 95% CI 0.91–0.98), and greater life satisfaction(p¼ 0.0213), even after adjusting for all other study variables (including age, gender,marital status, childhood trauma, non-government organisation experience) (Cardozo et al.,2012).

Perceived social support appeared to mediate the effects of high trauma exposure and PTSDseverity, although there was insufficient statistical data to confirm the strength of thisinteraction (Eriksson et al., 2001).

Many workers felt that informal ‘‘talking/sharing’’ was the most helpful way of dealing withdistressing thoughts and was significantly linked to lower levels of anxiety and depression(Ehring et al., 2011; Miles et al., 1984).

Social support was important for high trauma exposure in relief workers and there were nosignificant differences as to where this support came from. In UN soldiers involved indisasters, social support was important for low trauma exposure, but only friends andcolleagues were a significant buffer/moderator for post-traumatic stress symptoms(Kasperen et al., 2003).

Camaraderie within the team, mutual support, trust, understanding and cooperation amongcolleagues were perceived to be important (Bakhshi et al., 2014; Wang et al., 2011; Wycheet al., 2011).

Perceived work culture support appeared to mediate the effect of exposure to a natural disasteron job control, job demands, work strain, intrinsic job satisfaction, turnover intentions andwork engagement (Biggs et al., 2014).

It was suggested that the pre-departure period be used for team building to foster a resilientenvironment for when in the disaster area (Norris et al., 2005; Paton, 1994).

Having to live and work with colleagues could be a source of stress in itself if relationshipswere poor (Bjerneld et al., 2004).

(continued )


Continued

Theme Evidence

Perceived social support was significantly correlated with post-traumatic growth (Karanci &Acarturk, 2005).

Highly infrequent family contact was significantly associated with depression (West et al.,2008).

There was a significant association between perception of communication facilities as poor andnon-specific psychiatric morbidity and depression (Cardozo et al., 2005).

Lack of communication or poor facilities to communicate could be stressful (Bjerneld et al.,2004; Hearns & Deeny, 2007).

One study reported that participants found communication with home to be stressful due toloved ones being worried (Bakhshi et al., 2014).

During-deployment formal support Many participants felt that there was a lack of appropriate clinical and social services forsupport (Moynihan et al., 2005).

Occupational health support and policies for non-uniformed workers were not seen as equal tothose provided for first responders/uniformed services (Johnson et al., 2005).

When on-site psychological counselling sessions with professional counsellors or stressmanagement workshops were available, these were generally seen as helpful (Curling &Simmons, 2010; Yang et al., 2010).

Role Some non-managerial DRWs felt unexpectedly out of their depth when put in positions ofresponsibility and asked to make decisions, lead projects and teach skills when they werenot expecting to (Bjerneld et al., 2004).

Competing needs and demands often meant role diffusion and a need to adapt to multiple roles(Moynihan et al., 2005), which led to individuals having to modify their standard practices;at times this caused ethical and moral dilemmas (Yang et al., 2010).

59% rated clarity of service and rules and regulations of service delivery to be understandable(Soliman et al., 1998).

5% of volunteer workers experienced role uncertainty compared to 38% of fire-fighters (Paton,1994).

Role ambiguity appears to be more of a significant problem in the early stages of disaster work,but in many cases, roles and tasks soon fall into place (Bakhshi et al., 2014).

Employer and role flexibility is considered essential due to the nature of disaster work, in orderto accommodate for changing needs and to foster resilience (Paton, 1994; Pulido, 2012;Wyche et al., 2011).

A strong ‘‘chain of command’’/line management structure was believed to reduce confusion indisaster situations (Norris et al., 2005).

Demands, workload and long hours Job resources played a particular role in stressor-strain process after unpredictable andemotionally challenging work demands (Biggs et al., 2014).

Workers cited an inappropriate balance between workload and manpower – however, thisincreased team cohesion and spirit, as they needed to depend on each other, and likened theteam to a family (Hearns & Deeny, 2007).

Pressure and a perceived need to act quickly led to putting in long hours and neglecting normalactivities; participants believed hours worked per day should be limited, and adequatenumbers of staff were needed to reduce pressure on individuals (Norris et al., 2005).

A number of work hours per day were associated with poor subjective well-being and intensefatigue (Thormar et al., 2013; Yokoyama et al., 2014).

50% of fire-fighters and 19% of non-emergency service volunteers cited ‘‘being pushed to thelimit’’ as a stressor; however, only 1 (5%) volunteer and 4 (25%) fire-fighters reported‘‘exhaustion’’ as a stressor (Paton, 1994).

Complicated tasks, high expectations and excessive demands led to stress, particularly whenassociated with inadequate resources (Soliman & Gillespie, 2011).

Workers reported feeling exhausted and that they found the prolonged heavy workload, longhours and emotional exhaustion stressful (Bakhshi et al., 2014; Curling & Simmons, 2010;Paton, 1994; Wang et al., 2011).

Time off while on deployment was viewed as essential for maintaining emotional stability andbeing able to distance oneself from the work (Bakhshi et al., 2014; Stuhlmiller, 1994).

Simply taking breaks were not enough, as participants often felt that they were merely waitingfor their next shift; using the break to do some activity which helped take their mind offtheir work was useful, although some reported feeling guilty during time off and using it tohelp out informally (Bakhshi et al., 2014).

Safety and equipment Participants felt concerned about safety, poor living conditions and inadequate equipment andfacilities, which could lead to a sense of personal vulnerability (Clukey, 2010; Hearns &Deeny, 2007; Paton, 1994; Thormar et al., 2013; Yang et al., 2010).

Sustaining an injury on the job was a strong predictor of PTSD (Kenardy et al., 1996; Perrinet al., 2007).

Anxiety and PTSD symptoms increased in relation to not feeling enough safety measures werein place and fearing for one’s own safety (Miles et al., 1984; Thormar et al., 2013).

Near-death experiences and severe injuries occurring on the job were associated with PTSD(Huang et al., 2013).

Feeling personally threatened was associated with higher psychological distress (Marmar et al.,1996).

(continued )


Continued

Theme Evidence

Perceived severity of threat to life was correlated with post-traumatic growth (Karanci &Acarturk, 2005).

Participants felt that they lacked the appropriate personal protective equipment which was onlyprovided after complaints were made, which led to stress, anxiety and health complaints(Johnson et al., 2005).

Reassurance about safety from supervisors was helpful (Bakhshi et al., 2014).Self-doubt and guilt 24% of participants reported feeling ‘‘guilt’’ (Miles et al., 1984); workers who felt poorly

prepared for tasks were more likely to report feelings of guilt (Marmar et al., 1996). Workerswho had themselves been involved in the disaster often felt guilt at being alive when otherswere not (Wilkinson, 1983).

Participants reported wanting to have done more to relieve suffering and felt helpless,frustrated and that they were ‘‘failing’’ victims as they could not meet all of their needs(Miles et al., 1984; Pulido, 2012; Wilkinson, 1983).

Blaming oneself for not being able to help more was significantly associated with increasedpsychological distress (Ehring et al., 2011).

Workers doubted their own actions, especially when having to prioritise their own safety overothers, which led to shame and fear of judgment (McCormack & Joseph, 2013). It was alsocommon for workers to question their own capabilities (Stuhlmiller, 1994), and to fearmaking mistakes (Bakhshi et al., 2014).

Participants reported feelings of inadequacy and confusion and often felt that they did not‘‘deserve’’ to be there as they were unable to fix the situation or stop the suffering of victims(Brandt et al., 1995).

Staff felt more positive when they believed they had been helpful and felt appreciated bymembers of the public, but felt stressed if their work was not immediately beneficial to thepublic (Bakhshi et al., 2014).

Self-doubt and shame led to ‘‘narcissistic coping’’ including high-risk behaviours, poor self-care and becoming less compassionate to others (McCormack & Joseph, 2013).

Coping strategies 20% of respondents reported an increase in the use of tobacco or caffeine, 16% an increase intranquilisers, and 10% an increase in alcohol use (Miles et al., 1984).

Participants reported an increased reliance on alcohol, cigarettes, prescribed and non-prescribed medication and caffeine (Curling & Simmons, 2010).

Negative ways of coping such as evasion, fantasy, and repression led to a significantlyincreased likelihood of developing PTSD (Huang et al., 2013).

‘‘Talking and sharing’’ was seen as the most helpful way of coping with distressing thoughts(Miles et al., 1984; Wilkinson, 1983).

Other helpful coping mechanisms included writing, massage and deep breathing to fosterrelaxation (Norris et al., 2005).

For some occupations, such as military para-rescuers, a ‘‘press on’’, ‘‘do your job’’ strategywas used as a way to cope (Stuhlmiller, 1994).

Redefining the experience as a ‘‘realistic training exercise’’ or way of ‘‘skill building’’ wasuseful (Paton, 1994; Wyche et al., 2011), and remaining optimistic and appreciative of lifewere used as ways of coping (Wang et al., 2013).

Additional important coping strategies included dedication to work, finding a meaning in theirwork and goal/time management (Wang et al., 2011); active problem solving and self-reflection (Wyche et al., 2011); finding meaning and purpose in life through relief work(Wang et al., 2013); compartmentalising things they could not change, finding meaning andpurpose, re-evaluation of self-worth and re-connecting with the idea of the self as altruisticrather than bad (McCormack & Joseph, 2013).

Confrontive coping, distancing, seeking support, accepting responsibility, escape-avoidance,problem-solving and positive appraisal modified the effect of traumatic exposure on generalpsychiatric morbidity (Chang et al., 2008).

Fatalistic coping and problem-solving/optimistic coping approaches explained a largeproportion of variance in post-traumatic growth (Karanci & Acarturk, 2005).

Post-deploymentPost-deployment formal support Participants felt that the organisation should be responsible for providing debriefing and this

should be carried out automatically, not only when requested (Bjerneld et al., 2004).One-third of participants (n¼ 79) expressed a need for intervention within the first few weeks

following a disaster (Durham et al., 1985).Embassy workers felt that they had a lack of time to adjust to being back home and doing their

everyday work; this poor re-adjustment often led to feelings of ‘‘anti-climax’’ anddecreased motivation for normal work. However, those participants who were offered TRiMtraining found it helpful, and taking part in a qualitative study was also deemed helpful bymany, perhaps serving as a means for them to express their feelings and discuss theirexperiences (Bakhshi et al., 2014).

Participants felt that stress management and re-entry into home and society programmesneeded to be better (Hearns & Deeny, 2007).

Participants who had had a group debriefing reported that they felt that they were expected topublicly admit to vulnerabilities and acknowledge fears, which led to a fear of being seen asineffective; the debriefing also happened at the end of long work hours when they were

(continued )


Continued

Theme Evidence

exhausted, and listening to those less successful deflated the sense of accomplishment ofsuccessful rescuers (Stuhlmiller, 1994).

Debriefing had little effect on psychological distress (Kenardy et al., 1996).Technical and operational debriefing were reported positively, but participants felt that they

needed more contact with other workers involved in the disaster after returning home (Vander Velden et al., 2012).

Lack of support from peers post-disaster, including criticism, indifference, disinterest or beingtold to ‘‘get on with life’’ led to feelings of anger, betrayal, disconnection and lack ofvalidation, often leading to poor reintegration (McCormack & Joseph, 2013).

The ‘‘512 Psychological Intervention Model’’ (an intervention including debriefing onsymptoms of mental ill health, stress management and training in cohesion) was an effectivedebriefing method for rescue nurses, associated with a reduction in symptoms of PTSD,anxiety and depression (Wu et al., 2012).

Participants reported poor re-adjustment into home, society and work environments and a needfor support programmes (Bakhshi et al., 2014; Hearns & Deeny, 2007).

Media Exposure to media coverage of the disaster was the most common ‘‘trigger’’ of recall of thedisaster after the event (Miles et al., 1984).

Hours spent watching coverage of the disaster were related to PTSD (Nishi et al., 2012).Publicity was reported to be a stressor (Paton, 1994).Press attention left participants feeling they were working in the public view; criticism from the

media was taken personally; and demands for information from journalists increasedworkload (Bakhshi et al., 2014).

Participants felt training in skills for dealing with the media would be helpful (Norris et al.,2005).

Personal and professional growth Many participants viewed the experience as rewarding, in terms of feeling they had made acontribution; personal accomplishment and consequent improved confidence and self-esteem, increased compassion, and re-evaluation of the self and meaning of life (Bakhshiet al., 2014; Soliman et al., 1998; Wang et al., 2013; Yang et al., 2010).

The experience was generally seen as meaningful and fulfilling and workers were glad thatthey had experienced it (Alexander, 1993; Berah et al., 1984; Yang et al., 2010).

65% of participants felt that the experience had changed their lives in some way: for example26% saw life as more fragile and 15% felt more committed to living their lives fully (Mileset al., 1984).

96% of disaster-area personnel and 91% of home-base personnel reported their experience asmeaningful, and only 3% and 6% of disaster-area and home-base personnel, respectively,would rather have been without the experience (Thoresen et al., 2009).

77% of participants felt that their experiences had had a positive impact on their personal lives(Soliman et al., 1998).

Participants expressed satisfaction in having a sense of purpose and being able to educateothers and offer wisdom and skills (Zinsli & Smythe, 2009) and felt that they were makingimportant contributions to the relief effort (Moynihan et al., 2005).

Participants felt more connected to the community afterwards, and gained insights intoconceptual thinking about themselves and their professional work (Berah et al., 1984).

Humanitarian concern, work satisfaction and the feeling of ‘‘giving back’’ were motivators,and levels of perceived personal accomplishment were inversely related to PTSD (Putmanet al., 2009) and associated with higher levels of resilience and lower levels of secondarytrauma and burnout (Chang et al., 2011).

Participants felt that their experience led to a recognition of the transient nature of life; helpedthem develop a wish to lead a more significant life with more caring relationships; led to abetter appreciation of the value of their work and own self-worth; and that they felt‘‘touched’’ by seeing others’ altruism (Shih et al., 2002).

However, one paper found that a reportedly ‘‘better’’ experience and more positive evaluationof work was significantly associated with higher anxiety and burnout: this appears counter-intuitive, but it may be that the positive experience puts more responsibility on the worker ifthings do not go as planned (Cardozo et al., 2012).

79.7% of participants were satisfied with the effect on their professional growth; they alsofound a negative impact on workers if they felt their professional skills had not beenenhanced during their experience, though this finding must be interpreted cautiously as itmay be that those who felt more stressed were less likely to report professional growth(Soliman et al., 1998).

Participants felt that the experience had had a positive impact on their career (Bakhshi et al.,2014).

Participants felt that they gained a clearer concept of disaster care, enhanced knowledge ofsurvivors’ needs and enhanced ability to recognise factors hindering rescue operationswhich in turn strengthened professional competency, reinforced commitment to theprofession and led to positive life goals (Shih et al., 2002).

Socio-demographic and pre-deploymentcharacteristics

Age: Younger workers more likely to be depressed and anxious (Cardozo et al., 2005; Ehringet al., 2011; Thormar et al., 2013) and were at higher risk for acute stress disorder (Fullertonet al., 2004) and psychological complaints (Zhen et al., 2012). Another study found that

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Continued

Theme Evidence

depression was higher in younger workers but not to the point of significance (Wilkinson,1983). Older workers experienced less burnout and secondary stress (Musa & Hamid,2008). Two studies found no relationship between age and psychological outcomes(Eriksson et al., 2001; Hodgkinson & Shepherd, 1994).

Gender: One study reported females showed significantly higher levels of PTSD, mixedanxiety and depression, somatic symptoms and burnout (Ehring et al., 2011). Two studiesfound that males were more likely to have depressive symptoms (Holtz et al., 2002;Thormar et al., 2013). Females were more likely to report role clarity and positive effects ofthe experience (Soliman et al., 1998). Two studies found no significant relationship betweengender and psychological outcomes (Eriksson et al., 2001; Hodgkinson & Shepherd, 1994).

Ethnicity: Ethnicity was not found to predict PTSD (Putman et al., 2009).Education: Workers with social science educational backgrounds showed more positive

perceptions than those with other educational backgrounds (Soliman et al., 1998). One studyfound no correlation between educational level and psychological complaints (Zhen et al.,2012).

Family relationships: Married workers were more likely to develop acute stress disorder(Fullerton et al., 2004). Workers with children had significantly lower levels of PTSD anddepression (Ehring et al., 2011). Two studies found no association between marital statusand psychological outcomes (Hodgkinson & Shepherd, 1994; Zhen et al., 2012).

Having a family member injured in the disaster: Having a family member injured in theincident was associated with PTSD and depression when adjusted for age, gender and priorPTSD/depression history (West et al., 2008).

Previous experience/exposure: Greater previous disaster experience was significantlyassociated with higher levels of PTSD (Fullerton et al., 2004). Lifetime direct communityviolence exposure was significantly associated with PTSD, although lifetime indirectexposure was not (Putman et al., 2009). Outreach workers with longer experience in humanservices showed more positive perceptions with regards to the effects of service (Solimanet al., 1998).

Pre-deployment mental health: Previous psychiatric history was strongly associated withdepression and moderately associated with non-specific psychiatric morbidity (Cardozoet al., 2005). A history of mental illness contributed to increased risk of anxiety anddepression (Cardozo et al., 2012). Two studies found no association between psychiatrichistory and elevated symptoms post-disaster (Holtz et al., 2002; Wilkinson, 1983).

Post-disaster life events: The number of post-disaster life events was significantly associatedwith psychological wellbeing (Witteveen et al., 2007).


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