Literature review

Executive Summary

In an effort to move towards evidence based practice, this paper critically appraises the best available evidence from a variety of sources in relation to preventing job related posttraumatic stress disorder in remote areas. Specifically it attempts to identify high risk events, high risk reactions, and high risk individuals in a remote health context. Factors that affect recovery and the influence of cultural issues on appraisal and response to trauma are examined. The validity, usefulness and potential risks and benefits of interventions developed for urban practitioners are examined in the light of remote practice contexts.

A review of the literature concerning the vulnerability and resilience of those exposed to traumatic events suggests remote health practitioners are at high risk of developing posttraumatic stress disorder as a result of job related exposure to traumatic events. This is particularly so for on-site health practitioners.

Along with comparatively high levels of day to day occupational stress likely to increase the vulnerability of remote practitioners, there is much to suggest the unique roles and circumstances of remote practice places them at a higher risk of developing job related posttraumatic stress disorder than their urban counterparts. While all traumatic events have common elements, there are additional and unique dimensions of vulnerability which arise out of the remote workplace. Generally, job related traumatic events in remote areas are likely to be more complex psychological events in comparison to those in urban contexts.

Factors likely to intensify reactions and prolong recovery include high and prolonged level of exposure, multiple roles during the event, moral conflict and responsibility trauma due to inadequate preparation of practitioners for extended professional roles, lack of anonymity of all involved, and the often public nature of such events. After the event recovery processes may be compromised by limited opportunities for time out to appraise the event, lack of control or predictability of rest or recovery time, and the high likelihood of subsequent traumatisation. This is compounded by the community-wide impact of the event coupled with the lack of natural circuit breakers between home and work. Lack of anonymity, confidentiality issues, potential risks to personal and professional standing, and intensifying reactions of others, all work against the ability of practitioners to talk about their experiences and effectively work through and come to terms with what happened. When combined with the high likelihood of secondary traumatisation as a result of insensitive handling by managers or employers and, depending on perceptions of the practitioner's role in the event, incurring community blame or retribution, it becomes apparent remote practitioners are likely to experience difficulties in recovering after the event.

There is some evidence to support the notion that a range of generic, selected and targeted preventative strategies may be likely to reduce the incidence and severity of posttraumatic stress disorder among remote health practitioners.

A critical appraisal suggests models of interventions developed for urban contexts are unsuitable for application in remote areas. Interventions need to take account of the unique dimensions of vulnerability and risk associated with remote practice, and the complex nature of traumatic experience in small communities.

Universal strategies include the prevention of traumatic events where possible, the provision of skills to manage predictable and potentially traumatising events, stress management training, and a supportive organisational environment which recognises and validates practitioners' responses to difficult situations and aims to maximise their recovery.

Selective strategies include support services to facilitate recovery following exposure to job related trauma. These can be provided at a number of levels and include the provision of information, help lines such as Bush Crisis Line, employee assistance programs and the supportive management of job related traumatic events, including on-site interventions for individuals, teams and communities. Risks identified with group debriefings suggest these may not be therapeutic and may be potentially harmful in remote areas, particularly in cross-cultural contexts.

Guidelines for assessing risk to psychological well-being of practitioners exposed to job related traumatic events need and for the provision of appropriate interventions in remote areas are offered, as well as guidelines for supportive interventions for individuals, groups and communities.

Following a risk assessment, support strategies should be mapped onto the risk status of the employee, accommodate the support needs of the practitioner over time, and provide a safety net of follow up support, counselling and early referral if necessary.