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RATIonAle Providing support to people who have been trafficked is usually a highly rewarding experience. However, exposure to graphic details of abuse and to the ways in which abuse affects the lives of those who have been trafficked can be stressful for health providers.
It is not unusual for people working with trafficked persons to experience emotions of anger, pain, frustration, sadness, shock, horror and distress. The work could also affect energy levels and cause disturbed sleep, somatic complaints and hyper-arousal. Some health providers may experience intrusive images, thoughts and nightmares about their patients’ distressing experiences. These symptoms have been described as ‘secondary traumatic stress’ and are similar to post traumatic stress disorder, except that the exposure is to knowledge about a traumatizing event experienced by someone else. Health care providers re-experiencing a patient’s traumatic event often wish to avoid both the patient and reminders of his or her trauma.
They may also have increased concerns over their own safety and the safety of the people close to them.
Hearing about extreme trauma can change a health provider’s view of the world, of other people and of him- or herself. The provider may see the world as a more dangerous place, lose trust in other people and experience feelings of personal helplessness and hopelessness. Health care providers may react to such changes by distancing themselves from their patients and experiencing what is known as ‘compassion fatigue’, a reduced capacity or interest in being empathic or in bearing the suffering of patients. Compassion fatigue among health care providers also encompasses symptoms of job burnout. This is characterized by emotional exhaustion and reduced personal accomplishment in response to prolonged exposure to demanding interpersonal situations without adequate support.
98 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSResearch into the effects of supporting traumatized patients on health care providers suggests that a provider’s own beliefs about his or her role might be associated with secondary trauma and compassion fatigue.33 Common beliefs might include such thoughts as ‘I can help everyone and can help everyone immediately’; ‘the more time I give, the more I can help my patients’; and ‘I can know everything. I can love everyone’.
Systemic issues such as size of caseload, level of organizational support, training, case supervision and peer support are also associated with the effects of trauma work on health care providers.
RequIRed ACTIonS If you are worried about your safety because of the nature of your work please see action sheet 7, which provides recommendations for physical protection. Be aware, however, that increased concerns over danger may also be a symptom of secondary traumatic stress. The following recommendations provide information on how to put in place systems to minimize potential negative effects of providing care for trafficked persons.
Recommendations for organizations and managers
A basic requirement for the psychological well-being of personnel is a sense that their employer is taking all the necessary steps to ensure their security. First, it is important to ensure that personnel have and feel that they have the necessary level of training to carry out the duties the job requires.
• Make certain health care staff have job descriptions that clearly define the goals and limitations of their work and options for professional support and stress management. Make sure these are reviewed and appraised regularly. Clearly defined roles and available resources can prevent staff from feeling overwhelmed or helpless.
• Give staff copies of these guidelines and make them aware that they could potentially experience secondary trauma, job burnout and chronic fatigue.
• Schedule regular clinical supervision. Clinical supervision is essential to ensuring quality of care and minimizing the risk of compassion fatigue. The availability of such supervision will vary in different settings. Clinical supervision, which should be scheduled at regular times when possible, can be carried out in a group, but staff should also have individual See references at the end of this action sheet for more information.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSsupervision. Separating management issues from clinical supervision in important when the supervision is done by a manager.
• Establish clear guidelines regarding the size and complexity of the clinician’s caseload; this can help minimize the risk of job burnout. Caseloads should be reviewed regularly with supervisors to ensure a balanced caseload. When possible, a health care provider’s caseload should be varied. In a centre dealing only with trafficked persons, for example, direct patient care can be combined with work that does not involve direct contact with patients; it may also include having patients at different stages of rehabilitation.
• Discourage attitudes of controlled emotions and of bravado.
Where possible, services should foster a culture of peer support and an environment open to discussions of health care providers’ emotions in relation to their work.
• Establish a procedure for health care providers to request that personally challenging cases be transferred to other colleagues.
• Encourage health care providers to keep a healthy work-life balance. Health care providers should be discouraged from neglecting their own leisure and social life in order to help their patients.
Recommendations for health care providers
• Work with patients on agreed goals – goals that are derived directly from a treatment plan and based on a shared understanding of the difficulties facing the patient. This will help both you and your patient to have realistic expectations and avoid feelings of helplessness and hopelessness; it will also help define the boundaries of your work together.
• Discuss your cases regularly with your clinical supervisor or colleagues to ensure good practice and self care.
• If you are struggling with your caseload, bring this to the attention of your supervisor and colleagues. Not doing so could be harmful to your patients and yourself.
• Demonstrate caring attitudes towards your colleagues;
this will help create and maintain a supportive working environment in your service.
• Use your social support network and leisure activities as a way of looking after yourself. This could include such self-care behaviours as taking holiday leave, relaxing after work, and getting regular exercise.
100 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS
Identifying signs of fatigue or burn out Below are some early signs that can help you recognize whether you
are affected by your clinical work with trafficked persons:
If you have some of these symptoms, you might wish to fill in the compassion fatigue scale (following). You can use it to assess compassion fatigue, secondary trauma and job burnout.
How to address compassion fatigue If you think that you are affected by your work and suffer from compassion fatigue, secondary trauma or job burnout, discuss it with your supervisor. Do not ignore the signs of these difficulties, because they will not go away unless you address them. The same applies if you are a manager or clinical supervisor who suspects that a staff member is experiencing symptoms; these should not be ignored. A meeting between the health care provider and supervisor should be arranged as soon as possible. The aim of the meeting is to assess the health care provider’s needs and how those could
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSbe met, while considering how his or her clinical caseload could be covered.
The discussion in the meeting should cover following issues:
• If an occupational nurse or doctor is available, discuss referring the health care provider.
• If the organization does not have occupational support persons, review the health provider’s current responsibilities and agree on if – and to what extent – he or she can continue to carry out responsibilities towards patients.
• Discuss who could provide appropriate support and counselling to the health care provider.
• Agree on who to notify of the difficulties that the health care provider is encountering.
• Arrange a review meeting to discuss the health care provider’s progress and his or her care plan and job description.
102 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSCompassion fatigue scale34 Consider the following thoughts related to your work/life situation.
Write the number that best reflects your experiences using a scale of 1
The scale has three subscales: secondary trauma (items c, e, h, j and l);
job burnout (a, b, d, f, g, i, k and m); and chronic fatigue (all items). There are currently no cut-off scores for the scale but high scores are suggestive of the indicated conditions. The scale can provide a monitoring tool.
Adams, R. E. et al., “Compassion fatigue and psychological distress among social workers: a validation study”, American Journal of Orthopsychiatry, vol. 76, no. 1, January 2006, pp. 103–108.
CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERSRefeRenCeS And ReSouRCeS Adams, R. E. et al.
2006 “Compassion fatigue and psychological distress among social workers: a validation study”, American Journal of Orthopsychiatry, vol. 76, no. 1, January 2006, pp. 103–108.
Figley, C.R. (Ed.) 2002 Treating Compassion Fatigue, part of Psychological Stress Series, Brunner-Routledge Press, New York, NY, USA, 2002.
AC Action Sheet 9:
TION Patient data and files
RATIonAle Although most health providers have in place certain security precautions for patient medical files and rules around patient confidentiality, providers caring for persons who have been trafficked will need to institute extra safeguards for written, electronic and verbally communicated information on trafficked persons.
“Health data include all records pertaining to the physical, mental and social health of the trafficked person. A health information system is the way in which health data are collected, organized, stored and communicated.”35 As with all patient data, the way information is collected, stored and transferred between providers is important to accurate diagnosis and treatment.36 Because trafficked persons are particularly likely to face security risks, be referred to other providers and/or transferred from the original care location (e.g., internationally) or participate in one or more legal proceedings, it is especially important to follow good data management procedures to ensure the safety of each individual and the quality of follow-up and future care. Trafficking cases may involve organised criminal groups. Health data may be used in court or may be used to support or undermine an asylum claim. Notably, patient files may also identify health care staff involved in providing care.
Central to managing the health data of trafficked persons are: privacy, confidentiality and security (see chapter 3). These concepts are fundamental principles in handling trafficking-related data in general and certain sensitive International Organization for Migration (2007), p. 256.
Ibid., p. 255.
108 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERShealth information (e.g., HIV) in particular.37 Privacy refers to the patients’ right to control how they provide information, the use of this information and their access to it. Confidentiality indicates the right of patients to determine who has or does not have access to their patient information and for trafficked persons, suggests the importance of anonymity. Security suggests the need to safeguard patient files against security breaches during data collection, storage, transfer and use.
In managing data on trafficked persons it is important to recognize and balance the patients’ rights to protect and access their personal data and the need for health care providers to collect, use and disclose personal data in the course of providing care. The framework for protecting the confidentiality and security of HIV information provides a good example of mechanisms for managing the health data of trafficked persons.38 This action sheet focuses on the collection, storage, transfer and security of data management in cases involving or potentially involving trafficking and outlines actions to undertake in managing the health information of trafficked persons. It should be read alongside action sheets 7 and 10.
RequIRed ACTIonS39 In addition to adhering to the overarching principles for managing data, health care providers must also take specific actions throughout, and even after, a patient is in their care. Protecting patient information will often involve a number of individuals in a health care setting (e.g., reception staff, nurses, doctors, consultants, managers, data-entry clerks, etc.). All who have a potential role in communicating with trafficked persons, managing information or transferring file data should be made aware of the rules and procedures for patient information.
There are several phases in the management of patient information.
Many of the precautions are common for all patient information. In cases of trafficking or potential trafficking, health providers must take care to carry out these steps with the utmost care and attention to the immediate and future safety and well-being of the patient—and health care staff.
International Organization for Migration (2007); UNAIDS, Guidelines on Protecting the Confidentiality and Security of HIV Information: Proceedings from a workshop 15-17 May 2006 Geneva, Switzerland, interim guidelines, UNAIDS, Geneva, 15 May 2007.
Health care providers should also refer to how various forms of sensitive health data are managed within their respective organization.