International Journal of Nursing Practice 2009; 15: 231240

REVIEW PAPER

Interventions to reduce psychosocial disturbance

following humanitarian relief efforts involving
natural disasters: An integrative review
ijn_1766

231..240

Denise Susan Walsh MSN RN

Doctoral Candidate, University of Connecticut, Storrs, Connecticut, USA

Accepted for publication April 2009

Walsh DS. International Journal of Nursing Practice 2009; 15: 231240
Interventions to reduce psychosocial disturbance following humanitarian relief efforts involving
natural disasters: An integrative review
Because of the increased level of post-traumatic stress disorder (PTSD) reported post disaster work, it is imperative that
governmental and non-governmental agencies consider predisaster training of volunteers in not only clinical skills, but also
communication and team building. When these concepts are combined with ongoing support post disaster, a decrease in
the frequency and severity of PTSD has been reported. A review of 12 studies examined responses of relief workers to
various disaster situations. Experiences were extracted, categorized, and a data reduction model was developed to
illustrate the characteristics of the experiences and subsequent interventions that were reported. Three interventions that
positively affected the responses of relief workers to disaster experiences emerged: debriefing, team building and
preparation.
Key words: disaster planning, post-traumatic stress disorder, relief work, rescue work.

INTRODUCTION
A thousand eyes that see the pain in all the corners of the
universe and a thousand arms to reach out to all corners of the
universe to extend help
Tibetan Iconography
On the morning of 26 December 2004, the lives of
300 000 people were forever lost. An earthquake off the
coast of Indonesia caused a tsunami to cross the Indian
Ocean from Sumatra to Africa. Three waves traversed the
ocean at a speed of 500 mph unbeknownst to the world.
The resulting damage affected 12 countries, and was

Correspondence: Denise Susan Walsh, 217 Northwood Road, Fairfield,

CT 06825, USA. Email: walshroyal@aol.com
doi:10.1111/j.1440-172X.2009.01766.x

responsible for 175 000 deaths with 125 000 people still
missing and presumed dead. One million people were
displaced from their homes, and 500 000 people were
injured. Within hours the tsunami had directly affected
the lives of 1.8 million people both physically and psychologically, and millions more indirectly as the economies of
these countries were devastated.1
The Ampara District on the east coast of Sri Lanka was
hardest hit. A poor area already suffering from many years
of civil war between the Tamils in the North, and the
Singhalese in the South, this region reported seven out of
10 family members killed that morning and 79 000 people
had their homes destroyed. When the tsunami came
ashore in Sri Lanka the three waves measured 10, 20 and
30 feet high respectfully with a force never before seen in
the world.
2009 Blackwell Publishing Asia Pty Ltd

232

The humanitarian response to this natural disaster was

immediate and overwhelming. On the northeast coast of
Sri Lanka, United Nation Organizations provided tents to
the thousands of persons without any means of shelter,
and Oxfam International focused on bringing clean water
and toilet facilities to the tent cities that were quickly
rising along the coastline. Volunteer medical teams from
non-governmental organizations (NGOs) in the USA,
Australia, Canada and the UK coordinated surveillance
programmes for tracking malaria, tuberculosis and
cholera in the refugee camps.
The focus of the relief effort was treatment of injuries,
both physiological and psychological, and the settlement
of the growing refugee population. When the relief
workers arrived on the scene their senses were
assaulted.2 One volunteer reported that no amount of
field experience could have prepared you for the situation
of working at the tsunami. Observing devastation and
suffering on a mass scale and trying to function to the best
of your abilities with limited resources is a unique,
demanding experience.3
Increasingly, the world is becoming interconnected
and dependent upon the global community to offer assistance from challenges posed by disasters. As health-care
professionals respond to emergency situations and care for
trauma victims, relief agencies responsible for these volunteers must focus on their preparation of, and readjustment to, life after their term of service. Medecins Sans
Frontieres (Doctors Without Borders) has been sending
volunteers since 1971 to the most dangerous localities in
the world to provide medical help to those in crisis. The
Nobel Peace Prize winning organization is criticized for
the lack of effort it expends to readjust their members to
life at home and work upon their return. The organization
does a good job preparing volunteers for a mission, but
no preparation to come home. This lack of preparation
results in the inability to relate to home life and work life
for weeks and sometimes months.4
The relief workers who answered the call to action in
Sri Lanka were not only exposed to the stress of the
disaster, but also to the stress of the role of caregiver to
the victims.5 The effects of these stressors can ultimately
lead to post-traumatic stress disorder (PTSD).6 Current
research shows a critical need to examine the impact on
the practice of health-care volunteers returning from
disaster relief and the role of humanitarian organizations
in supporting and protecting their volunteers from developing stress-related disorders. By exploring the shared
2009 Blackwell Publishing Asia Pty Ltd

DS Walsh

experiences of relief workers after their return from a

humanitarian crisis, and identifying interventions, it is
hoped that organizations will incorporate these findings
into a re-entry programme to home and work.
The purpose of this review is to describe and synthesize
the research of the characteristics of the psychosocial
responses of relief workers and identify interventions that
reduce the occurrence and severity of PTSD following
these experiences. Specific aims of the review are (i) to
identify psychosocial effect of the experience of relief
work; (ii) and describe interventions that have been identified in reducing the severity of psychosocial disturbances
upon return. The implications for research are presented.

METHOD
Review methodologies proposed by Whittemore and
Knafl were used to analyse and synthesize research related
to relief work experiences and subsequent interventions.7
The framework consists of a clear identification of the
problem supported by a well-defined literature search,
data evaluation and analysis and synthesis of results. With
the assistance of a research librarian a thorough search was
undertaken using multiple medical/nursing, health and
social science journals, online sites, news sites, case
reports and unpublished manuscripts. All searches were
limited to English language publications. Exhaustive
searches of CINAHL, Ovid, Global Health Database,
PsychINFO, MEDLINE and REFWorks databases were
undertaken using the following key concepts: Tsunami,
relief workers, PTSD, humanitarian nursing, psychosocial impact of disaster care, natural disasters,
experience of disaster nursing, support after trauma.
Both an ancestral method of tracking information from
one citation to another as well as the descendency method
of gathering information based upon central topics were
used in the studies included in the review.8
Criteria for inclusion included: (i) those empirical
research studies that measured certain characteristics of
post relief work with scales or instruments; or (ii) the
qualitative research of the experiences of the workers in
their own voices. A total of 33 articles were reviewed
with 12 studies meeting the inclusion criteria. Jackson
suggests that an integrative review consist of a broad
stratum of data that can illustrate different interactions of
the characteristics of the research.9 The researcher concentrated on the humanitarian efforts of professional and
non-professional workers, and knowingly excluded military or national defence responses. A majority of the

Reducing Psychosocial Disturbances

research involved the response of survivors of disasters.

These studies were eliminated from the review.
Research reviewed included relief workers from professional and non-professional backgrounds, and both
natural and man-made disasters. Multiple research designs
and methods were represented in the twelve manuscripts.
Some of the methods were questionnaires with open and
closed question format, focus groups, case reports, interviews, thematic and content analysis, and quantitative
rating scales for specific diagnoses. A data collection tool
was designed to assist in analysing each research study.
Studies were thoroughly read and the following characteristics were identified and organized using an Excel
spreadsheet: the purpose of the study, the sample,
research methodology, procedure for data collection and
results. A table was developed with a concise description
of each of the characteristics (see Table 1). From this
table, a matrix was constructed to evaluate and synthesize
the results of the research studies using two
variablesthe quality of the methodology and the themes
that were identified. The purpose in grouping the studies
was to capture both the empirical results and the qualitative experiences of the workers, and identify shared points
of interests.
In reviewing the studies, results were extracted and
categorized, and a series of interrelated patterns emerged
describing the psychosocial responses of relief workers in
a disaster situation. Subgroups were identified and compared item by item. A one-page synopsis was constructed
of each study and commonalities were integrated into a
holistic description of the workers responses.
Validity is threatened in integrative research when
important details of the research studies are incorrectly
interpreted.8 To address this threat, the literature search
consisted of primary sources and an analysis strategy was
developed that synthesized information in an unbiased
method. A systematic, reliable coding procedure was used
to analyse and synthesize the information thereby ensuring
validity of results.7

RESULTS
Review of these 12 studies supports the value of integrating results from both qualitative and quantitative research
to synthesize a more complete understanding of the
combined research results. This review included three
quantitative studies, eight qualitative studies and one
mixed methodology study.

233

The research studies sampled were from a variety of

disciplines, disaster circumstances and sample groups.
The time frame ranged from 1984 to 2007 with diverse
locations of disasters researchedGermany, Sri Lanka,
Taiwan, Thailand, Turkey, New Zealand, Iran, Israel,
Australia and the USA. The sample group was also divided
between professional and non-professional workers,
including fire fighters, physicians, nurses, mental health
personnel, rescue workers and lay volunteers.
The inclusive sample from the twelve studies consisted
of a total of 1523 persons. A total of 332 (22%) participants had no prior experience working at disaster sites,
770 (50%) participants had professional experience
(health-care workers, fire fighters, rescue workers) and
421 (28%) participants were enlisted as a comparison
group in one research study. A data reduction model was
formatted to organize the characteristics of the experiences in the studies and integrate specific interventions
that were identified in the research (see Fig. 1). Three
interventions emerged that affected the responses of relief
workersdebriefing, team building and preparation.

Psychosocial effects
Workers who responded to the call to action in a humanitarian crisis exposed themselves to not only physical but
also psychological danger. The experience resulted in
highly reported sleep disturbances and nightmare,1012,15,18
and a marked increase in feelings of helplessness, anxiety
and increased arousal.5,14,15,18
Three studies reported a measurable range (24
63.6%) of participants exhibiting depressive symptomology. The self-rated DSM PTSD-IV Scale19 and Zung SelfRating Depression Scale20 was used by Fullerton et al.11 to
compare 207 disaster workers and a comparison group of
421 non-participating workers. The study reported 42%
of the exposed disaster workers at the crash of a commercial DC-10 airliner developed PTSD. The ClinicianAdministered PTSD Scale-I21 interview was administered
to relief workers returning from the tsunami in 2004 with
63.6% of the sample exhibiting at least one of the
reported symptoms.15 Guo et al.14 assessed relief workers
following an earthquake in Taiwan and determined that
24.6% of the volunteers (20% of professional verses 33%
non-professional) reported PTSD using the Chinese
version of the Davidson Trauma Scale22 and Startle, Physiological Arousal, Anger and Numbness Scale.23
It is important to note that one study followed workers
at high risk for developing PTSD year a 3-year period.12 A
2009 Blackwell Publishing Asia Pty Ltd

Purpose

Describe experience of
volunteer mental health
workers at brushfire
disasterphysical and
psychological responses

Investigate psychological
responses to thematic
stressworkers at air
show disaster

To investigate the
psychological impact of fire
fighters to traumatic stress

Investigate the
phenomenology of PTSD
Following natural disaster

To better plan for the

health of disaster
volunteers, researched
PTSD, depression in
disaster workers

Study occurrence of PTSD

in professional/
non-professional rescue
workers focusing
similarities/differences in
the groups

Author, year, place

Berah et al.,10 1984,

New Zealand

Brandt et al.,5 1995,

Germany

Fullerton et al.,11 1992,

USA

2009 Blackwell Publishing Asia Pty Ltd

McFarlane,12 1988,
Australia

Fullerton et al.,13 2004,

USA

Guo et al.,14 2004,

Taiwan

252 rescue workers (85

non-professional and 167
professional)

207 exposed disaster

workers and 421
unexposed comparison
group

45 firefighters from 315 at

high risk for developing
PTSD

2 groups of fire fighters

total 25 participants

252 respondents with 99

attending voluntary
debriefing sessions

19 workers from Prince

Henry Hospital,
Melbourne

Sample

Table 1 Published research articles involving the experience of relief workers

DTS-C Trauma Scale

SPAN-C

PTSD-IV and Zung

Self-rating Depression
Scale and comparison

Structured interview
GHQ, IES Scale

Debriefing groups

Descriptive studyopen
thematic analysis of case
studies

Questionnaire with open/

closed ended questions
thematic analysis

Method

On-scene workers were

offered psychological
debriefing, followed by a
questionnaire

Both groups examined at

2, 7 and 13 months after
disaster

Interview firefighters who

worked at bushfires at 8-,
11- and 29-month intervals

Case reports developed

from 8 debriefing sessions

6 weeks after the disaster

questionnaire distributed
with debriefing session held
1 week after returning
questionnaire

4 weeks after working at

disaster site, questionnaire
completed and
anonymously returned

Procedure

Rescue workers, even

those trained, experience a
higher level of stress,
leading to mental health
problems

Disaster workers increased

rate of PTSD, depression,
seek medical assistance at a
higher rate

Pattern of chronic and

disabling PTSD with
attention disturbances, or
panic symptoms in 16 of
50 firefighters

4 characteristic
responseshelplessness,
guilt, fear of unknown,
identify with the victims

Feelings of helplessness and

guilt, and camaraderie
among workers
debriefing session helped
integrate experience

Team felt shocked, tired,

helpless, stressedused
debriefing methods offered
in community

Results

234
DS Walsh

To explore the experience

of disaster relief in the
Bam earthquake as seen
from Iranian nurses

Identify beliefs, concerns

of RNs working in
hospitals designated as
receiving sites during
emergencies

Describe the perception,

reaction, feelings of RNs
who care for victims of
terrorist attacks, and
recommend policy for RN
trauma training

Nasrabadi et al., 162007,

Iran

OBoyle et al.,17 2006,

Minnesota, USA

Riba and Reches,18 2002,

Israel
60 RNs from the ED,
OR, ICU and Imaging
departments

33 hospital RNs who

work in ED or critical
care units at least 8 h
every 2 weeks, employed
6 months

13 Iranian RNs with BSN,

2 weeks experience as
RNs during Bam disaster,
and 12 years clinical
experience as RNs

33 team members

Ongoing and summative

content analysis were
used to develop and
refine themes

Qualitative study using

focus groups

Qualitative,
semi-structured serial
interview analysed by
latent content method

CAPS-1 PTSD Interview

scale

Focus groups met on 4

occasions, and staff were
asked to describe their
experiences. Responses
were recorded

Focus groups of 29 met

during coffee breaks or
lunch for 3045 min
discussing concerns, coping
mechanisms to function
during a crisis

Each nurse was

interviewed for 4590 min
and tape-recorded. An
interview guide was used
to focus the interview

Interviews performed by
after tsunami

RNs described 4 stages of

involvementcall up of
staff to the hospital,
waiting for casualties,
treating victims and
incident closure. Need to
broaden RN training and
caring for caregivers.
Frustration, guilt and
depression were described

RNs felt unready to cope

with bioterrorism, felt an
increased loss of control,
loss of freedom, decreased
safety, concern of
abandonment by hospital,
no freedom to leave,
insufficient protective
equipment

3 themes emerged: need

for prepared protocols,
teambuilding and establish
comprehensive training
programmes in disaster
relief nursing.

PTSD diagnosed in 24.2%

participants with > 3
experiences

BSN, Bachelor of Nursing; CAPS-1, Clinician Administered PTSD Scale-1; DTS-C, Chinese version of the Davidson Trauma Scale; ED, emergency department; GHQ, General Health
Questionnaire; ICU, intensive care unit; IES, Impact of Event Scales; OR, Operating Room; PTSD, post-traumatic stress disorder; RN, registered nurse; SPAN-C, Startle, Physiological
Arousal, Anger and Numbness Scale.

Identify PTSD in relief

workers after tsunami in
Asia

Armagan et al.,15 2006,

Turkey

Reducing Psychosocial Disturbances

235

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236

DS Walsh

Data Reduction Model

Psychosocial factors
Physiological changes
Preventative measures
Attention deficit
Voluntary session

Debriefing

Seek emotional care

Social support
Cognitive integration of
the experience
Develop emotional ties
to victims

Relationship with peers

Emotional distancing
Effective communication
Bond with co-worker
Alliance among workers
Need for centralized
leadership

Coordination of workers

Importance of infrastructure

Seamless care

Team building

Utilization of volunteers

React in precise manner

Gaps in medical/nursing
education
Culturally appropriate
Formal education
Preplanned protocols
Leadership training

Preparation

Clinical/resource readiness
Institutional support
Fear of abandonment
Commitment
Clear chain of command

Figure 1. Data reduction model.

pattern of chronic and disabling PTSD emerged within the

group emphasized by attention disturbances, panic symptoms and nightmares. The fact that attention deficit was
noted at the 8-month mark and also as late as 42 months
accentuates the need for ongoing intervention if the
severity of the effects of relief work is to be reduced.
Qualitative studies included focus groups with registered nurses after terrorist attacks in Israel,18 interviews
with firefighters after two Australian brushfires10,12 and
descriptive studies following an air show crash.5
Although the psychosocial responses from the workers
were consistent in all the research studies, the circumstances surrounding each crisis were different. The
2009 Blackwell Publishing Asia Pty Ltd

responses by the staff in the focus groups further

described burnout and frustration, guilt and anxiety over
surviving.18 Mental health workers interviewing the individuals and families working at the bushfires reiterated
the emotional toll on workers as reported including
shock and confusion.
The act of emotional distancing is an adaptive process
that disengages workers from the experience at hand.
Distancing places the workers at risk for exhaustion as
they continue to function as an uninvolved person. Three
studies noted an increase in stress levels of workers after
instinctively divorcing themselves from the situation.5,11,18
After the patients were cared for, the staff turned their

Reducing Psychosocial Disturbances

emotions back on, and reported a need to verbalize their

experience.

Debriefing as an intervention
The need for preventative interventional measures11 was
described in the forms of voluntary sessions and meetings
offered by organizations,11,18 as well as participants
seeking emotional care and social support on their
own.10,13,24 Post-tsunami workshops in Sri Lanka utilized
the concept of support groups by focusing on training
local young adults who were indigenous to the villages to
conduct debriefing sessions.25 Although no formal measurement was obtained after the programme, there was a
positive reception of the education component of the programme, which included information related to growth
and development, substance abuse and suicide. Feedback
consisted of verbal reports and observations from the
coordinators and the project directors.
The use of support groups to cognitively integrate the
experience was also described by Fullerton et al.11 in a
study involving an airplane crash in Iowa and fire in New
York City. Social support after the situations and the
opportunity for workers to share their experiences were
seen as important. Relief workers reported developing
emotional ties to the victims.5,11 When workers felt an
emotional connection with the victims, they began to
visualize themselves or their family members as victims.
This process placed the workers at risk for exhaustion as
they continued to try to function as an uninvolved person,
and increased the stress of working at the disaster site.
A summation of the individual themes was formulated
into three subgroups: preventative measures, voluntary
sessions and social support (see Fig. 1). A higher level of
abstraction resulted in the general intervention of debriefing. Debriefing offered a venue for ventilating emotions
and reduced the impact of the stress on relief workers
lives.10

Team building as an intervention

Effective communication and coordination of workers
was underscored throughout the research for its importance in reducing the severity of psychosocial adjustment.
The relationship one held with their peers,11,14 and the
development of bonds with co-workers,5,15 were positive
experiences and fostered an alliance among the workers.
There was a dichotomy between the joy in taking care
of people and the poor teamwork among the medical
people managing the situation during an earthquake in

237

Iran.16 The lack of trained leadership made the coordination of the workers, especially from other countries, very
difficult. This resulted in ineffective outcomes for the
patients. Communication of a clear and simple plan was
paramount to the survival of victims.24 This communication entailed not only the relationship between the
workers, but also addressing the gaps in nursing education
regarding emergency response, building a relationship
between government organizations and hospital administrators to ensure seamless care after a disaster, and
improving the infrastructure within the hospital system to
address team training and responsiveness.16,18,24 Research
following the tsunami in Thailand illustrated a wellorganized procedure for handling the treatment and
evacuation of victims from a small rural area.24 The case
study suggested that the success of this relief effort was
attributed to the effective communication from the
medical director, the efficient use of volunteers as they
appeared on the scene to help, and the coordination of
scarce resources in treating the patients.
The intervention of team building was found to consist
of the relationship workers held with their peers and
leaders, and the ability to deliver care to the victims in a
coordinated fashion (see Fig. 1). Fostering alliances and
coordinating with co-workers resulted in the seamless
delivery of care, and factored into the concept of team
training as an important intervention in relief work.

Preparation as an intervention
The concept of preparing not only relief workers but also
organizations for the unplanned emergency situation was
found to positively impact the response of workers. The
commitment of the organization to assure support to staff
during a time of social unrest and panic with a clear chain
of command was considered by workers to be extremely
important in reducing stress levels.10,1618 Staff reported a
high level of anxiety in not knowing what the potential
danger could be to themselves and their families, yet they
professed a sense of commitment to care for and protect
the patients during a crisis.10,1618
Clinical skill development and the ability to function at
a high level of expertise reduced workers feelings of
anxiety, fear and anticipation.11,18 Formal education in
trauma and disaster management in nursing school
curriculums, development of preplanned protocols and
ongoing inservice training to prepare nurses for the
demands of caring for disaster victims were reported in
several studies.17,18,24,25 Miller noted the importance of
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DS Walsh

culturally appropriate training and support programmes

in a study post-tsunami in Sri Lanka.25 Workers were
involved in overseeing support groups for the survivors of
the tsunami. Preplanning for worker/client response is
paramount for the success of any relief activity. Communities embraced the concept of support groups, but the
impact could have been greater had the planning focused
on local cultural beliefs and less on utilizing Western
suppositions.
Workers reported a definite fear of abandonment, both
by their institution and governments.17,18 It is important to
realize that the staff who are prepared for the unplanned
emergency can be as stressed as the first responder.
Although hospitals had readiness plans in place, the staff
did not perceive the institutions as having the ability to
sustain them during a disaster, lacking the infrastructure
to support staff during any crisis situation. The role of the
charge nurse was identified as crucial to the success of the
staff. Specific leadership training should be directed to
those in the role of charge nurse.17,18
The individual themes that were found to be the framework of the intervention of preparation included the
importance of training, development of protocols and
institutional support as evidenced by staff clinical readiness. Integrating these themes resulted in the major concepts involving the importance of a functioning chain of
command, need for formal education in leadership training, and institutional support to staff to reduce the anxiety
of the work expected of them under trying conditions
(see Fig. 1).

DISCUSSION
Synthesis of results
Disaster relief poses not only physical but also psychosocial danger to participants. Empirical research has examined the effect on workers and reported a marked increase
in PTSD, depression and stress disorders. These responses
were exhibited in sleeping, eating and drinking disorders,
feelings of frustration and sadness, and inadequacy. One
cannot focus only on the detrimental effects of assisting in
relief efforts. From these experiences workers were able
to empower individuals to help themselves through teaching, feel the joy in helping others, and realize a deep
commitment and compelling need to respond. This altruism and dedication was a guiding force in keeping workers
motivated when conditions were at times difficult.
Debriefing is a mechanism that enables workers to elicit
the feelings and responses that result from the experience.
2009 Blackwell Publishing Asia Pty Ltd

It offers a supportive network for workers to reconstruct

their experiences and verbalize their thoughts and feelings
and reduce the impact on their lives.
Decreasing the psychosocial effects of relief work
centres around the importance of adequately training
relief workers prior to undertaking an assignment. This
should include the development of curricula for education
and training in disaster preparedness, triage systems,
teamwork and adjustment to the scope of devastation that
can result from a humanitarian crisis. Workers must form
a cohesive team that is in control of the environment and
cognizant of team skills and hierarchy of command. There
should exist a level of confidence within the organizational
infrastructure that staff will have sufficient supplies to
support their efforts. Maintaining control with open communication is key to the success of any relief project.
For workers to react effectively there should be clear
and concise disaster plans further underscoring the importance of preparing for a disaster. The development
of a documented chain of command, training and safety
protocols, exit strategies, location and procurement of
supplies and the process for mobilizing, inter-agency
agreements, volunteer and governmental relations, and a
national policy for disaster response will contribute to
providing for future safety of workers.
Based on the results of this review there is a gap in the
education of the volunteer and professional responders to
disaster situations. Trauma training and disaster management should not only be included in the curriculum of
nursing, medical school and professional responder
courses, but in volunteer organization orientation
programmes. Ongoing disaster training in hospitals and
governmental agencies should be a mandatory competency to assure that clinical skill level, as well as organizational and management skills, are maintained at a high
level of responsiveness.
The relationship between government agencies and
health-care institutions must assure a seamless plan of care
for victims, and supportive services for the staff. The
development of clear and simple disaster plans using the
tenets of team training is necessary for an organized
response to a crisis. The staff should be assured that they
will have the full support of the organization at a time of
social unrest. The availability of psychosocial support
services post disaster has been shown to decrease the
negative effects of relief work.
Communication is the commonality throughout the
process of disaster relief. It is key in preparing for a crisis,

Reducing Psychosocial Disturbances

maintaining availability of support and supplies required

to care for patients during the situation, and assuring that
relief workers are cared for physically and psychologically
post crisis.
In the wake of the terrorist attack on the Twin Towers
in New York City on 11 September 2001, there has been
an emphasis on research regarding disaster relief and the
effect on workers both physically and psychologically.
Dionne reviewed the support systems provided by the
Emergency Medical System in New York following 911,
and through the voice of the responders discovered the
inadequacy of the support systems.26 Inconsistent critical
incident debriefing, lack of counselling support systems,
and punitive responses to behavioural issues were
reported by members of an emergency system recognized
as a leader in disaster training with the availability of the
best resources in the country.26

CONCLUSION
In summary, it is suggested that because of the high level
of PTSD reported post disaster work, it is imperative that
governmental and non-governmental agencies consider
the psychological consequences and costs of rescue
work.
Predisaster training, evaluation and teaching of volunteers, as well as ongoing support post disaster might
reduce the frequency or severity of developing PTSD.
Organizations with the mission to participate during
humanitarian crises should continue to research the experiences of workers. Proper education and training regarding working with teams, multicultural immersion prior to
leaving for a humanitarian mission, combined with a
support network upon return, will optimize the performance of the workers, as well as ease re-entry into their
lives at home.

Implications for practice

Relief workers and humanitarian volunteers will continue
to face the challenge of caring for people in the most
extreme circumstances. It is the responsibility of the professions of nursing, emergency care and medicine, and
those humanitairian organizations that have taken on the
role of responding to these situations to properly prepare
and subsequently care for their members. Formal education and clinical readiness and support, specific curricula
in disaster management, training in teamwork and proper

239

utilization of volunteers and a social support framework

have been shown to have an effect on the development of
PTSD.
Further research is warranted on this topic to continue
to determine the long-term effects on workers of witnessing the devastation of a natural disaster. The integrated
review is a method that synthesizes diverse sources into a
holistic understanding of a particular event.7 Disaster
research pertains to all cultures, all circumstances and the
key concepts should continue to be identified to assist in
caring for those workers and expanding the knowledge
base to further delineate cultural differences.
It would be helpful to expand the research to include
indirect or vicarious trauma as reported by those who
support the victims of relief work. Vicarious trauma is the
result of cumulative exposure exposed to the trauma
stories from others, not experiencing the trauma oneself.
Clark and Gioro (1998) researched nurses and indirect
trauma and reported that the steps for prevention of
developing chronic and long-term PTSD included
acknowledging that it can occur, connecting and talking
with other nurses.27 These findings concur with the findings of this review. Humanitarian aid and disaster relief
organizations have recognized vicarious trauma as one of
the more serious occupation hazards experienced by their
staff, both in the field and in the home office.28 Healthcare and humanitarian organizations should take a proactive approach to providing assistance and, through further
research, analyse its effects in order to lessen its impact on
those who assist in humanitarian relief work.

REFERENCES
1 World Health Organization. Tsunami Situation Reports.
Available from URL: http://www.who.int/hac/crises/
international/asia_tsunami/sitrep/en/. Accessed 2006.
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