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Working conditions, mental health and coping of staff in social work with refugees and homeless individuals: A scoping review

2019; Wiley; Volume: 27; Issue: 4 Linguagem: Inglês

10.1111/hsc.12730

1365-2524

Tanja Wirth, Janika Mette, Jerrit Prill, Volker Harth, Albert Nienhaus,

Geriatric Care and Nursing Homes

Health & Social Care in the CommunityVolume 27, Issue 4 p. e257-e269 REVIEW ARTICLEOpen Access Working conditions, mental health and coping of staff in social work with refugees and homeless individuals: A scoping review Tanja Wirth, Corresponding Author Tanja Wirth t.wirth@uke.de orcid.org/0000-0001-6762-4430 Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany Correspondence Tanja Wirth, Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany. Email: t.wirth@uke.deSearch for more papers by this authorJanika Mette, Janika Mette Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorJerrit Prill, Jerrit Prill Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorVolker Harth, Volker Harth Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorAlbert Nienhaus, Albert Nienhaus Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany Department of Occupational Medicine, Hazardous Substances and Public Health (AGG), Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, GermanySearch for more papers by this author Tanja Wirth, Corresponding Author Tanja Wirth t.wirth@uke.de orcid.org/0000-0001-6762-4430 Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany Correspondence Tanja Wirth, Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany. Email: t.wirth@uke.deSearch for more papers by this authorJanika Mette, Janika Mette Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorJerrit Prill, Jerrit Prill Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorVolker Harth, Volker Harth Institute for Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, GermanySearch for more papers by this authorAlbert Nienhaus, Albert Nienhaus Competence Centre for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany Department of Occupational Medicine, Hazardous Substances and Public Health (AGG), Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, GermanySearch for more papers by this author First published: 01 March 2019 https://doi.org/10.1111/hsc.12730Citations: 36 Funding information This work was supported by the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), Hamburg, Germany. The funds were provided by a non-profit organisation that is part of the social security system in Germany. The funder had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract The refugee and homeless population has been increasing worldwide in recent years. Staff in social work provide practical help to these populations, but often struggle with high job demands. This scoping review aims to systematically map the job demands, resources, mental health problems, coping strategies and needs of staff in social work with refugees and homeless individuals. Relevant studies were identified by searching seven electronic databases from their inception until the end of May 2018, as well as Google Scholar and reference lists of included articles. The methodological quality of the included studies was assessed using the Mixed Methods Appraisal Tool. A thematic analysis was conducted. Twenty-five studies were included in the review. Fourteen studies followed a quantitative approach, six a qualitative approach and five a mixed-method approach. Most studies were conducted in the homeless sector (56%), in North America (52%) and published after the year 2009 (68%). Common job demands included the bureaucratic system, high caseloads, clients' suffering and little experience of success. Maintaining professional boundaries counted both as a job demand and a coping strategy. Deriving meaning from work and support from the team were identified as important job resources. The prevalence of mental health problems among staff was high, but difficult to compare due to the use of different instruments in studies. Staff expressed a need for ongoing training, external counselling and supervision. Further studies should examine the effectiveness of workplace health interventions. What is known about this topic The numbers of refugees and homeless individuals have recently been increasing worldwide, leading to a need for qualified staff in social work providing practical help to these highly vulnerable client groups. Staff in social work with refugees and homeless individuals may face particular job demands, as their clients often suffer from serious traumatic experiences. What this paper adds Encountering client's suffering and the inability to change the situation of clients was specifically demanding for staff in social work with refugees and homeless individuals. Staff had good job satisfaction regardless of mental health problems. The effectiveness of workplace health interventions aimed at reducing job demands and strengthening job and personal resources should be further investigated. 1 INTRODUCTION Flight and homelessness are increasing social problems today. The number of refugees worldwide is at the highest level ever recorded. By the end of 2017, 25.4 million refugees were counted (UNHCR, 2018). Homelessness has considerably increased during recent years in almost all countries of the European Union (FEANTSA & Fondation Abbé Pierre, 2018). In the course of these developments, the need for qualified staff in social services in countries such as Germany has increased considerably, especially in the area of refugee aid (Filsinger, 2017). Staff in social services such as reception centres, emergency shelters, counselling centres and outreach and drop-in services provide a variety of social work activities to refugees or homeless individuals. Amongst others, they support them in legal matters, in preparing applications, in finding accommodation, accompany them to local authorities and refer them to further assistance (Filsinger, 2017; Kosny & Eakin, 2008). The structure of staff, their professional education and their specific work tasks differ between services and countries. In this review they are further described under the collective term ‘staff in social work’ and it is aimed to examine their working conditions as a whole. This review follows two different theoretical models, namely the Job Demands-Resources model (J-DR model; Bakker & Demerouti, 2007) and the Transactional Model of Stress and Coping (Lazarus & Folkman, 1984). The J-DR model assumes that every occupation has its own specific job resources and demands. These can refer to areas such as the organisation of work, the job content, the social relations or the physical work environment. The model further assumes that available job resources have a motivational potential and can lead to engagement, while job demands are associated with employees' strain and the development of health problems (Bakker & Demerouti, 2007). The Transactional Model of Stress and Coping describes how people try to manage and cope with demands they perceive as stressful. The model assumes that coping has two functions: one refers to regulating emotional distress caused by a stressful situation (emotion-focused coping) and one refers to solving the problem (problem-focused coping; Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986; Lazarus & Folkman, 1984). Studies have examined the job resources and demands of social workers in various fields of work. Some general resources and demands for social work can be derived from these studies. On the one hand, social workers find reward in helping others, are committed to their workplace and perceive their social support from colleagues and supervisors as high (Drüge & Schleider, 2016; Stalker, Mandell, Frensch, Harvey, & Wright, 2007). On the other hand, they struggle under permanent changes in social policy and legislation, restricted financial resources and limited control and decision latitudes (Lloyd, King, & Chenoweth, 2002). In a study sample of social workers from the Nordic countries, 42% experienced heavy workloads and 45% major role conflicts (Blomberg, Kallio, Kroll, & Saarinen, 2015). German social workers perceived their quantitative demands (mean [M] = 62 vs. 55) and emotional demands at work (M = 69 vs. 52, both p < 0.001) higher than other professionals did (Drüge & Schleider, 2016). In accordance with the J-DR model, job resources such as finding reward, commitment and a sense of community were associated with job satisfaction, while high workload, role ambiguity and bureaucratic working conditions were associated with burnout (Beckmann, Maar, Otto, Schaarschuch, & Schrödter, 2009; Söderfeldt, Söderfeldt, & Warg, 1995; Yürür & Sarikaya, 2012). Accordingly, studies found that social workers experienced above-average levels of burnout (Borritz et al., 2006; Lloyd et al., 2002). The use of coping strategies was found to buffer the effects of work stress on burnout variables and job satisfaction in social work samples (Stalker et al., 2007). Anderson (2000) found that if child protection workers used active coping strategies such as problem solving more, it lessened their feelings of depersonalisation and increased their sense of personal accomplishment. Refugees and homeless individuals represent highly vulnerable client groups who often suffer from traumatic experiences. Refugee aid workers and staff in shelters for the homeless reported that about 40%–60% of their clients were traumatised (Pell, 2013; Schutt & Fennell, 1992). These numbers indicate that staff in social work with refugees and homeless individuals are likely to be exposed to the serious traumatic histories of their clients. It is known that professionals working with traumatised clients are susceptible to secondary traumatic stress, also described as vicarious traumatisation or compassion fatigue (Figley, 1995). These concepts refer to the negative impacts of indirect trauma exposure, leading to symptoms of intrusion, avoidance and arousal (Figley, 1995; Molnar et al., 2017). So far, literature reviews have focused on stress, burnout, job satisfaction or resilience in child welfare workers (McFadden, Campbell, & Taylor, 2015; Stalker et al., 2007), mental health social workers (Coyle, Edwards, Hannigan, Fothergill, & Burnard, 2005) or in unspecified fields of social work (Lloyd et al., 2002; Söderfeldt et al., 1995). Although it can be assumed that staff in social work serving refugees and homeless individuals may face particular demands in their work with clients, little is known about their specific working conditions and potential strain. To the best of our knowledge, this is the first study which aims to systematically map the existing literature about the job demands, personal and job resources, mental health, coping strategies and needs of staff in social work serving highly vulnerable client groups (refugees and homeless individuals). By this, the review aims to identify existing gaps in the literature and to create a basis for the development of specific health promotion measures for employees in this field of work. 2 METHODS A scoping review was conducted because it allows to answer wider research questions and to include studies with a variety of study designs. This review followed the framework introduced by Arksey and O'Malley (2005). 2.1 Stage 1: Identifying the research questions This scoping review addressed the following research questions. All of them refer to staff in social work with refugees and homeless individuals. What job demands and job and personal resources of this staff are described in the literature? How prevalent are mental health problems among this staff? Which demands and resources are associated with the mental health of this staff? What coping strategies are adopted by this staff in handling their perceived job demands? What kind of interventions and needs for improving the work and health situation of this staff are known from the literature? 2.2 Stage 2: Identifying relevant studies Relevant studies were identified through an extensive search in the following seven electronic databases: PubMed, MEDLINE, PsycINFO, PSYNDEX, CINAHL, Web of Science and SOWIPORT. All databases were searched from their inception until the end of May 2018, except for SOWIPORT which was searched only until December 2017 because the database was closed after that. English search terms were combined which referred to the population, exposure (field of work and client group) and outcome. The search strategy was initially developed for the PubMed database and then converted to all other databases (see Table S1). To identify any further relevant studies, Google Scholar was searched, first, combining the terms (“refugee” or “asylum seeker” or “homeless”) and (“worker” or “professional” or “staff”) and (“demands” or “resources” or “mental health”) and, second, combining German translations of these terms. The first 100 hits, sorted according to their relevance, were screened in Google Scholar. Four potentially relevant studies published in English and two published in German were identified. Finally, reference lists of all articles included after the full text screening were searched by hand. 2.3 Stage 3: Study selection The study selection was based on predetermined inclusion and exclusion criteria. The review included studies conducted on staff engaged in social work activities who offered practical help and support to refugees or homeless individuals and had direct contact with these clients. If studies involved besides staff with social work activities, also other occupational groups of an organisation (e.g. administrative staff), these were also considered for this review. Studies which solely focused on voluntary workers or clinical social workers/therapists were excluded, as well as studies which were conducted in war and crisis areas. Studies were included when they reported results on the main outcomes of interest such as job demands, jobs and personal resources, mental health, coping and workplace health interventions. Observational studies, qualitative and mixed methods research designs and intervention studies were included in the review. Reviews, letters, editorials, conference papers, commentaries, reflections, policy statements and books were not considered. Full texts had to be published and made available in languages the research team was capable of (English, German, French, Spanish, Italian, Portuguese and Turkish). The title and abstract screening was conducted by one reviewer (TW). Titles/abstracts for which no decision could be made by the reviewer (N = 23) were discussed with the research team. Full texts of studies were screened independently by two reviewers (TW and JP). Whenever different decisions about inclusion or exclusion were made, these were discussed in the research team until consent was reached. The inter-rater reliability was measured by Cohen's kappa statistics. 2.4 Stage 4: Charting the data Data from the included studies were extracted by one reviewer (TW) and verified by a second reviewer (JM). At first, general information on authors, year of publication, country, publication type, aims and objectives, study design, population, exposure, outcomes and data collection instruments were extracted from studies into a standardised Excel® spreadsheet. Then, key findings of studies were also charted using a standardised Excel® spreadsheet according to the different research questions. The following major categories were deductively developed: demands and resources (with subcategories: organisation of work, job content, social relations, work environment, personal factors), mental health, coping strategies and interventions and needs. Key findings from qualitative components of studies were coded to these categories using auxiliary qualitative software (MAXQDA version 11). For one study, additional information on findings were requested from the author (Sundqvist, Hansson, Ghazinour, Ogren, & Padyab, 2015). 2.5 Stage 5: Collating, summarising and reporting the results The charted characteristics of the studies were summarised descriptively, including the calculation of frequencies, and presented in tables. A thematic analysis was conducted using qualitative data analytical techniques, as suggested by Levac, Colquhoun, and O'Brien (2010) to organise and summarise the findings of the studies. Findings related to the study questions were reported narratively and in a table according to the major categories and subcategories. 2.6 Quality assessment The application of a quality assessment in scoping reviews is still under discussion (Arksey & O'Malley, 2005; Levac et al., 2010). Daudt, Mossel, and Scott (2013) recently recommended adding this stage into the framework. In this scoping review, we sought to make statements on the methodological depth of the existing literature. Therefore, two reviewers (TW and JM) independently assessed the methodological quality of the included studies using the Mixed Methods Appraisal Tool (MMAT; Pluye et al., 2011). Differing results were discussed until consent was reached. The inter-rater reliability was measured by Cohen's kappa statistics. 3 RESULTS Overall, 2,162 records were screened in accordance with the inclusion and exclusion criteria. A total of 2,116 records were excluded and 46 full texts were assessed for eligibility. Finally, 25 studies were included in the scoping review (Figure 1). A good inter-rater agreement for the full text screening was reached between the two reviewers (Cohen's Kappa = 0.73). Figure 1Open in figure viewerPowerPoint PRISMA flow chart of the study selection process 3.1 Study characteristics Characteristics of the 25 studies are described in Table 1. Of the 14 studies in the homeless sector, five examined agency staff, three were conducted in community programs, two in homeless shelters and four included several settings. Eleven studies examined professionals working with refugees. Seven of these studies were conducted at agencies or service centres, one at non-governmental organisations, one at reception centres, one examined participants of a training course and one included several settings. Three studies involved the same sample of social workers who served unaccompanied refugee children due for forced repatriation (Sundqvist, Ghazinour, & Padyab, 2017; Sundqvist et al., 2015; Sundqvist, Padyab, Hurtig, & Ghazinour, 2017). Some studies did not only include staff in social work, but also other occupational groups, such as administrative staff, nurses, directors or paraprofessionals. In all but one study, the majority of participants were female (54%–84%). Five studies did not report gender distributions. Only one study had a longitudinal design and was intervention-based (Chapleau, Seroczynski, Meyers, Lamb, & Haynes, 2011). For detailed study characteristics, please see Table S2. Table 1. Overview of characteristics of included studies (N = 25) Characteristics n % Study approach Quantitative 14 56 Qualitative 6 24 Mixed methods 5 20 Continent of study North America 13 52 Europe 9 36 Asia 1 4 Australia 1 4 Australia and Europe 1 4 Year of publication 2010–May 2018 17 68 2000–2009 4 16 1990–1999 3 12 <1990 1 4 Publication type Journal article, peer reviewed 20 80 Thesis or dissertation 3 12 Journal article, non-peer reviewed 1 4 Study report 1 4 Client group Homeless individuals 14 56 Refugees 11 44 3.2 Demands and resources reported by participants in the included studies In qualitative interviews and surveys, study participants reported job demands which they perceived as negative or lead to feelings of frustration and stress, as well as a variety of job and personal resources which helped them to stay passionate and positive about their jobs. We assigned these demands and resources to the categories of organisation of work, job content, social relations and personal factors; none were identified in the context of the work environment. 3.2.1 Organisation of work Five studies found that working in a bureaucratic environment was a job demand for staff in social work in the refugee and homeless sector. In particular, staff perceived the welfare system as unfair and limiting their possibilities to help their clients, for example due to poor financial resources. They also reported difficulties in accessing mainstream services and in dealing with other agencies (Guhan & Liebling-Kalifani, 2011; Kidd, Miner, Walker, & Davidson, 2007; Kosny & Eakin, 2008; Robinson, 2014). Francis (2000) explicitly noted contradictions between the bureaucratic system and client needs, which led to role conflicts faced by case managers for the homeless. Three studies further mentioned low pay as causing financial stress to staff in the refugee and homeless sector (Hagen & Hutchison, 1988; Kidd et al., 2007; Robinson, 2014). Some further job demands were only named in studies concerning the refugee or homeless sector. Two studies of caseworkers working with homeless individuals identified excessive paperwork and documentation as a job demand (Chapleau et al., 2011; Sutton-Brock, 2013). Being employed only on short-term contracts and dealing with rapid changes in policies were described as challenges for frontline refugee workers (Robinson, 2014). Only one study identified a job resource in the context of the organisation of work. Some caseworkers in a homeless shelter perceived their unconventional working hours as a benefit, allowing for greater flexibility (Sutton-Brock, 2013). 3.2.2 Job content With respect to staffs' job content, a high caseload was named in five studies as a relevant job demand. In a cross-sectional survey, one fourth of caseworkers in a homeless shelter regarded their caseload as too high (Sutton-Brock, 2013). In qualitative interviews, staff reported heavy and increasing workloads and caseloads. As a consequence, they worked overtime, felt a lack of control over clients and were concerned about a diminished quality of service (Chapleau et al., 2011; Guhan & Liebling-Kalifani, 2011; Robinson, 2014; Sutton-Brock, 2013). Another demand identified was a low decision latitude and low control. In a German survey, 60% of refugee aid workers reported having low control at work, mainly due to legal regulations (Grimm et al., 2017). Further studies found that caseworkers for the homeless were concerned about having little or no impact on management's decisions (Chapleau et al., 2011; Sutton-Brock, 2013). Four studies in the refugee sector and three studies in the homeless sector identified encountering clients' suffering and regularly hearing clients' stories and traumatic experiences as a major demand (Ferris et al., 2016; Grimm et al., 2017; Guhan & Liebling-Kalifani, 2011; Kidd et al., 2007; Kosny & Eakin, 2008; Lusk & Terrazas, 2015; Robinson, 2014). The inability to change the situation of their clients or the little success staff experience in their work were also frequently reported (Chapleau et al., 2011; Kidd et al., 2007; Lusk & Terrazas, 2015; Robinson, 2014; Sutton-Brock, 2013). Furthermore, ethical questions played a role: in one study, staff members of a refugee centre experienced distress caused by moral dilemmas in situations in which they became aware of unlawful behaviour of their clients (Guhan & Liebling-Kalifani, 2011). Similarly, youth workers in ‘zero-tolerance’ agencies for the homeless perceived themselves to be in an ethically questionable position when they had to discharge youth onto the streets for minor infractions (Kidd et al., 2007). Other demands concerning the job content were more specific to the refugee or homeless sector. Lakeman (2011) conducted in-depth interviews with homeless sector workers having served people who had subsequently died. Particularly stressful to these workers were sudden and unexpected deaths, deaths caused by overdose, suicide or homicide and being witness to the death of a person or the dead body. Two studies from the refugee sector identified language barriers in the communication with clients (Grimm et al., 2017; Guhan & Liebling-Kalifani, 2011). About half of the refugee aid workers participating in a German cross-sectional survey reported communication problems as a distress factor (Grimm et al., 2017). On the other hand, it was noted in a variety of studies that working in the refugee and homeless sector strongly supported staffs’ beliefs, values and interests (Guhan & Liebling-Kalifani, 2011; Kidd et al., 2007; Robinson, 2014). Furthermore, they could derive strong meaning from their work (Ferris et al., 2016; Kidd et al., 2007; Robinson, 2014). In a cross-sectional survey of service providers for the homeless population, 65% believed that their work positively influenced people's lives, and 83% felt at least moderately successful in their work with clients (Hagen & Hutchison, 1988). Similarly, among caregivers working with refugees, all participants reported being proud of their work and 90% gained satisfaction from helping people (Lusk & Terrazas, 2015). Two studies found that seeing change in refugees and homeless individuals and receiving their gratitude was most rewarding to staff in social work (Guhan & Liebling-Kalifani, 2011; Kidd et al., 2007). 3.2.3 Social relations Demands and resources in the context of social relations were connected to clients as well as to colleagues and supervisors. One of the main job demands for staff in social work was to maintain professional boundaries with their refugee and homeless clients, as they often felt personally responsible for them (Guhan & Liebling-Kalifani, 2011; Kidd et al., 2007; Kosny & Eakin, 2008; Mowbray, Thrasher, Cohen, & Bybee, 1996; Robinson, 2014). One study reported that staff were taking risks to help their clients. This included seeing clients in unfamiliar places or interacting with drug dealers (Kosny & Eakin, 2008). Some qualitative studies also found that staff struggled with unrealistic demands from clients and encountered violent and aggressive behaviours by clients (Guhan & Liebling-Kalifani, 2011; Kidd et al., 2007; Kosny & Eakin, 2008). Among a sample of refugee aid workers, 27% perceived aggressive behaviour by clients as a distress factor (Grimm et al., 2017). Other job demands were only reported in studies concerning the refugee or homeless sector. Two studies from the homeless sector mentioned problems with supervisors and colleagues. Chapleau et al. (2011) found that case managers were frustrated about the little support and recognition they received from direct supervisors and management. Kidd et al. (2007) noted that high turnover of staff in agencies for homeless youth disrupted collaborative work within the team. In three studies, refugee workers struggled with negative reactions from family, friends or the general public towards their work. Specifically, they reported a lack of understanding from others in relation to their work and feelings of isolation (Guhan & Liebling-Kalifani, 2011; Lusk & Terrazas, 2015). Moreover, they described discrimination and racism by mainstream providers and members of the public and even physical attacks on themselves by members of the public (Robinson, 2014). In most studies, support from the team was mentioned as an important job resource concerning social relations (Ferris et al., 2016; Kidd et al., 2007; Lusk & Terrazas, 2015; Mowbray et al., 1996). Kidd et al. (2007) noted that youth workers described the importance of a good leader in the development of a collaborative working environment. Among caregivers working with refugees, 81% reported that they felt supported by their supervisors (Lusk & Terrazas, 2015). 3.2.4 Personal factors Personal resources were only identified in a few studies. Two studies from the homeless sector reported a sense of humour as a personal resource which helped staff to relieve stress and frustration (Kidd et al., 2007; Mowbray et al., 1996). Kidd et al. (2007) further mentioned being able to connect to homeless youth as a personal resource. Two other studies found specific persona