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Effective methods for addressing psychological challenges among anesthesia providers returning from practice in austere environments: a literature review with professional recommendations
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Effective methods for addressing psychological challenges among anesthesia providers returning from practice in austere environments: a literature review with professional recommendations
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ANESTHESIA IN AUSTERE ENVIRONMENTS
Effective Methods for Addressing Psychological Challenges Among Anesthesia Providers
Returning from Practice in Austere Environments: A Literature Review with Professional
Recommendations
by
Cristina D. Flores Simons
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2024
ANESTHESIA IN AUSTERE ENVIRONMENTS
ii
The following manuscript was contributed to in equal parts by
Harry A. Ford, Cristina D. Simons, and Kali M. Wachter
ANESTHESIA IN AUSTERE ENVIRONMENTS
iii
Dedication
We would like to dedicate this work to the uncountable and un-trackable selfless
individuals who lend their hearts and hands to help those in need. While the literature may have a
hard time tracking the efforts made by healthcare volunteers, each individual life transformed by
their care is a living testament.
We hope that through our small effort, a light can begin to shine on the mental health and
wellness needs of the giver, so that they may continue giving.
ANESTHESIA IN AUSTERE ENVIRONMENTS
iv
Acknowledgements
Our research team would like to acknowledge Dr. Joshua Carr and Dr. Elizabeth
Bamgbose for their guidance, expertise, and patience. This project would not have been possible
without their deft mentorship.
In addition, we acknowledge and thank our own biggest support system: our friends and
families, who have supported us so much as we complete our studies in nurse anesthesia.
ANESTHESIA IN AUSTERE ENVIRONMENTS
v
Table of Contents
Dedication ...................................................................................................................................... iii
Acknowledgements ........................................................................................................................ iv
Abstract .......................................................................................................................................... vi
Chapter 1 ......................................................................................................................................... 1
Introduction ................................................................................................................................. 1
Research Question and Specific Aims ........................................................................................ 2
Background and Significance ..................................................................................................... 2
Operational Definitions ........................................................................................................... 2
Anesthesia Practice in Austere Environments ........................................................................ 4
Importance of Mental Health Support .................................................................................... 6
Chapter 2 ......................................................................................................................................... 8
Methods....................................................................................................................................... 8
Chapter 3 ....................................................................................................................................... 10
Literature Review...................................................................................................................... 10
Impacts of Austere Environments on Medical Volunteers ................................................... 10
Positive Impact.................................................................................................................. 10
Negative Impact ................................................................................................................ 12
Models of Support................................................................................................................. 16
Methods of Support for Humanitarian Aid Workers ........................................................ 16
Military Reintegration Model ........................................................................................... 18
Chapter 4 ....................................................................................................................................... 24
Results ....................................................................................................................................... 24
Educational Support Recommendations ............................................................................... 24
Organizational Support ......................................................................................................... 25
Research Recommendations ................................................................................................. 26
Chapter 5 ....................................................................................................................................... 28
Discussion and Conclusion ....................................................................................................... 28
References ..................................................................................................................................... 30
Appendix A: Literature Matrix ..................................................................................................... 36
ANESTHESIA IN AUSTERE ENVIRONMENTS
vi
Abstract
Countless anesthesia providers volunteer their time and resources to deliver care around
the world to those who need it, and the demand for surgery is disproportionally severe in
underserved areas. Current literature establishes the jarring finding that humanitarian aid workers
and other similar volunteers suffer negative mental health consequences after returning from
service in austere environments. Some organizations, including non-government organizations
and the military, offer specific psychologically protective care for those returning from austere
environments. This paper offers recommendations to provide a framework for mental wellness
support, specific to anesthesia providers, with the intention for it to be employed by national and
state associations.
ANESTHESIA IN AUSTERE ENVIRONMENTS
1
Chapter 1
Introduction
Across the globe, up to five billion people do not have access to safe, affordable surgical
and anesthetic care, and although one-third of the global population resides in the poorest parts
of the world – only 6% of annual surgical procedures take place in such areas (Meara et al.,
2015). Policies and programs aimed at stimulating increased levels of volunteerism couple with
strengthened support for those who engage in medical missions is crucial to reducing the amount
of unmet need.
By 2030, there will be an estimated shortage of 18 million healthcare professionals
worldwide, including physicians and nurses (World Health Organization [WHO], n.d.). Critical
shortages of these essential individuals will have a negative impact on global health, especially
for countries with the greatest provider deficits. Recent survey data (Lough, 2015) indicated
about one million United States residents volunteer abroad every year, 14% of whom volunteer
with organizations providing health care-related services. In addition to providing their time,
many also contributed financially to participate with an organization. Caldron et al. (2016) found
United States physicians personally contributed an average of $11,000 per trip, with an estimated
composite economic outlay of $3.7 billion annually, inclusive of direct costs, business loss, and
support staff. The same data set indicated mean annual physician volunteerism has been steadily
increasing year-over-year since the 1970s. A shrinking pool of professionals, economic strain,
and a rise in healthcare worker burn-out threatens to reverse this trend.
Given the existing care gap and mounting challenges related to provider availability,
efforts should be made to ensure that those who volunteer are provided with adequate tools,
resources, and strategies to make the experience rewarding and psychologically safe. Current
ANESTHESIA IN AUSTERE ENVIRONMENTS
2
literature regarding provision of medical care, specifically anesthesia services, in austere
environments rarely includes the topic of psychological challenges providers experience or
report. Similarly, there is a lack of guidance for the most effective way(s) to prevent negative
psychological outcomes of volunteer efforts in austere environments.
Research Question and Specific Aims
The authors pose the following research question: What are effective methods for
addressing psychological challenges among anesthesia providers returning from practice in
austere environments?
The specific aims of this paper are to:
1. Conduct a thorough literature review, examining and synthesizing best evidence
regarding the mental health effects on those providing anesthesia services in austere
environments.
2. Conduct a thorough literature review, examining and synthesizing best evidence
regarding psychological protective measures previously implemented among those
providing medical care in austere environments.
3. Develop policy or practice recommendations to support mental health and wellness for
anesthesia providers providing short-term care in an austere environment.
Background and Significance
Operational Definitions
Degrees of austerity vary based upon the geography and context in which healthcare is
delivered. United States Army Regulation 635- 40, defines an austere environment as an area (a)
that regularly experiences significant environmental hazards (i.e., heat, cold, altitude, etc.) that
would exacerbate existing medical conditions; (b) with limited access to a reliable source of
ANESTHESIA IN AUSTERE ENVIRONMENTS
3
electricity; (c) that requires immunizations or force health protection prescription products;
and/or (d) with limited medical services. For the purpose of this literature review, the operational
definition of an austere environment, in relation to practicing anesthesia, is delivering healthcare
services in a resource-constrained environment, inclusive of medical missions in low- and
middle-income countries or in response to natural disasters and/or humanitarian crises. Resource-
constrained environments demonstrate an overall increased demand of otherwise limited
resources - technology, medication, medical equipment, personnel, communication, and/or basic
infrastructure. Short term medical missions are periods of time ranging from a few days up to
several months when an individual volunteers to provide healthcare. For the purpose of this
review, only medical missions lasting six months or less by any group of organized medical
volunteers were included.
A reliable definition of reintegration is inclusive of transitioning back into personal and
organizational roles following deployment; this is specifically true when referring to military
service members and veterans (Currie et al., 2011). When addressing community reintegration,
the term is traditionally defined as the return of individuals to their previous life, including
functions and participation, or cultural adaptation of an individual returning from a foreign
country (Resnik et al., 2012). For the purposes of this review, these authors will use a unified
definition of reintegration to include both the process and outcome of resuming roles in family,
community, and workplace which may be influenced at different levels of an ecological system
(Elnitsky et al., 2017a). The reintegration process applies to volunteer medical personnel and
military service members.
ANESTHESIA IN AUSTERE ENVIRONMENTS
4
Anesthesia Practice in Austere Environments
Providing surgery in low- and middle- income countries poses unique challenges. Meara
et al. (2015) identified obstacles including poor hygiene and a lack of clean water supply that can
lead to increased illness; insufficient reserves of antibiotics to prevent, treat, or limit the spread
of infection; and layers of corruption and coercion that can come between the patient and the
care they seek. Similar conditions were described by Messair et al. (2010) after the devastating
earthquake in Haiti that resulted in more than 200,000 casualties, critically injured thousands,
and displaced over one million people. The authors detailed the efforts made by a trauma team
from Miami, Florida who deployed within 24 hours to deliver immediate medical relief. Health
care facilities that were not demolished by the earthquake could not function due to
compromised gas lines, electricity, water, transportation, and communications. As such, the
scope of surgical treatment was limited by available anesthesia and surgical staff, equipment, and
supplies; the team worked in a tent that lacked sterile conditions, oxygen administration
capabilities, surgical equipment, solid infrastructure, or general medical supplies. Despite the
many challenges, this group of first responders served as a bridge until more resources were
available and an advanced field hospital was established for surgical and critical care. Even
though the relief team lacked basic medical resources, upon arrival they urgently provided
resuscitative care, emergency amputations, and life-saving wound care – producing a profound
impact on hundreds of injured and affected Haitians.
The WHO, in collaboration with the World Federation of Societies of Anesthesiologists
published guidelines titled, International Standards for a Safe Practice of Anesthesia (ISSPA),
which set baseline standards for providing anesthesia in any setting (Gelb et al., 2018). There
were three levels of strength identified – suggested, recommended, or highly recommended –
ANESTHESIA IN AUSTERE ENVIRONMENTS
5
and all standards fell into five categories: professional aspects, facilities and equipment,
medications and IV fluids, monitoring, and conduct of anesthesia. The guidelines included tables
that can be used as checklists, allowing comparison of current practices to the recommendations.
In one study, Tao et al. (2020) used the provided checklists to evaluate anesthesia services
delivered in a low-income Cambodian hospital. They discovered significant deficits in 26 areas
(out of approximately 150 areas audited) related to professional aspects, monitoring, and conduct
of anesthesia that did not meet the ISSPA-recommended standards. Specifically, a lack of
commonly used drugs and monitoring equipment was noted, posing major threats to the safety of
anesthesia practice, especially in emergency situations.
Meara et al. (2015) examined the current state of access to surgical procedures around the
world and outlined goals for the year 2030. The authors’ recommendations were geared
predominantly towards increasing the total number of safe surgical procedures in low- and
middle-income countries. To save lives and prevent disability, an estimated 143 million
additional surgical procedures are needed every year in these countries. For perspective,
approximately 19 million surgical procedures were performed in the poorest countries in 2015.
The authors’ analysis identified unmet surgical needs ranging from 301 to 5,625 cases per
100,000 population. The need was not evenly distributed among low- and middle-income
countries; the greatest need existed in eastern, western, and central sub-Saharan Africa, and south
Asia. In order to meet the surgical demand by 2030, the primary recommendations involved
increasing in-country existing resources; however, the authors also identified that in the interim,
consistent volunteer groups are a viable option.
ANESTHESIA IN AUSTERE ENVIRONMENTS
6
Importance of Mental Health Support
Circumstances involving high stress, such as providing care in an austere environment,
may lead medical volunteers to experience serious psychological consequences, such as
depression, anxiety, social isolation, Post-Traumatic Stress Disorder (PTSD), or emotional
trauma (Psychosocial Centre, 2012; Raudenska et al., 2020). The National Institute of Mental
Health (NIMH) defines PTSD as an anxiety disorder after seeing or living through a dangerous
or traumatic event (NIMH, 2019). Quevillon et al. (2016) found that while some medical
volunteers had a renewed sense of motivation and appreciation for their work, others experienced
negative sequelae. Leaving reintegration unaddressed had the potential to lead to provider
distress and an impaired ability to care for others in the future. Quevillon and colleagues also
proposed psychosocial support as a way to mitigate the mental health consequences of stressful
experiences. Support aimed at processing positive experiences could also contribute to personal
and professional growth, resilience, confidence, and a greater sense of control over difficult
events.
Currently, CRNAs who volunteer in austere environments do not have a central source
for mental health support upon returning home. While individual organizations may offer options
to their respective volunteers, the support is siloed and difficult to formally track. As a
professional organization representing more than 59,000 CRNAs, the AANA mission statement
declares the AANA advances, supports, and protects nurse anesthesiology, and one of their core
values is to put members first (American Association, n.d.). The AANA currently has explicit
support for CRNAs across several specific domains (i.e., substance use disorders, a suicide
prevention line, and wellness training at the state level). However, the organization lacks specific
ANESTHESIA IN AUSTERE ENVIRONMENTS
7
and substantive mental health resources for CRNAs who have volunteered in austere
environments to assist in their transition back into their former roles.
ANESTHESIA IN AUSTERE ENVIRONMENTS
8
Chapter 2
Methods
This literature review utilized a two-step search approach. First, the following databases
were examined for literature: PubMed, PsycINFO, the Cumulative Index to Nursing and Allied
Health Literature (CINAHL), and Web of Science Core Collections. The following search terms
were used alone and in combination: anesthesia, certified registered nurse anesthetist, austere
environment, austere medicine, volunteer, medical volunteer experience, mission, post-traumatic
stress disorder, humanitarian aid worker, nurse, psychosocial support, mental health, military,
post-deployment, disaster relief, and reintegration. For the second step, the “Similar Articles”
feature in PubMed was used, in addition to a manual search of reference lists from the relevant
primary sources. The inclusion criteria consisted of peer-reviewed, full-text, English-language
sources; articles pertaining to mental health disorders, the psychological impacts of traumatic
events from healthcare-related settings, and military and healthcare professionals working in or
deployed to austere environments. Sources published between 2011-2021 that focused on the
psychological implications of volunteering in an austere environment were included. However,
sources were excluded if the austere environments examined were not included in our
operational definition (i.e., space exploration), or if the focus was on the risks and benefits of
short-term medical missions to the underserved community (i.e., becoming reliant on aid
missions, limited availability for follow up of outcomes including postoperative complications,
communication barriers affecting patient care, etc.), as shown in Figure 1. In total, 22 full-text
articles were included in the literature matrix (Appendix A).
The psychological impact of volunteer work is a complex human process. Additionally,
the nature of volunteer work is decentralized. As a result, research on this topic has not been
ANESTHESIA IN AUSTERE ENVIRONMENTS
9
extensively performed or well-funded. Therefore, many of the included articles are
observational, anecdotal, and/or qualitative. The authors sought out literature from reputable
journals and organizations; the result is an aggregation of differing levels of evidence on a
largely unexamined phenomenon.
Figure 1
PRISMA Diagram
ANESTHESIA IN AUSTERE ENVIRONMENTS
10
Chapter 3
Literature Review
Impacts of Austere Environments on Medical Volunteers
Positive Impact
McCauley et al. (2021) performed a mixed-method study using interviews and an online
survey with a Likert scale to assess the impact of short-term international volunteering among
262 medical professionals including obstetricians, anesthetists, and midwives. Study participants
were all volunteers of the Making It Happen program with locations in nine Sub-Saharan African
countries and three Asian countries. The organization aimed to reduce maternal and newborn
morbidity and mortality by developing the clinical skills of local healthcare providers. The
researchers assessed different components of the volunteer experience including reasons for and
impact of volunteering, and attitudes towards support. During interviews, volunteers described
their experiences as cultivating feelings of humility and increasing cultural sensitivity. Based on
survey data, respondents (n=262) reported increased confidence (98%), improved multi-cultural
teamwork skills (95%) and enhanced leadership skills (90%) from volunteering. Of note, 79% of
respondents endorsed a desire to better understand the challenges facing healthcare providers in
resource poor clinical settings, which indicates pre-departure support with education on health
system capacities in resource poor countries, and realistic expectations of the environment and
accommodations. When interviewed, medical volunteers expressed it would have been beneficial
to have before-and-after briefings, as well as insight from previous volunteers.
Tyler et al. (2018) performed a systematic review and meta-synthesis on the personal and
professional development outcomes of international volunteer work, including any positive or
negative developments. The systematic review included 55 peer-reviewed studies with
ANESTHESIA IN AUSTERE ENVIRONMENTS
11
participants who were healthcare professionals or health professional students. The Delphi
method was then used to extract common themes and group outcomes into core outcome sets.
The authors reported 133 unique outcomes, including 105 of which were positive. Themes of
positive outcomes consisted of clinical skills, management skills, communication and teamwork,
patient experience and dignity, policy, academic skills, and personal satisfaction and interest.
Thirty-three variables that influenced these outcomes were identified and included: (a)
preparation, (b) volunteer dynamics, (c) length of experience, (d) level of support, (e) differences
between host and origin country, (f) commitment of the local staff, (g) income of the host
country, and (h) resources in the host country. Other significant variables included opportunities
for reflection, skill development, and leadership.
Zamora et al. (2019) evaluated the economic value gained from skills and attitudes
acquired among 279 international volunteers. The authors first performed a systematic review of
literature and datasets from various health partnerships in the United Kingdom and identified
improvement in the following skills: clinical, leadership, communication, cultural, educational,
and patient service. These skillsets were then categorized into competencies known to affect
productivity based on an analytical framework developed by the World Bank. Competency
categories included labor skills and attributes, labor market characteristics (perceptions of
employers and staff, retention, promotion), partnerships, innovation, leadership, and service
delivery. By viewing acquired skills in terms of competencies achieved, the authors hypothesized
that international volunteer experience led to a more competent labor force and increased
productivity and economic value. Based on the competencies achieved, the authors quantified
productivity of 279 international volunteers by applying input indices to measure competencies,
labor growth, staff volume and monetized earnings (based on 2017 pre-volunteer NHS staff
ANESTHESIA IN AUSTERE ENVIRONMENTS
12
earning data). Comparisons across groups were presented in terms of the percentage point
increase in volume of NHS staff and of average productivity gain based on earnings per
volunteer. For example, if a novice 1
st
level nurse returned from international volunteer work
with new skill sets and competencies that qualified him/her for a higher-level nursing position,
then those skills would be valued by the difference in earnings between the two levels. The
researchers found the development of new skills by nurses post-volunteering was valued at
£19,034 per nurse (roughly equivalent to $23,000), which was an average productivity gain of up
to 62% per nurse. International volunteerism also was found to increase the productivity of
physicians by an average of 37%.
Negative Impact
McCauley et al. (2018) surveyed 17 medical professionals to explore their experience
after volunteering for a year in Ethiopia with Voluntary Service Overseas. The mission of this
organization was to create sustainable improvements to health by addressing the lack of trained
healthcare providers in low- and middle-income countries. The 17 medical volunteers in this
study included nurses (n=2), midwives (n=3), and doctors (n=11) including pediatricians,
obstetricians, general practitioners, and anesthesiologists. The volunteers provided medical
services and trained local healthcare providers to improve their clinical knowledge and practical
skills. Following the volunteers’ return home, they were given a ten-point questionnaire with
close-ended questions. There was a 94% response rate which provided insight into the challenges
felt by volunteer medical professionals. Results included reported sentiments of inadequate
clinical infrastructure (68.8%), dealing with difficult clinical scenarios, such as potentially
preventable deaths of patients (50%), feeling that the impact of their work was not sustainable
(45%), noting that essential equipment and resources were lacking (43.8%), occurrence of
ANESTHESIA IN AUSTERE ENVIRONMENTS
13
gender issues, such as a male-dominated work environment and undermining of female input
(43.8%), and corruption (43.8%). Due to the small sample size and limitations of a close-ended
questionnaire, the authors recommended further qualitative research to explore the experiences
of medical volunteers in low resource settings.
Tyler et al. (2020) conducted a systematic review of 55 peer-reviewed articles that
identified potential negative outcomes after international volunteering. The authors extracted 33
commonly reported negative outcomes, some of which included pressure to work outside one’s
competence, ethical dilemmas, lack of recognition by colleagues after volunteering, culture
shock, general frustration, and the financial cost of undertaking international volunteer work.
The authors then used these outcomes to develop their own close-ended questionnaire that was
distributed to a convenience sample of 169 healthcare professionals in the U.K. who had
participated in international volunteer work. While 94% of respondents reported an overall
positive experience, they also reported feeling a lack of support when returning to work or
reintegrating (92.9%), a lack of formal recognition (78%), feeling uncomfortable working
outside of their competence (34%), and exposure to corruption (30%).
Psychological Conditions in Humanitarian Aid Workers
De Jong et al. (2021) conducted a prospective study to observe mental and physical
health changes among 609 international humanitarian aid workers returning from short term (< 1
year) medical emergency assignments. The participants completed assessments at three time
points: 0-14 days prior to site deployment, within 4 weeks upon returning, and 2 months after
returning. Self-report assessments given measured stress, health outcomes, PTSD, burnout,
social functioning, emotional well-being, fatigue, and pain. Mental health professionals also
administered clinical interviews using the Mini International Neuropsychiatric Interview
ANESTHESIA IN AUSTERE ENVIRONMENTS
14
(M.I.N.I. 7.0.2) to assess for major depressive disorder, anxiety disorders, PTSD, eating
disorders, and/or alcohol or substance use disorder. Anxiety was found to be significantly higher
prior to deployment with a mean score of 1.50, and then returned to baseline upon returning with
a mean score of 1.39 (p<0.01). Other outcomes were found to be significantly worse upon return:
burnout due to emotional exhaustion (M=1.66; 1.81; 1.78; p<0.01), lower levels of social
functioning (M=86.9; 83.6; 85.1; p=0.02), and higher levels of fatigue (M=71.5; 62.8; 68.3;
p<0.01). Levels of PTSD were found to be stable across the three time points, with mean scores
of 8.89, 7.84, and 8.19 (p=0.13). Self-reported levels of depression, PTSD, and anxiety were
significantly higher than those detected by clinical interviews with a trained professional (the
gold standard of mental health screening). In fact, self-reported scores were three times more
likely to indicate the presence of an anxiety disorder, eight times more likely for PTSD, and 25
times more likely for a depression disorder than interviews. Ten of the 38 clinically diagnosed
individuals accessed mental health resources at 12-month follow-up and the prevalence of
alcohol and substance use disorders was significantly higher (13%) when compared to the global
population prevalence (4%).
Greene-Cramer et al. (2021) sought to identify patterns of stress responses (i.e.,
posttraumatic stress, not to be confused with the clinical diagnosis of Post-Traumatic Stress
Disorder [PTSD]) in aid workers using longitudinal survey data. The authors solicited survey
responses from 154 participants at three key points in time relative to their aid work: pre, post,
and 3-6 months follow-up. The pre-deployment survey data assessed for risk and protective
factors previously identified in prior research: (a) demographics (age, sex, marital status, English
proficiency, and education level), (b) psychiatric history (including early trauma, prior
medication, and therapeutic interventions), (c) previous number of volunteer assignments, and
ANESTHESIA IN AUSTERE ENVIRONMENTS
15
(d) nature of deployment. The immediate post-deployment data assessed moderators of stress
during the deployment period: (a) chronic stressors, (b) traumatic experiences (current and
previous missions), (c) organizational support, and (d) social support. Lastly, the follow-up
survey was administered 3-6 months post-deployment and assessed posttraumatic stress levels
and whether they met criteria for a diagnosis of PTSD. Three subgroups of participants emerged
from the data - resistant, resilient, and non-resilient. Resistant individuals demonstrated low
levels of posttraumatic stress pre-deployment and remained low at both post deployment and
follow-up. Resilient described individuals whose posttraumatic stress levels were high pre-
deployment, increased immediately post-deployment, then returned to equal or lower levels at
follow-up when compared to initial assessment. Non-resilient describes those whose levels of
posttraumatic stress were elevated immediately post-deployment and remained high or increased
at follow-up. However, certain factors emerged as significant in determining whether individuals
would be classified as resilient versus non-resilient. For example, those who were single - as
opposed to coupled or married - were 70% less likely to be in the resilient subgroup, while those
with one prior deployment were 3 times more likely to be non-resilient than resistant compared
to those with no previous deployments. Those with more than 2 deployments showed no
significant difference between the 3 subgroups. Across all 3 groups, higher levels of prior trauma
suggested higher levels of posttraumatic stress at every point of measurement. However, across
all time points measured, the rates of individuals who met diagnostic criteria for PTSD were low
(1.3%). The research results indicated mental health support is especially vital for aid workers
who return from their first deployment, as well as more seasoned volunteers who may suffer
from the cumulative effects of stress and trauma.
ANESTHESIA IN AUSTERE ENVIRONMENTS
16
Aldamman et al. (2019) surveyed 409 humanitarian volunteers from the Sudanese Red
Crescent Society to determine how organizational factors impacted volunteer mental health and
well-being. Two significant findings emerged: perceived organizational support was directly
associated with Perceived Self-Efficacy, while inversely correlated with Perceived Helplessness.
Further, Perceived Self-Efficacy was found to be associated with mental well-being, while
Perceived Helplessness was associated with adverse mental health scores. The authors concluded
the volunteers’ perception of support from the organization is a key factor in mental wellness,
and that increasing amounts of organizational support led to lower levels of anxiety and
depression.
Models of Support
Methods of Support for Humanitarian Aid Workers
The Antares Foundation is an organization aimed at improving the quality of
humanitarian aid and has partnered with the Centers for Disease Control and Prevention (CDC)
and Non-Governmental Organizations (NGOs) to develop an approach to mitigating stress in aid
workers (Antares, 2012). This partnership resulted in the publication titled, Managing Stress in
humanitarian workers: Guidelines for Good Practice. The report provided a broad
organizational framework on understanding, screening, assessing, supporting, and monitoring
stress. The guidelines were developed by a group of experts incorporating both theoretical and
practical perspectives on stress experienced by the aid worker, which included NGO officials,
academic and clinical experts in stress and in managing “normal” and post-traumatic stress, and
NGO psychosocial staff. The goal of the guidelines was to provide a single, central source of
current and effective approaches to stress management for organizations to reference.
Organizations are incentivized to protect the wellbeing of the aid workers and help manage their
ANESTHESIA IN AUSTERE ENVIRONMENTS
17
stress in order to fulfill their field objectives. Based on the guidelines, at the end of an
assignment an operational exit interview should be conducted, allowing the individual to share
their experiences from an austere environment and feel heard. They also recommend a one-time
stress assessment and review, during which an individual may share their thoughts and feelings
about what they experienced with someone who can refer them to additional resources, if
necessary. The authors indicated the exit interview, stress assessment, and review should be
offered with confidentiality, and preferably with someone with whom the returning volunteer has
a pre-existing relationship. In addition, they suggested organizations should have a clear follow-
up policy with respect to adjustment, emotional, and/or family problems, which should occur
within weeks after they return from their assignment.
The Reference Centre for Psychological Support of the International Federation of Red
Cross and Red Crescent Societies (IFRC) developed a thorough psychosocial support toolkit for
caring for volunteers (Psychosocial, 2012). This toolkit provided guidance on how to monitor
and evaluate aid workers for warning signs of burnout, mental health issues, and trauma. The
authors suggested psychosocial supportive measures that can be offered before deployment of
volunteers, which included a briefing on difficult tasks that may be encountered, emphasizing the
importance of wellbeing, and providing verbal and written information about stress, coping and
resilience. After deployment, the IFRC suggested volunteers have the opportunity to reflect on
their experiences, both individually and with their deployed team. In addition, they suggested a
separate ongoing peer support program with clear roles, whether informal (i.e., a buddy system),
or formal (i.e., with matching, a structured schedule, and set format for debriefing). The IFRC
employed a methodology for supporting the mental health needs of returning volunteers called
Psychological First Aid, which involved showing warmth and empathy while providing a safe
ANESTHESIA IN AUSTERE ENVIRONMENTS
18
and secure environment. Psychological First Aid includes removing the volunteer from excess
stimulation (sights, sounds, smells), providing food and drinks, active listening, validating their
feelings and reactions, and ensuring they have access to further ongoing support.
Psychological First Aid was designed for a one-on-one format but Corey et al. (2021)
performed a literature review of Group Psychological First Aid, which provides the same
benefits in a group setting. The authors identified 15 studies detailing the utility of group
psychological support for humanitarian workers and they also incorporated input from a core
reference panel, which consisted of an academic with mental health experience and two mental
health program administrators who had experience designing and implementing mental health
support within NGOs (including individual and Group Psychological First Aid). The study
authors reported that Group Psychological First Aid enables individuals to understand their
reactions to stressful events, develop adaptive coping strategies, and build social connections that
promote feelings of security. One major benefit of an integrated, or automatic, format after
returning from deployment is that volunteers were linked to additional support and had their
psychosocial needs addressed. The authors concluded that Group Psychological First Aid can
serve as an entry point to access to a wider system of other resources. They suggested groups
have two trained facilitators and group members should have similar rank levels and experiences.
Military Reintegration Model
The Uniformed Services and Employment and Reemployment Rights Act of 1994
(USERRA) established the cumulative length of time an individual may be absent from work for
military duty while retaining reemployment rights:
Subchapter II: 4312. Reemployment rights of persons who serve in the uniformed
services.
ANESTHESIA IN AUSTERE ENVIRONMENTS
19
(e)(1) Subject to paragraph (2), a person referred to in subsection (a) shall, upon
the completion of a period of service in the uniformed services, notify the
employer referred to in such subsection of the person's intent to return to a
position of employment with such employer as follows:
(A) In the case of a person whose period of service in the uniformed services was
less than 31 days, by reporting to the employer—
(i) not later than the beginning of the first full regularly scheduled work period on
the first full calendar day following the completion of the period of service and
the expiration of eight hours after a period allowing for the safe transportation of
the person from the place of that service to the person's residence (section 4313
(a) (1) (2) (A) & (B) 20 CFR 1002.197)
Under USERRA (1994), military service members have protected time off after
deployment to assist with their transition into their former roles. For example, if a soldier was
deployed for more than 30 days but less than 180 days, the soldier can return to work within 14
days of returning home; however, if they were deployed for 181 days or more, they have up to 90
days after returning home to resume work. This federal statute protects time off, allowing the
soldier time to reflect and process their experiences, readjust to first world luxuries, and rekindle
any social relationships that may have been stressed due to time and distance apart.
Military OneSource is a program from the Department of Defense that provides resources
and tools for military members and their families’ health and wellbeing, and confidential help is
available 24 hours a day, seven days a week (Military OneSource, 2022). Although civilian
volunteer work is vital to impoverished or disaster-stricken communities, unlike American
military service members returning from deployment, civilian volunteers do not have federally
ANESTHESIA IN AUSTERE ENVIRONMENTS
20
protected time off after returning home from volunteer missions, nor do they have access to
structured support if a volunteer expresses concerns of traumatization.
Rivers et al. (2017) surveyed military nurses (n=119) and found physical and emotional
issues tend to emerge during reintegration, sometimes even months after returning home. Using a
mixed-methods approach, the authors surveyed and interviewed military nurses who provided en
route care and were deployed for at least 30 days during Operation Enduring Freedom/Operation
Iraqi Freedom. Based on quantitative survey data, nearly 53% of participants indicated they
needed behavioral health support after deployment, but only 32.8% actually sought assistance.
Qualitative data consisted of 22 one-on-one interviews to assess the reintegration experience,
which revealed four themes related to the quantitative data: “leadership matters” (career
challenges), “I don’t fit in” (social difficulties), “here is my suffering” (intimate relationship
problems/health concerns) and “the terror of war—you don’t unsee that” (health concerns/PTSD
symptoms). Of those surveyed, 68% felt pressure to return to work shortly after returning home,
and over 50% described being easily irritated or feeling anxious. In addition, 34% of participants
expressed hesitancy in talking about their experiences with friends, family, and coworkers;
however, they were more comfortable sharing with individuals to whom they could relate based
on similar past experiences. Interview responses revealed 61% of participants perceived a change
in themselves or others (including families) during their deployment, 45% indicated it affected
their ability to adapt to their previous familial role, and 51% felt pressure to get back to
“normal.”
Currie et al. (2011) assessed post-deployment reintegration experiences of Canadian
junior noncommissioned officers (n=409). The authors analyzed data from voluntary survey data
completed within six months upon returning from deployment in Afghanistan. The authors
ANESTHESIA IN AUSTERE ENVIRONMENTS
21
examined how formal support (organized structured debriefings, transitioning personnel,
homecoming events) and informal support (unstructured supportive interpersonal interactions,
coworker discussion) influenced participants’ levels of affective organizational commitment,
post-traumatic stress, alcohol consumption, and intentions to leave their current job. Affective
commitment was described as the extent to which an individual is emotionally attached to an
organization, identifies with, and/or is involved with. The survey results indicated that ongoing
personal social support versus a single large-scale event (i.e. a homecoming parade) helped
soldiers reestablish their personal relationships and societal roles. The soldiers’ perceived
effectiveness of reintegration was associated with affective commitment (p<0.01). Informal
support (i.e., coworker solace) was found to be significantly correlated with both enhanced
affective commitment (p<0.01) and lessened posttraumatic stress (p<0.01). An increased number
of completed deployments was associated with higher levels of affective commitment (p<0.01),
but not with higher posttraumatic stress. However, posttraumatic stress was associated with
higher amounts of alcohol consumption (p<0.01). The authors found that successful reintegration
included reestablishing multiple relationships and roles, which may be best facilitated by
ongoing informal personal support, an important antecedent to affective commitment.
Sayer et al. (2010) surveyed 1,226 American combat veterans who served in Iraq and
Afghanistan and utilized Veteran Affairs (VA) services. Study participants completed a
questionnaire in order to determine prevalence and types of community reintegration issues, and
to gauge interest in interventions facilitating readjustment within their community. Secondarily,
the authors sought to identify associations between a probable PTSD diagnosis, reintegration
problems, and interest in treatment. The survey assessed overall difficulty in readjusting to
civilian life, specific functional domains (social relations, productivity, community participation,
ANESTHESIA IN AUSTERE ENVIRONMENTS
22
perceived meaning in life, and self-care and leisure activities), and other life difficulties
(accessing health care, finances, divorce, legal issues, career, spiritual/religious). Finally,
physical and mental health were assessed using the 12-item Short-Form Health Survey and
Primary Care PTSD Screen. Of the 754 respondents, 25-56% endorsed “some” to “extreme”
difficulty in social functioning, productivity, community involvement, and self-care. Thirty-eight
percent of Veterans’ responses suggested substance abuse problems. Additionally, 41% screened
positive for a probable diagnosis of PTSD, which was associated with more difficulties
readjusting after deployment and a higher interest in support services.
Hinojosa et al. (2012) conducted 20 in-depth semi-structured interviews with National
Guard and Reserve military members who served in Operation Enduring Freedom/Operation
Iraqi Freedom. A major theme identified was difficult communication between the soldier and
their family. The reported challenges were security/restricted access, miscommunication and
“nothing new to say.” Open communication between the soldier and family is often unattainable
due to Operational Security, which prevents disclosing mission-sensitive information such as
location, environment, specific combat experiences, future operations, dates, etc. In addition,
communication equipment could fail, leading to technical problems. The respondents’ narratives
detailed a lack of reliable, open, and clear communication which played a major factor that led to
strained family relationships and misunderstandings. The participants emphasized the importance
of a support system of individuals who have gone through similar experiences for successful
reintegration. Having veteran friends provided positive, effective support because other military
members had a genuine understanding and could relate to described experiences - something
family members could not provide.
ANESTHESIA IN AUSTERE ENVIRONMENTS
23
Elnitsky et al. (2017b) conducted a critical analysis of existing research addressing
military service members and veteran’s (MSMV) reintegration. The review adapted
Bronfenbrenner’s (1979) social ecological systems model— that views individuals being
impacted or influenced by individual, interpersonal, communal, and societal factors— and
applied it to MSMV reintegration to help guide practices and recommendations for future
research. The authors analyzed 186 articles, including quantitative, qualitative, and mixed
studies; they reported individual level factors that affected MSMV reintegration included
psychological and physical health, cultural and demographic characteristics, and impediments in
productivity due to PTSD or traumatic brain injuries. Interpersonal level factors focused on
relationships (with veteran friends, families, spouses, partners, and children), highlighting that
support systems play different roles, or contribute to different stressors, depending on their
relationship to the MSMV. Community-level factors hindering reintegration included health care
access barriers, new mental health diagnoses or disabilities, structural barriers to disabilities, and
community resources. Lastly, societal-levels factors, such as the Department of Defense and VA
benefits and programs, influence reintegration needs. Ultimately, the authors reported
reintegration is a multidimensional phenomenon. Individual, interpersonal, community and
societal level factors all interfere with reintegration, emphasizing the importance of a systematic
approach to enhance reintegration knowledge and perspectives, from individual to societal
levels.
ANESTHESIA IN AUSTERE ENVIRONMENTS
24
Chapter 4
Results
An emerging theme identified in the literature was the importance of a supportive
environment before, during, and after volunteering. Factors contributing to a supportive
environment include informative guidance, setting expectations, opportunities for reflection,
insight from previous volunteers, recognition, and post-volunteer debriefings (McCauley et al.,
2018; Meara et al, 2015; Quevillon et al., 2016; Tyler et al., 2020). Just as a supportive
environment influenced the positive outcomes experienced by medical volunteers in austere
environments, a lack of support was cited as a negative outcome. Tyler et al. (2020) reported
92% (155 of 169) of their study respondents cited a lack of support upon return from the
volunteer experience.
Research on effective methods of support to mitigate the negative psychological
consequences of high-stress experiences in humanitarian aid workers and military personnel was
used to guide the authors recommendations of needed support for CRNAs that volunteer in
austere environments.
Educational Support Recommendations
In an effort to reduce the stress impact on healthcare volunteers, the authors recommend
the AANA take an active role in establishing a supportive environment for CRNA volunteers by
providing the following:
• Evidence-based online modules to provide education on volunteering in austere
conditions. Training should include, but not be limited to, challenges of working in
resource poor environments, standards of care that may be unmet in austere or disaster
settings, preparation for commonly encountered ethical dilemmas, sources and effects of
ANESTHESIA IN AUSTERE ENVIRONMENTS
25
stress and signs of psychological impact on oneself and team members, coping
mechanisms, and approaches to self-care. Stress management guidelines should also be
considered, consisting of integrative web-based modules, explanations of key concepts in
risk reduction, approaches to self-care, podcast presentations and workshops that address
stress management and facilitating resiliency (Antares, 2012).
• House a Recognition and Volunteer Connection portion on the aana.com webpage. This
voluntary list serves two purposes: (a) Recognizing the contribution and value of past
volunteers; (b) A method of social connection and support with others who have been
through a similar experience (McCauley et al., 2021; Tyler et al., 2018; Antares, 2012).
• Provide links on the aana.com website for recommended mental health specialists with
experience in post-traumatic stress, and the self-help toolkits from the American
Psychological Association’s (APA) Psychological First Aid
(https://www.apa.org/practice/programs/dmhi/psychological-first-aid/resources; APA,
n.d.), and the IFRC Caring for Volunteers Manual
(https://pscentre.org/trainings/trainings-offered-by-the-ps-centre/; Corey et al., 2021).
Organizational Support
As described by the American Association of Nurse Anesthesiology (AANA)’s “Mission
Trip Frequently Asked Questions for CRNAs,” mission trip expenses vary by sponsoring agency,
although most mission trips are predominantly self-funded (American Association of Nurse
Anesthesiology, n.d.). In order to provide free high-quality care to a community in need,
volunteers may be financially liable for their own transportation, lodging, food, and any other in-
country related expenses. Upon completion of the trip, oftentimes the volunteer reports to their
ANESTHESIA IN AUSTERE ENVIRONMENTS
26
traditional healthcare job soon after returning home, and reintegration is not addressed by the
employer.
• Private employers should offer paid time off for employees returning home from medical
volunteerism. Employers have an opportunity to support the mental well-being of
returning volunteers by offering protected time off akin to the military model (USERRA,
1994). Although private employers may not have the resources to offer equivalent paid
time off, any support would bolster volunteer/employee mental health, and increase the
employee’s affective commitment to the employing organization (Aldamman et al., 2019;
Currie et al., 2011).
• Sponsoring organizations should offer post-deployment debriefings for returning
volunteers led by mental health professionals (or specially-trained past volunteers)
(Antares, 2012; McCauley et al., 2021; Tyler et al., 2018).
Research Recommendations
An extensive literature search did not yield any results pertaining directly to the
psychological impacts on anesthesia providers providing care in austere environments. However,
there are numerous sources that highlight the importance of mental health support after high
stress events for similar populations such as humanitarian aid workers and military
servicemembers (Antares, 2012; Corey et al., 2021; Currie et al., 2011; De Jong et al, 2021;
Greene-Cramer et al, 2021; Hinojosa et al., 2012; McCauley et al., 2021; Psychosocial Center,
2012; Quevillon et al., 2016; Raudenska et al., 2020; Rivers et al., 2017; Sayer et al., 2010; Tyler
et al., 2018, 2020). Further qualitative and quantitative research should be conducted with
CRNAs specifically to explore the mental impact – both positive and negative – on them
ANESTHESIA IN AUSTERE ENVIRONMENTS
27
volunteering in austere environments. More specifically, the direction of future research should
be driven in the following directions:
• The impact of pre- and post- volunteer interviews and briefings.
• The effectiveness of formal support programs for CRNA volunteers and how that affects
their affective commitment, burnout level, and indicators of mental wellbeing.
• The impact of ethical pre-deployment briefings on CRNAs – that is, ensuring volunteers
understand their role and expectations prior to volunteering in austere environments.
ANESTHESIA IN AUSTERE ENVIRONMENTS
28
Chapter 5
Discussion and Conclusion
Currently, a standardized mental health support system is not routinely offered to any
medical volunteers, including anesthesia providers, after returning home from austere
environments. In addition, there is a lack of literature identifying how stressors impact the mental
health of medical volunteers. The authors attempted to provide evidence-based recommendations
to bridge the gap in three arenas: educational support, organizational support, and research
support. The AANA is optimally poised to provide valuable educational and research support to
anesthesia providers who volunteer, while individual NGOs and other institutions can offer
further support.
We can gain insight from the more conclusive literature on the psychological conditions
identified in humanitarian aid workers, who are often immersed in similar austere environments.
Their assignments range from short-term responses to disasters to longer-term assignments
working to solve large societal problems such as disease, poverty, armed conflict, or famine.
Given that they too are surrounded by human suffering, unmet needs, and limited resources, they
experience moral anguish over difficult choices based on limited supplies. The emotionally
demanding conditions humanitarian aid workers face during their assignments can lead to
numerous mental health issues such as anxiety, depression, and PTSD (Greene-Cramer et al.,
2021). If left unaddressed, these issues can lead to general distress, increased alcohol
consumption, and social isolation (Aldamman et al., 2019).
There were several limitations of this review, which included a lack of research literature
specific to anesthesia provides, and the authors’ lack of professional mental health training.
While existing resources upon returning home are scattered and largely dependent upon the
ANESTHESIA IN AUSTERE ENVIRONMENTS
29
sponsoring organization, creating a framework for mental health support within existing
structures can provide for a need that thus far has been largely unmet. Future work could involve
smaller-scale research focusing on individual or team anesthesia volunteers.
Following an extensive review of the existing research literature, these authors propose
several categories of professional recommendations: (a) key integrations within the existing
structure of the AANA to support providers upon return from volunteer work in austere
environments, with educational resources including online modules and training on self-care and
preparation, peer support groups, and volunteer recognition, (b) private organizations provide
protected time off from regular work duty, as well as offer post-deployment briefings with
mental health professionals, and (c) fund future research analyzing the effectiveness of
interventions among anesthesia provider volunteers in reducing negative mental health
outcomes.
ANESTHESIA IN AUSTERE ENVIRONMENTS
30
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36
Appendix A: Literature Matrix
APA Reference Aim of study Type of
Research
Methods Main Findings of Study Capstone Application
Aldamman K,
Tamrakar T,
Dinesen C,
Wiedemann N,
Murphy J, Hansen
M, Elsiddig Badr
E, Reid T,
Vallières F. Caring
for the mental
health of
humanitarian
volunteers in
traumatic contexts:
the importance of
organisational
support. Eur J
Psychotraumatolog
y. 2019 Dec
3;10(1)
To understand the
relationship between
mental health and
support, and mental
well-being among
humanitarian
volunteers.
Mixed
Qualitative
and
Quantitative
Surveys
A sample of 409 humanitarian
volunteers from the Sudanese Red
Crescent Society completed an
online, anonymous, survey
comprised of the Perceived
Supervision, Perceived
Organizational Support, Team
Support, and Perceived
Psychological Stress scales, as well
as the Generalized Anxiety
Disorder and Patient Health
Questionnaire scales, (GAD-7 and
PHQ- organizational and the
Warwick-Edinburgh Mental Well-
being Scale. Study objectives were
tested using structural equation
modelling (SEM) procedures.
Perceived organizational support is a key
determinant of the mental health of
humanitarian volunteers, with greater
perceived support associated with lower
distress symptomology and greater mental
well-being.
Humanitarian agencies should take actions
to improve their internal organization
support systems to mitigate the stress
associated with working in traumatic
contexts.
Can be used when
discussing the
importance of having
support for volunteer
medical workers
There is data
suggesting that support
can decrease distress
and is associated with
greater mental well-
being
Antares
Foundation.
(2012). Managing
Stress in
humanitarian
workers:
Guidelines for
good practice.
(Third Edition)
https://www.antare
sfoundation.org/fil
estore/si/1164337/1
/1167964/managin
g_stress_in_human
itarian_aid_worker
s_guidelines_for_g
ood_practice.pdf?e
To guide humanitarian
organizations in caring
for their staff in
relation to mental
health and stress. To
reduce the sources of
individual
vulnerability and to
increase and
strengthen the sources
of individual
resilience
Report The Antares Foundations and the
CDC formed a partnership with
NGOs to develop a consensus
approach to mitigate stress in aid
workers: “The Guidelines for Good
Practice: Managing Stress in
Humanitarian Workers published
in 2004 and revised in 2012
Not findings but provides information and
recommendations:
Direct exposure to misery, people
affected by humanitarian crises, poor
safety conditions, and limited available
resources mean that humanitarian
workers are exposed to a wide variety of
sources of stress.
Humanitarian work is stressful. Aid
workers respond to the human costs of
disasters such as wars, floods, earthquakes,
famines, or refugee crises, or respond to
longer term issues such as poverty,
hunger, and disease. Some work as rescue
or relief workers in the days immediately
This report discusses
the responsibility of
humanitarian aid
agencies to reduce the
risks faced by their
staff and to provide
staff with support.
Psychosocial support
is important for stress
management and
prevention of post-
traumatic stress
We could apply this
ideology to short term
medical volunteer trips
ANESTHESIA IN AUSTERE ENVIRONMENTS
37
tag=4a88e3afb4f73
629c068ee24d9bd3
0d9
To report on the
importance of
addressing stress
following a disaster. Others work over
longer periods providing humanitarian
aid.
Regardless of the type or length of work,
aid workers are exposed to personal
tragedy, and they may themselves
witness gruesome scenes, have horrific
experiences, or be chronically exposed to
serious danger. Staff often live and work
in physically demanding and / or
unpleasant conditions, characterized by
heavy workloads, long hours and
chronic fatigue, and lack of privacy and
personal space. They experience moral
anguish over the choices they often
must make
in austere
environments because
although these trips
are shorter in duration,
these volunteers are
also exposed to
personal tragedy,
resource poor
environments,
unfamiliar and
disturbing disparities
and a variety of
stressors that can
affect them mentally
and they should also
have resources and
support when they
return home
Has good
recommendations on
stress management (#4
and #5)
Caldron, Paul &
Impens, Ann &
Pavlova, Milena &
Groot, Wim.
(2016). Economic
assessment of US
physician
participation in
short-term medical
missions.
Globalization and
Health. 12. 45.
10.1186/s12992-
016-0183-7.
The magnitude of
monetary and
manpower inputs
towards STMMs is
not clear. The
objective of this study
is to estimate
the prevalence of
physician participation
in STMMs from the
US and the related
expenditures of cash
and resources.
Quantitative:
survey data
An online survey solicited
information on physician
participation in STMMs.
Responses regarding costs were
aggregated to estimate individual
and global expenditures.
Including opportunity cost, average total
economic inputs for an individual
physician pursuing an STMM exceed
$11,000.
Composite expenditures for STMM
deployment from the US are estimated at
near $3.7 billion annually and the resource
investment equates with nearly 5800
physician fulltime equivalents.
Help put a dollar
amount on physician
short-term mission
costs, and collective
US monetary “output”
Campbell,
Campbell, D.,
Krier, D.,
Kuehlthau, R.,
Hilmes, T., &
Stromberger, M.
(2009). Reduction
in burnout may be
Looked to evaluate
some of the benefits of
short-term medical
missions
-Looked at whether
volunteering on short
term medical missions
Quantitative
study
-36 physicians/nurses (69%) and
other nonmedical personnel who
volunteered through CPR between
2002-2007.
-served ~1000 pts, 2/3rd being
children.
-questionnaire pertained to
occupational stressors
-low sample size, however, they found
there’s some personal emotional benefit to
medical providers that volunteer for short
term medical missions.
-There was a reduction in burnout for
medical workers who had moderate levels
of burnout prior to volunteering.
-Older article: 2009.
-”61 million
Americans volunteers
in 2007”
-cprestoration.org
may be a helpful site
as it is devoted to
facilitating personal
ANESTHESIA IN AUSTERE ENVIRONMENTS
38
a benefit for short-
term medical
mission volunteers.
Mental Health,
Religion &
Culture, 12(7),
627–637.
https://doi.org/10.1
080/136746709031
24541
had a positive impact
on burnout and
whether this impact
was sustained after the
service ended
Assessment tool: each participant
completed Maslach Burnout
Inventory-sent out at 1 and 6
months via mailed survey.
-Most positive effects in: increased
feelings of success and achievement AND
decreased feelings of being overextended
emotionally occurred a few months after
returning from the mission.
-Medical personnel who are emotionally
exhausted and have an impersonal
response towards their patients and lack a
sense of accomplishment/success benefit
by working hard with numerous patients in
an international context.
-those who volunteer may do so because
of frustration or dissatisfaction with their
current situation and a desire to see more
immediate effects of their work.
-readily expressed appreciation by pts in
high-need areas.
renewal for healthcare
professionals through
volunteer service.
-ties in beneficial
outcomes for
volunteering--not just
personal satisfaction
but decreasing civilian
job burnout. Could be
an incentive for
hospitals in preventing
high turnover
Clark J and Lewis
S. Impact beyond
volunteering. A
realist evaluation
of the complex and
long-term
pathways of
volunteer impact.
London: VSO,
2017
To identify changes in
the volunteer and
long-term impacts
after a volunteer
experience
Literature
Review,
discussion
and
interviews
that
informed a
mass survey
Mixed Methodological Approach
using Grounded Theory (review
data to see a theory emerge)
statistical tests were run on various
relationships identified:
Stage 1: interactive web-based
discussion platform with 600
participants
Stage 2: 63 in-depth interviews
with VSO volunteers after recent
volunteering
Stage 3: Mass survey informed in
design by the analysis of the
previous two stages and a literature
review, sent to VSO’s wider
alumni network with responses
from 2,735 respondents
Authors looked at 4 categories:
1. Impact of volunteering on host
communities
2. Impact of volunteering on the
volunteer
3. Motivations for volunteering
4. Links between volunteer experience
and subsequent change
Extensive report that discusses positive
findings such as skills developed,
knowledge attained, greater awareness,
changes in attitude such as confidence,
adaptability or motivation. Also reports on
challenges experienced by the volunteer,
personal challenges and other.
Extensive report that discuse positive outcomes
of volunteering such as skills obtained,
knowledge learned, changes in attitude
Can be used for either
positive or negative
impacts
Corey J, Vallières
F, Frawley T, De
Brún A, Davidson
S, Gilmore B. A
Rapid Realist
Review of Group
Psychological First
Aid for
Reviewed Group
Psychological First
Aid (GPFA) with the
aim of understanding
for whom and in what
context does this work
and does it work for
humanitarian first aid
A Rapid
Realist
Review
Generated initial theories and then
conducted a systematic search of
databases and a rapid realist review
GPFA enables individuals to understand
their natural reactions, develop adaptive
coping strategies, and build social
connections that promote a sense of
belonging and security
The integrated design of GPFA ensures
that individuals are linked to additional
While the evidence is
sparse on GPFA, its
ability to provide
support to
humanitarian workers
is promising
ANESTHESIA IN AUSTERE ENVIRONMENTS
39
Humanitarian
Workers and
Volunteers. Int J
Environ Res Public
Health. 2021 Feb
4;18(4):1452.
workers and
volunteers
support and have their basic needs
addressed.
De Jong, K.,
Martinmäki, S.
E.,Te Brake, H.,
Haagen, J., &
Kleber, R. J.
(2021). Mental and
physical health of
international
humanitarian aid
workers on short-
term assignments:
Findings from a
prospective cohort
study. Social
science & medicine
(1982), 285,
114268. https://doi-
org.libproxy2.usc.e
du/10.1016/j.socsci
med.2021.114268
Aims to clarify
discrepancies between
international
humanitarian aid
workers’ health
studies by reporting
on a structured clinical
interview
and a comprehensive
set of self-reporting
health indicators,
focusing on
various mental and
physical health
indicators, and quality
of life, as well
as traumatic,
organizational and
environmental
stressors.
Quantitative:
prospective
observationa
l study
- Sample: 609 Doctors without
Borders Amsterdam HAWs
- 3 assessments: T1: 0-14 days pre-
trip, T2: immediately post up to 4
weeks, and T3: follow-up 2 months
after return
- Assessment tools (mix of self-
reporting and clinical interview):
stressors, heath and outcome
measures, PTSD, Maslach Burnout
Inventory, RAND-36, M.I.N.I.,
- Anxiety and depression: higher before
going, then lower after returning
- PTSD: not statistically significant across
3 measurement points
- Burnout: significantly higher burnout
assessment post-trip “emotional
exhaustion”
- RAND-36: lower levels of vitality, lower
levels of social functioning post-trip, did
not return to baseline at T3 follow-up
- Clinical interview: self-reporting
overestimated anxiety (3x), PTSD (8x),
and depression (25x) when compared to
gold-standard interviewing with
professional psychologist
- Only 10 out of 38 DSM-5 disorder-
diagnosed accessed mental health
resources at follow-up
- The iHAWs’ 12-month prevalence rate
of alcohol use disorders
(AUD) was substantially higher (12 %)
compared to the global 12-month
alcohol and other substance use disorder
rate (4 %)
- Not guaranteed to get
PTSD after exposure
- Under-utilized
mental health
resources: evidence for
pushing awareness of
resources
- Vitality, emotional
exhaustion
and high alcohol use
are particularly useful
post-assignment health
screeners. PTSD is
another important
health indicator to
monitor because of the
repeated exposure to
assignment related
PTEs.
- “Watchful waiting”:
don’t need to
overtreat, but
symptoms can
manifest well after
return.
Gelb, A. W.,
Morriss, W. W.,
Johnson, W.,
Merry, A. F.,
Abayadeera, A.,
Belîi, N., Brull, S.
J., Chibana, A.,
Evans, F., Goddia,
C., Haylock-Loor,
C., Khan, F., Leal,
S., Lin, N.,
The intent of the 2018
International
Standards, like its
predecessor, is not to
supersede the
established national
standards of any
country. They are
intended primarily as
a
Special
report, non-
research.
Gray
literature.
Special collaboration between
World Federation of Societies of
Anesthesiologists (WFSA), a non-
profit organization representing
anesthesiologists in 150 countries,
and the World Health Organization
(WHO).
Develop baseline safety standards
for delivering anesthesia all over
the world.
Three categories of recommendations:
“Suggested,” “Recommended,” or “Highly
Recommended.”
Categories of:
- Professional Aspects
- Facilities and Equipment
- Medications and IV Fluids
- Monitoring
- Conduct of anesthesia
- Outlines specifics of
how anesthesia should
be delivered around
the world in any
setting.
- Baseline for care.
ANESTHESIA IN AUSTERE ENVIRONMENTS
40
Merchant, R.,
Newton, M. W.,
Rowles, J. S.,
Sanusi, A., Wilson,
I., Velazquez
Berumen, A.
(2018). World
Health
Organization-
World Federation
of Societies of
Anaesthesiologists
(WHO-WFSA)
International
Standards for a
Safe Practice of
Anesthesia.
Anesthesia and
analgesia, 126(6),
2047–2055.
https://doi.org/10.1
213/ANE.0000000
000002927
resource for those
countries that do not
already have
national standards and
define minimum
standards for any
facility where
anesthesia is
administered.
Greene-Cramer, B.
J., Hulland, E. N.,
Russell, S. P.,
Eriksson, C. B., &
Lopes-Cardozo, B.
(2021). Patterns of
posttraumatic
stress symptoms
among
international
humanitarian aid
workers.
Traumatology,
27(2), 177–184.
https://doi.org/10.1
037/trm0000286
To build on the
research looking at
risk and protective
demographic and
workplace factors
associated with
negative mental health
outcomes among aid
workers,
specifically, by
assessing the burden
of PTS among
expatriate
humanitarian aid
workers
longitudinally, and to
identify unique
patterns of risk and
resilience.
Quantitative,
longitudinal
- 154 participants, completed
assessment at 3 points of time.
- Questionnaire with 3 categories:
pre-deployment protective
factors (demographics (age, sex,
marital status, English proficiency,
and education level), psychiatric
history (including early trauma,
prior medication, and therapeutic
interventions), previous number of
missions, and nature of deployment
moderators during deployment
(chronic stressors, traumatic
experiences (current and previous
missions), organizational support,
and social support)
and study outcomes
Single individuals were less likely to be in
the resilient group than in the resistant
group compared to coupled individuals.
Individuals with one prior deployment
were three times more likely to
be nonresilient than resistant compared to
individuals with no previous deployments.
There was no significant difference in
resistant, resilient, and nonresilient
classification for individuals with 2
deployments.
Findings suggest a
need for supplemental
training and
psychosocial support
post the first
deployment as well as
resources focused on
potential cumulative
effects of stress and
trauma exposure for
more seasoned
deployers.
- Focus on outreach
should be on folks
returning from FIRST
deployment
ANESTHESIA IN AUSTERE ENVIRONMENTS
41
Lough, Benjamin.
(2015). A Decade
of International
Volunteering from
the United States,
2004 to 2014.
10.7936/K7B56J73
.
Describe volunteers
from 2004-2014.
Grey
Literature,
research
brief
Data from the volunteer
supplement of the CPS are
collected from nearly 60,000
households during one
week in September each year. All
members of surveyed households
are asked about their volunteer
activities for the previous year.
Those who answer
“yes” to whether they volunteered
are asked if
any of their volunteer work took
place outside the
United States or its territories.
Descriptive data detailed in report - B&S: Can provide
extrapolated data
about the number of
people volunteering
(about 700k-1M per
year) and the type of
volunteering (Provide
counseling, medical
care, or protective
services = 21.1%)
Lough, B. J.,
McBride, A. M., &
Sherraden, M. S.
(2007). The
estimated
economic value of
a US volunteer
abroad (CSD
Working Paper No.
07-29). St. Louis,
MO: Washington
University, Center
for Social
Development.
https://doi.org/10.7
936/K769733F
Quantify the estimated
value of US
volunteers abroad.
Grey
Literature
In 2005, according to the US
Current Population Survey,
approximately one million
individuals
reported engaging in some form of
international service (Lough,
2006). The table below reports the
average amount of volunteer time
spent in other countries. Based on
its calculation that one year’s
worth of volunteer time is 1700
hours, the Independent Sector
assumes that full-time volunteers
average 32.6 hours per week
(Hudson Institute, 2007). For a
conservative estimate, missing
values
are assumed to be less than one
week in length. Because the
absolute time spent abroad by
those
reporting serving “more than two
months” is unknown, the length of
their service was estimated to
be approximately 5 months (22
weeks), based on measures of
central tendency as reported by
these volunteers in the 2005
Based on these assumptions and estimates,
total US volunteer hours abroad in 2005
are estimated at
161.8 million (see Table 1). When
multiplied by an hourly wage of a skilled
volunteer at $18.04, the
total value of US volunteer hours abroad
was $2.92 billion.
- Provide an estimate
of how much value (in
USD) volunteers
provided in 2005 as a
reference point.
ANESTHESIA IN AUSTERE ENVIRONMENTS
42
Current Population Survey (Lough,
2006); although the actual length
could be
shorter or longer.
McCauley M,
Amado Y, van den
Broek N. A survey
of international
medical volunteers'
experiences of
working with
Voluntary Service
Overseas in
Ethiopia. Trop
Doct. 2018 Oct: A
survey of
international
medical
volunteers’
experiences of
working with
Voluntary Service
Overseas in
Ethiopia
To assess the views
and experiences of
returning medical
professionals that
volunteered overseas
Qualitative
Study
(Survey)
A ten-item close-ended
questionnaire from a larger survey
previously used by VSO was
distributed to a group of medical
volunteers (majority were MDs
from the UK) that volunteered in
Ethiopia for 8 months to a year
through
VSO (Voluntary Services
Overseas)
Small sample size = 16, but with a
94% response rate
This study also mentions a
previous larger VSO study and its
findings
Working in a country with a different
culture, language, and resource poor
clinical setting can be challenging and a
stressful experience for many volunteers
but there are also positive rewards
Positive:
increase in the following: cultural
sensitivity; global awareness; adaptability;
interpersonal skills; handling
responsibility; stress management;
confidence; self-assurance; problem
solving; team working; management;
leader- ship; and strategic thinking.
Changes in attitude, knowledge and
learning, increased resilience. Personal
satisfaction that they have made a
difference in the lives of others
Negative:
Challenges such as dealing with difficult
clinical scenarios, lack of essential
equipment and resources, gender issues for
women in a male dominated work
environment, inadequate clinical
infrastructure
volunteers reported feeling frustrated
(76%), lonely (61%), over- whelmed
(55%), stressed (52%), demotivated (35%)
and a loss in confidence (33%)
“Medical volunteering
is not straightforward,
and each individual
volunteer has a unique
and personal
experience” that
includes positive and
negative experiences
VSO recognizes the
mental challenges and
provides
comprehensive
support in each base
country, including
online and residential
weekend courses for
outgoing and returning
volunteers
(they can do this in the
base country because
it’s a longer volunteer
experience, but we
could offer resources
like this after a short-
term volunteer group
returns home)
McCauley M,
Raven J, van den
Broek N.
Experiences and
impact of
international
medical
To assess the
experience and impact
of medical volunteers
who facilitated
training workshops for
healthcare providers in
maternal and newborn
A mixed-
methods
study using
qualitative
interviews
Qualitative interviews for medical
volunteers based in the UK (n=38),
and an online survey (n=262) to
assess healthcare providers from
both the UK and LMIC (total
n=300) regarding their views and
medical volunteers were motivated by
altruism, and perceived volunteering as a
valuable opportunity to develop their skills
in leadership, teaching and
communication, skills reported to be
transferable to their home workplace
Describes reasons for
volunteering,
expectations, and
experiences
ANESTHESIA IN AUSTERE ENVIRONMENTS
43
volunteering: a
multi-country
mixed methods
study. BMJ Open.
2021 Mar 23;11(3)
emergency care in 13
countries.
experiences of international
medical volunteering
Outcome measures Expectations,
experience, views, personal and
professional impact of the
experience of volunteering on
medical volunteers based in the
UK and in LMIC
Medical volunteers based in the UK and in
LMIC (n=244) reported increased
confidence (98%, n=239); improved
teamwork (95%, n=232); strengthened
leadership skills (90%, n=220)
Has a nice table on the
impact of their
experience
Meara, J. G.,
Leather, A. J.,
Hagander, L.,
Alkire, B. C.,
Alonso, N., Ameh,
E. A., Bickler, S.
W., Conteh, L.,
Dare, A. J., Davies,
J., Mérisier, E. D.,
El-Halabi, S.,
Farmer, P. E.,
Gawande, A.,
Gillies, R.,
Greenberg, S. L.,
Grimes, C. E.,
Gruen, R. L.,
Ismail, E. A.,
Kamara, T. B., …
Yip, W. (2015).
Global Surgery
2030: evidence and
solutions for
achieving health,
welfare, and
economic
development.
Lancet (London,
England),
386(9993), 569–
624.
Establish goals for
global access to
surgery by 2030
Special
Report/Com
mission,
Gray
Literature
Formed four working groups that
focused on the
domains of health-care delivery
and management.
workforce, training, and education;
economics and
finance; and information
management. The Commission
has five key messages, a set of
indicators and
recommendations to improve
access to safe, affordable surgical
and anesthesia care in LMICs, and
a template for a national surgical
plan.
Extensive - 56 pages of analysis and
recommendations.
- B&S: Data and
statistics on the global
need for safe,
affordable surgical
services (including
anesthesia)
Missair, A.,
Gebhard, R.,
Pierre, E., Cooper,
L., Lubarsky, D.,
Frohock, J., &
Describe conditions in
Haiti surrounding the
2010 earthquake.
Detail the
development of relief
Special
Report/Obse
rvational
N/A: observational report Regional block anesthesia critically
important at beginning phase of such a
disaster
Recommendations for a surgical team that
is equipped to provide regional nerve
Describes an austere
environment post-
disaster
ANESTHESIA IN AUSTERE ENVIRONMENTS
44
Pretto, E. A., Jr
(2010). Surgery
under extreme
conditions in the
aftermath of the
2010 Haiti
earthquake: the
importance of
regional anesthesia.
Prehospital and
disaster medicine,
25(6), 487–493.
efforts, as well as an
anesthesiologist’s
experience
block anesthesia and pain management can
be dispatched rapidly as a bridge to more
advanced field surgical and intensive care
Describes four
“periods” of disaster
relief that an
anesthesia provider
could be working
within.
Quevillon RP,
Gray BL, Erickson
SE, Gonzalez ED,
Jacobs GA.
Helping the
Helpers: Assisting
Staff and Volunteer
Workers Before,
During, and After
Disaster Relief
Operations. J Clin
Psychol. 2016
Dec;72(12)
To discuss the
importance of
organizational
supports and self-care
strategies in disaster
relief settings
A report
based on
literature
and
experiences
The authors are managers of
Disaster Relief Operations and
state they derived suggestions from
“suggestions are derived from the
empirical and experiential literature
and extensions from the theoretical
background, and from our
experience as managers”
self-care before, during, and after an
operation may benefit relief workers by
preventing distress and compassion fatigue
and enabling them to experience positive
outcomes after a relief operation.
organizations of relief efforts must also
promote self-care and social support relief
workers
discusses the
psychology related to
relief workers, and the
importance of “helping
the helper”
Rivers, Dukes, S.,
Hatzfeld, J., Yoder,
L. H., Gordon, S.,
& Simmons, A.
(2017).
Understanding
post-deployment
reintegration
concerns among en
route care nurses:
A mixed-methods
approach. Military
Medicine, 182(S1),
243–250.
To understand the
post-deployment
behavior health
symptoms
and readjustment/
reintegration
experience by military
nurses who provided
en route care while
serving in Operation
Enduring
Freedom/Operation
Iraqi Freedom.
Mixed:
quantitative
and
qualitative
-Data gathered through an
electronic survey and single, one-
on-one interview with a subset of
the sample.
-119 nurses completed survey; 22
completed the interview
Quantitative Data: 36 item
instruments with 5 subscales: total
score(36-180);Career challenges
(5-25); Social Difficulties (7-35);
Intimate relationship problems (5-
25); health concerns (5-25);
concerns about deployment (6-30);
PTSD symptoms( 8-40).
Qualitative Data: Interview were
25-90 mins in setting of
participants choice
- 74% used Military Behavioral Health
services following deployment.
-~53%
-themes: Leadership matters, I don’t fit in,
Here is my suffering, The terror of war-
you can’t unsee that.
Survey results: post deployment:
39%: I don’t fit in socially
61%: I’ve changed/others have changed
51%: felt pressured to be back to normal
-These individuals were not the same
person when they came back from
deployment; somethings were not as
important as they were pre-deployment
-suppressed feelings because others
couldn’t relate to their experiences
-difficulty getting back into the family role
**a lot more data can
be extrapolated from
this article
-participants described
they didn't’ want to
talk about their
experiences with those
who had not been
deployed in a similar
situation; lack of
relatability and
understanding
- Support within 6
months
ANESTHESIA IN AUSTERE ENVIRONMENTS
45
-Leaders play a key role in the
reintegration process, often being more
understanding and caring.
Roche, S.,
Ketheeswaran, P.,
& Wirtz, V. J.
(2016).
International short-
term medical
missions: a
systematic review
of recommended
practices.
International
Journal of Public
Health, 62(1), 31–
42.
https://doi.org/10.1
007/s00038-016-
0889-6
identify practices for
conducting
international short
term medical missions
recommended in the
literature and examine
how these link
STMMS to recipient
countries’ existing
health systems.
systematic
review
92 articles included 67%
recommend at least one practice
that would link the ‘visiting
medical team’ to the local health
system.
-54% of articles recommended included
the local healthcare providers in the
STMM, to educate “a volunteer's role is
that of a teacher, rather than the primary
provider of service to patients” Educate
so that these locations don’t become
dependent on your mission work.
-Clear global standards are needed to
ensure services delivered are beneficial to
the patients and to the healthcare systems
of recipient countries. There’s lack of
consensus around standard of care, and
recommended duration of commitment.
Due to the lack of
standards of care, this
can be a source of
moral anguish for the
provider. I used some
of the data for the
background that
contributes to some of
the negative
experiences felt
Background:
Literature extensively
supports ongoing
connection to local
health system, harmful
effects of STMMs
without proper
education of host. “We
will not review in this
paper”
Stone, & Olson, K.
R. (2016). The
Ethics of Medical
Volunteerism. The
Medical Clinics of
North America,
100(2), 237–246.
https://doi.org/10.1
016/j.mcna.2015.0
9.001
to provide insight into
the ethical challenges
and impact short term
medical missions have
on the community
they’re aiming to help.
-Literature
Review
-Extensive literature review that
evaluates:
-limited time and resources,
lessons from international research,
principles for medical
volunteerism, partnerships,
personal preparation, reflection,
support, and sustainability.
-volunteers may feel pressured to work
beyond their scope and expertise which
could be dangerous to patients.
-short term missions don’t offer adequate
follow up, including complications
-if no education is done with the
community, they become reliant on these
volunteer missions
-collaborative partnership vital to
empower the community
-preparation for missions is essential:
equips volunteers with a framework of
expectations and tools to process the
experiences and challenges.
-space and time for reflection allow for
personal growth
-support is vital to decrease burnout,
depression, anxiety and emotional
exhaustion; mentorship or onsite support is
often missing during these short mission
trips.
-use the emotional
effects to tie into the
paper.
-good sources for
some statistics and
positives and negatives
to volunteer medical
mission work.
-primary focuses on
the potential
detriments to the
community they’re
helping (lack of
follow-up,
communication
barriers affecting
patient driven care,
etc)
ANESTHESIA IN AUSTERE ENVIRONMENTS
46
Tao, Km., Sokha,
S. & Yuan, Hb.
The challenge of
safe anesthesia in
developing
countries: defining
the problems in a
medical center in
Cambodia. BMC
Health Serv Res
20, 204 (2020).
https://doi.org/10.1
186/s12913-020-
5068-z
To describe anesthesia
service in one main
public hospital during
an 8-month
medical mission in
Cambodia and
evaluate its anesthetic
safety issues
according to the
ISSPA (International
Standards for a Safe
Practice of
Anesthesia).
Quantitative,
retrospective
observationa
l
1953 patients at the Preah Ket
Mealea hospital. Patient
demographics, anesthetic
techniques, and complications were
reviewed according to the registers
of the anesthetic
services and questionnaires. The
inadequacies in personnel,
facilities, equipment, medications,
and conduct of
anesthesia drugs were recorded
using a checklist based on the
ISSPA.
A total of 1792 patients received general
and regional anesthesia in the operating
room, while 161 patients received sedation
for gastroscopy. The three most common
surgical procedures were abdominal ,
orthopedic
, and urological surgery . General
anesthesia, spinal anesthesia, and
brachial plexus blocks were performed in
54.3% , 28.2%, and 9.4% of patients,
respectively. One death occurred. Twenty-
six items related to professional aspects,
monitoring, and
conduct of anesthesia did not meet the
ISSPA-recommended standards. A lack of
commonly used drugs and
monitoring equipment was noted, posing
major threats to the safety of anesthesia
practice, especially in
emergency situations.
- Limited studies
looking at how austere
environment
anesthesia delivery
holds up to ISSPA
standards. Good
example of quality
control/measuring.
- Reveals gap between
ISSPA
recommendations and
reality in LMIC
settings.
Tyler N, Chatwin
J, Byrne G, Hart J,
Byrne-Davis L.
The benefits of
international
volunteering in a
low-resource
setting:
development of a
core outcome set.
Hum Resource
Health. 2018 Dec
20;16(1):69
Meta-Synthesis:
Aimed to detail the
personal and
professional
development
outcomes of
international volunteer
work
To report the variables
that influence these
personal and
professional
development
outcomes
Delphi Study:
To develop a set of
core outcomes
To evaluate the impact
of the volunteer
experiences on the
volunteers.
Systematic
Review &
Meta-
Synthesis
Participants were health
professionals. Conducted a
systematic or meta-synthesis of 55
peer-reviewed papers and
consolidated qualitative research
and individual accounts of
experiences of health professionals
volunteering in resource-poor
settings. They found 133 unique
outcomes and 34 potential
variables. Then used a Delphi
method, an interactive process of
rounds in which data are collected
and condensed into a group
consensus in or to generate the core
outcomes (COs) of the study.
Found 40 individual benefits in seven
domains: clinical skills, management
skills, communication and teamwork,
patient experience and dignity, policy,
academic skills and personal satisfaction
and interest.
Found 28 potential negative outcomes.
(discussed in another follow up paper
focusing on the negative outcomes)
will supports section
on benefits of
volunteering in austere
environments
ANESTHESIA IN AUSTERE ENVIRONMENTS
47
Tyler N, Ackers
HL, Ahmed A,
Byrne G, Byrne-
Davis L. A
questionnaire study
of the negative
outcomes for UK
health professional
volunteers in low-
and middle-income
countries. BMJ
Open. 2020 Jun
15;10(6)
This is a continuation
of the 2018 study, but
this report aims to
explain the negative
outcomes from
international volunteer
work
Systematic
Review &
Meta-
Synthesis
Same as previous Tyler study from
2018
Found 28 potential negative outcomes.
(discussed in another follow up paper
focusing on the negative outcomes)
will supports section
on negative outcomes
of volunteering in
austere environments
Withers, Browner,
C. H., & Aghaloo,
T. (2012).
Promoting
Volunteerism in
Global Health:
Lessons from a
Medical Mission in
Northern Mexico.
Journal of
Community Health,
38(2), 374–384.
https://doi.org/10.1
007/s10900-012-
9627-z
-obtain a better
understanding of how
to promote regular
volunteerism
-what motivates
volunteers is
important for orgs to
develop long-term
volunteers to meet the
need for health care
services
-case study -examined health clinic in Baja,
Ca, Mexico because of long history
of successful motivation and
recruitment of volunteers (for over
20 years).
-30 open ended, semi structured
interviews conducted with a
convenience sample of students
x6, residents x3, nurses x5, dentists
x6, oral surgeons x3 and
community volunteers x7.
-motivating factors included psychological
and emotional rewards. career related
benefits, opportunities for interpersonal
interaction, the opportunity to serve
disadvantaged communities and personal
relevance of the mission.
-professionals volunteers for sense of
satisfaction; students volunteered for the
career related benefits
-establish relationships btw fellow
volunteers and pts
-positive 1st volunteer experience
enhances continuation of volunteering in
the future. 1st impressions played a vital
role.
-lots of benefits to
volunteering, which
encourages continued
volunteerism
- Mentors to help with
preparation and
follow-up
Abstract (if available)
Abstract
Countless anesthesia providers volunteer their time and resources to deliver care around the world to those who need it, and the demand for surgery is disproportionally severe in underserved areas. Current literature establishes the jarring finding that humanitarian aid workers and other similar volunteers suffer negative mental health consequences after returning from service in austere environments. Some organizations, including non-government organizations and the military, offer specific psychologically protective care for those returning from austere environments. This paper offers recommendations to provide a framework for mental wellness support, specific to anesthesia providers, with the intention for it to be employed by national and state associations.
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Asset Metadata
Creator
Flores Simons, Cristina Danielle
(author)
Core Title
Effective methods for addressing psychological challenges among anesthesia providers returning from practice in austere environments: a literature review with professional recommendations
School
Keck School of Medicine
Degree
Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Degree Conferral Date
2024-05
Publication Date
09/11/2023
Defense Date
09/10/2023
Publisher
Los Angeles, California
(original),
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anesthesia,austere,Disaster relief,medical volunteers,mental health consequences,mental health support,OAI-PMH Harvest,psychological impact,resource-poor environment,Volunteer
Format
theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
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Advisor
Carr, Joshua (
committee chair
), Bamgbose, Elizabeth (
committee member
), Meier, Adrienne (
committee member
)
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cfsimons@gmail.com,floressi@usc.edu
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Tags
anesthesia
austere
medical volunteers
mental health consequences
mental health support
psychological impact
resource-poor environment