Psychosocial support and resilience building among health workers in Sierra Leone: interrelations between coping skills, stress levels, and interpersonal relationships

Effect of counseling on coping, stress and relationships

Table 1 presents the results of the descriptive analysis that addressed coping skills, stress
levels and relationships. In the post-test period, health workers’ ability to apply
coping techniques, overall and for each of the three domains (communication, self-care
and social connectedness), was significantly higher in the intervention district of
Kono than in the control area (p=0.000). In the intervention district, differences
in coping skills from the retrospective pre-test to the post-test periods were positive
and statistically significant (p=0.000). On average, health workers reported lower
stress levels in the intervention district (captured by an aggregate score of 2.40)
compared with the comparison district (2.48), marked by a statistically significant
difference (-0.086, p=0.034).

Table 1. Coping skills, stress levels and relationships

Table 1 also shows that between the retrospective pre-test and post-intervention periods
within Kono, there were improvements in overall relationships (p=0.000), relationships
with co-workers (p=0.000), and relationships with clients (p=0.000). The difference
in overall relationships between the intervention and control sites in the post-test
period was also significantly significant (p=0.025). Although a positive difference
was observed for relationships between providers working at the same facility, the
difference between intervention and control groups was not statistically significant
(p=0.110). The mean value of relationships between providers and clients was found
to be slightly lower in Kono than in the comparison district, though the difference
was not statistically significant (p=0.320).

Association between change in coping skills, stress levels and change in relationships

To address objective 2, Table 2 presents the Pearson correlation coefficients between the changes in coping skills
from the pre-test to the post-intervention, the overall post-test perceived stress
levels, and the changes in relationships from the pre-test to the post-intervention
for the 129 health workers interviewed in the intervention district. An increase in
coping skills was associated with a reduction in stress levels and was statistically
significant (-0.197, p0.05), though the association was rather weak. The association
was stronger for communications skills (-0.237, p0.01), weaker for social connectedness
(-0.177, p0.05), and virtually non-existent for self-care skills. Lower post-test
stress levels were associated with sharper increases in relationships. The three observed
linear relationships, which were all statistically significant, appear rather weak
for the relationships with co-workers (-0.202, p0.05), for the relationships with
patients (-0.191, p0.05), and for the overall relationships variable (0.223, p0.05).

Table 2. Pearson correlation coefficients between change in coping skills, stress levels, and
change in relationships

The associations between changes in coping skills and changes in relationships were
strong (+0.475, p0.01). The correlation of change in overall coping skills was stronger
with a change in relationships between providers and patients (+0.415, p0.01), than
with a change in relationships between co-workers (+0.330, p0.01). Among the three
domains of coping techniques, social connectedness and communication skills had the
strongest correlations with relationships with co-workers (+0.335 and +0.281, respectively),
and with relationships with patients (+0.381 and +0.388, respectively).

In-depth insights on associations between coping skills and relationships

The main themes that emerged from the qualitative analysis of health worker feedback
were perspective-taking and awareness, empathy, mutual accountability, and striking
a work-life balance. For clients, the qualitative analysis revealed a primary concern
with health worker behavior as an impediment to quality care. The following results
address objective 3. Most health workers interviewed reported learning about and using
coping and stress management skills that were completely unknown to them prior to
the project. In their narratives, some respondents reported that they became more
aware of compassionate client care techniques and acknowledged their importance both
for improving quality of care and for improving their personal quality of life.

Health workers interviewed in the project district identified client health-seeking
behavior patterns as one of their main causes of stress. For example, respondents
described being “interrupted” by patients needing urgent care during times when they
were not working. One interviewee said, “People in this community do not have respect
for medical [providers]. They can even enter my room [of my home] without knocking
the door [at odd hours].” Other health workers spoke about client delays in seeking
care, not following medical advice and a perceived lack of gratitude as additional
sources of frustration related to client behaviors. Perspective-taking, the cognitive
or intellectual understanding of another person’s experience, was commonly reported
as a useful skill in improving provider-client relationships during similar instances
18]. Many health workers reported that being able to see a problem from another person’s
viewpoint is a skill they gained from the intervention, and which helped them cope
with situations that presented stressors both for themselves and for their clients.
One health worker made the following comment when asked how he would handle a previous
altercation with a patient now that he had completed the training:

“I don’t think I will go out of my temper because I have now known that maybe the
woman has a stress or a problem that is bothering her from her home, so I will talk
to her nicely and try to know her problem and see how best I can help her.”

By looking beyond the situation at hand and taking stock of the potential broader
issues causing the conflict from the client’s perspective, such as stress related
to limited health resources, the respondent found an effective coping mechanism. The
same health worker also discussed how it could be difficult to call patients because
many were speaking loudly in the waiting area. The way he learned to cope with this
stressor was to approach them and ask them to lower their voices as “others were struggling”
whereas before the training he shouted at patients. He said, “I know that with time
they will change through the way I am talking to them.”

Empathy, a more emotional than cognitive response, was another effective stress management
tool reported by health workers to improve their interactions with clients 18]. One health worker explained:

‘‘I am very much patient with people which I did not use to have. I always put myself
in people’s position, thinking that if I’m the one that was in that situation [how
would] it have been? So because of that [I] will know how to talk to them in that
cool manner.’’

Health workers were able to reflect on the change in their own behaviors and attitudes
toward their clients after the counseling and training they received. One health worker
remarked: “The project was able to change…the harsh way I use[d] to talk to patients.
After the training I changed…When they come to the clinic…I don’t shout at them.”

Apart from provider-client interactions, many health workers also described positive
impacts of the intervention on relationships with their colleagues. Respondents reported
that they were better able to work as a team, gained a better understanding of mutual
accountability, had increased empathy for one another, and generally had “amicable
and cordial” relationships with co-workers after the intervention. One respondent
commented:

‘‘You know that this work is not a single man’s work. We need to work as a team; you
alone cannot do all the work…Before that program came, my co-workers [and I] were
not in good terms but now I can see reasons, if you have done a bad job… I will show
you where you do not understand.’’

Fostering solidarity among colleagues helped health workers channel frustration into
more productive actions such as mutual training to prevent stress-causing mistakes
in the future.

An additional finding from the qualitative analysis was the importance of striking
a work-life balance and improving self-care for health workers. One respondent described
the difficulties with self-care:

“Like for most of us the health workers, whenever we see patient in the morning packed
in the hospital, we will hardly take our breakfast. You will keep on walking and by
the time you will want to eat you will have no appetite to eat. I’m a human being
I can also fall sick but it is very hard for me to treat myself.”

She also reported that she would treat other people’s children before treating her
own and blamed this practice for the death of her son. From the training she learned
that “you should not do that. Before solving another man’s problem, you should solve
your own first.” By doing so, this respondent and others felt they were more capable
of doing their jobs well because they were healthier, both physically and emotionally.

During all client FGDs in Kono, clients prioritized issues related to relationships
between themselves and health workers as their main health service concerns. Clients
mentioned absenteeism of health workers’ behavioral issues as major impediments to
positive interactions. Most FGD participants did not report any changes or improvements
in health workers’ behaviors and their interactions with them; those who did were
hesitant, as they did not know if the changes were going to be consistent.