Sieveking et al. (1981, pp 101-102) remind us that, 'Regardless of how valid our selection is, and how thorough our orientation, most any employee will encounter difficulties . . . we can never leave even the best employee alone'.
As part of the preparation package, expatriates should receive information about where they can go for help should they have health problems or other difficulties overseas. Sending agencies should have a policy on this issue. For mild difficulties, information may be sufficient. In more severe cases, consultation with a health professional should be arranged. Ideally, organizations should obtain information about health services in the area, and how they can be accessed, before the expatriate arrives.
Ongoing contact from the sending agency can reduce the sense of isolation and anxiety, including anxiety about what will happen when they return home. Aycan (1997, p. 33) reported that, 'expatriates who feel confident about company support are likely to adjust better than those who experience uncertainty and stress about their future'. It can be useful to check that they are not working excessively long hours, and that they are taking days off regularly. They should be informed about how they can provide feedback, make requests or ask for help (practical or emotional) at any time should they require it. Adequate supervision should be provided. Inviting their suggestions for changes and improvements can foster job satisfaction. Chronic stress problems are less likely to materialize in an environment where people feel free to acknowledge difficulties and request help at an early stage.
Very little has been written about models of care that can be provided in international settings and there are no data in the literature that would distinguish one model of care as being more effective than another. The possibilities include: (1) self-reliant staff who develop their own network and health care providers; (2) national staff who have received international training who are familiar with the culture of the home country; (3) international clinics staffed by persons who are also members of that expatriate community; (4) clinics staffed by members of the same organization; and (5) reliance on networks that have been established by the embassy for their personnel.
Although 'self-care' is necessary, it appears that most do seek help from health care professionals for more complex medical problems. Professional help should also be sought in cases of psychosis, severe depression, suicidal ideation, anorexia nervosa, PTSD, serious difficulties with a child (including the possibility of abuse), or any mental health problem that appears to be getting worse. Organizations could increase the potential for more effective care by fostering a culture that promotes help-seeking behaviour (MMWR, 1999).
Expatriates can feel isolated and undervalued if they are not asked periodically how their workload is, and how they are coping personally. Even without sophisticated technology, satellite telephones and e-mail links will often provide timely counsel for persons in remote regions.
Self-care is often strengthened by access to reputable web sites, many of which have been developed for travelers who do not have formal medical training. Patients now have the potential to access their medical records via the Internet. Although care through electronic mediums is often limited to general advice rather than formulation of a specific diagnosis and management plan, one can often provide guidance that will help expatriates to determine an appropriate course of action. Results of laboratory testing can be faxed, and good quality films from a variety of diagnostic imaging services can be couriered to a tertiary care center for a fraction of the cost of repatriation.
Soon that will seem archaic. With technology that is currently available, telemedicine is experiencing a resurgence of interest. Several models of medical care have been developed that can serve as practical examples, such as the Yale Telemedicine Center which has created links with physicians in Saudi Arabia. It is probable that the military will establish a number of precedents, given their established communication links. When utilizing tele-medicine it is difficult to know the limits of medical licensure and difficult to determine medical-legal boundaries. Many are critical of endorsement without careful attention being given to the standards of care and the appraisal process.
If appropriate treatment is not available locally, or the expatriate is unwilling to accept it, there may be a need for repatriation. A local medical professional may be able to liaise with the organization in such cases. The expatriate should be helped to accept that repatriation is not a sign of failure. Comprehensive travel insurance includes cover for emergency repatriation (Medivac). By accessing the company's helpline (given on the insurance documents), travel arrangements will be made by the assistance company.
A common situation is evacuation due to deterioration in the security situation. It is very helpful if organizations have clear evacuation policies, which expatriates are asked to adhere to as a condition of their contract. It is not uncommon for expatriates to refuse to follow an evacuation policy, perhaps because they do not believe that there is any danger, or because in the heat of a crisis they develop a 'martyr instinct' and insist that they will not abandon their local friends. Expatriates who have consented to a policy before going overseas, having been informed of the reasons for it, are more likely to adhere to it later. Organizations should also have policies on such issues as abuse and hostage situations.
If an expatriate does experience evacuation or any other traumatic incident, it may be appropriate to offer critical incident stress debriefing (CISD) (Mitchell, 1983). If there are several expatriates working in close proximity, it may be beneficial to ensure that at least one of them is trained in such debriefing. CISD was proposed originally as an intervention where groups of people who had experienced a traumatic incident would meet together 24—72 h after the incident, and describe in a structured way the facts about what had happened, and then their thoughts, followed by their feelings. Participants would then be helped to normalize their reactions, and then to move towards future planning.
There is currently considerable debate about the effectiveness of CISD. No randomized controlled trials have been conducted for CISD in groups, and there have only been six such trials using CISD with individuals (Rose and Bisson, 1998). These six trials had mixed results, possibly due to methodological shortcomings. It appears from the literature that most people who receive CISD report finding it helpful, although it is not clear whether it actually leads to a reduction in post-traumatic symptoms. Further research will hopefully add further insight to this debate.
After any traumatic incident, it is wise to ensure that there is adequate time to rest. Accidents are more common following a stressful experience, and so the individual should be encouraged to take particular care, especially when driving. PTSD can develop months or even years after a traumatic event, perhaps being triggered by a subsequent event, and so follow-up support should be offered should the expatriate wish to receive it at any point.
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