Victims of the Terrorist Attacks in Belgium and Professional Mental Health Aid Barriers: A Qualitative Study.

Introduction: Terrorist attacks can cause short and long-term stress-reactions, anxiety, and depression among those exposed. Sometimes, professional mental health aid, meaning all types of professional psychotherapy, would be appropriate, but victims often delay or never access mental health aid, even up to a decade after the initial event. Little is known about the barriers terrorist-victims encounter when they try to access professional mental health aid. Method: Using a qualitative design, 27 people exposed to the 22/03/2016 terrorist attack in Belgium were interviewed using half-structured, in-depth interviews, on their experiences with professional mental health aid. A reflexive thematic analysis was employed. Results: Five main barriers for professional mental health aid seeking by victims were found. First, their perception of a lack of expertise of mental health aid professionals. Second, the lack of incentives to overcome their uncertainty to contact a professional. Third, social barriers: people did not feel supported by their social network, feared stigma, or trusted that the support of their social network would be enough to get them through any difficulties. Fourth, a lack of mental health literacy, which seems to be needed to recognize the mental health issues they are facing. Finally, there are financial barriers. The cost of therapy is often too high to begin or continue therapy. Conclusions: This study showed that the barriers for seeking professional mental health aid are diverse and not easily overcome. More mental health promotion is needed, so that there is a societal awareness of possible consequences of being exposed to terrorist attacks, which might result in less stigma, and a quicker realization of possible harmful stress reactions due to a disaster.

Impact of terrorist attacks on social relationships.

BACKGROUND: People that experience a trauma might also experience problems in their social relationships. However, how witnessing a terrorist attack influences social relationships is still understudied. This is important, as currently, there is more focus on the individual's mental health and not on how this mental health can impact the individual's social relations. In this study, the impact of the experience of a terrorist attack on social relationships was studied. METHODS: In-depth interviews were conducted, with 31 directly exposed people during the 22 March 2016 attacks in Belgium. Data were analysed using reflexive thematic analysis. RESULTS: Three factors related to the impact on social relationships were found. First, participants felt that they had changed. This includes feeling more aggressive, guilty, distrusting or psychosomatic factors, such as migraine attacks, which can hamper social visits. Second, the reactions of others on the participant's expressing their feelings and behaviour also caused participants to not feel understood by their social relationships. Third, due the first two factors, participants coped in different ways (e.g. remaining silent and avoiding certain triggers), which in turn caused their social relationships to change. CONCLUSIONS: The social relationships of witnesses of terrorist attacks can be hampered due to both themselves as well as the reaction of others. More awareness seems to be needed on the possible mental health consequences of terrorist attacks for witnesses.

Compassion fatigue of funeral directors during and after the first wave of COVID-19.

BACKGROUND: Compassion fatigue has not been studied among funeral directors. Yet, funeral directors have been exposed to the same risks for compassion fatigue as other caregivers during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: An online survey was spread two times to 287 employees of funeral home DELA, in Belgium. Once during the height of the first wave of COVID-19 in Belgium, and a second time at the end of the first wave. The professional quality of life-scale 5 (PROQOL-5) was used to measure compassion fatigue, which includes burnout, compassion satisfaction and secondary trauma. Non-parametric tests were performed. RESULTS: In total, 104 participants answered the first survey, and 107 the second. Burnout increases from survey 1 to survey 2 (P < 0.001), while compassion satisfaction (P = 0.011) and secondary trauma decrease (P < 0.001). In survey 1, only age (P = 0.007) and gender (P = 0.040) were found to be significantly associated with secondary trauma. In survey 2, having more work experience is associated with having a higher burnout (P = 0.008) and secondary trauma (P = 0.001) score. Neither for burnout (P < 0.001), nor for secondary trauma (P < 0.001) are there any respondents in the highest category. CONCLUSIONS: Although overall funeral directors do not have acute problems with compassion fatigue, burnout scores increase significantly after the first wave.

Withholding/Withdrawing Life-Sustaining Treatment in a Multiethnic Critical Care Setting: An Ethnographic Study.

Background: Critical care physicians often have to make challenging decisions to withhold/withdraw life-sustaining treatments. As a result of society's increasingly cultural diversity such decision making often involves patients from ethnic minority groups, which might pose extra challenges. Objective: To investigate withholding/withdrawing life-sustaining treatments with patients from ethnic minority groups and their families during critical care. Design: Ethnographic fieldwork (observations, in-depth interviews and reading patients' medical files). Setting/Subjects: Eighteen patients from ethnic minority groups, their relatives, physicians and nurses were studied in one intensive care unit of a multi-ethnic urban hospital (Belgium). Results: During decision making physicians had a very central role. The contribution of patients and nurses was limited, while families' input was more noticeable. Decision making was hampered by communication difficulties between: (1) staff and relative(s), (2) relatives, and (3) patient and relative(s). Different approaches were used by physicians to overcome difficulties, which often reflected their tendency to control decision making, for example, stressing their central role. At times their approaches reflected their inability to align families' wishes with their own, for example, when making decisions without explicitly informing relatives. Conclusions: Withholding/withdrawing life-sustaining treatments in a multi-ethnic critic care context has a number of alarming difficulties, such as how to take families' input correctly into account. It is important that decision making happens in a cultural sensitive way and with involvement tailored to patients' and relatives' needs and in close consultation with interprofessional health care workers/other services.

Intercultural mediators in Belgian hospitals: Demographic and professional characteristics and work experiences.

OBJECTIVE: To investigate the 1) socio-demographic characteristics, 2) working environment, 3) tasks and responsibilities and 4) work experiences of intercultural mediators (IMs) working in Belgian hospitals. METHODS: Cross-sectional quantitative survey among all IMs working in Flemish and Brussels hospitals (n = 66). Data were descriptively analyzed. Meaningful associations between variables were also studied. RESULTS: Most IMs are young women from first- and second-generation migrant groups with different levels of education. They work under different superiors and most IMs are not employed full-time. They work mainly with patients from their own ethnic group. Mostly they intervene directly in daily intercultural communication, as per their official task description, but they also perform other tasks, such as offering support to patients/families/staff/management. IMs would prefer more of the tasks they perform to be formalized. Furthermore, they want to have policy-making responsibilities. IMs have positive and negative work experiences, e.g. working overtime. CONCLUSIONS: IMs' socio-demographic characteristics (ethnic origin - sex - education) and official task description is only adapted to needs in the workplace to a limited extent. Furthermore, intercultural mediation is poorly integrated into hospitals' organizational structure. PRACTICE IMPLICATIONS: Different measures are needed, including tailored education and offering IMs enough organizational support and policy responsibilities.

Preventing Conflicts Between Nurses and Families of a Multi-ethnic Patient Population During Critical Medical Situations in a Hospital.

Introduction: Little is known about how to avoid intercultural nurse-family conflicts in critical care settings. In this article, strategies are discussed that may be useful to prevent or mitigate intercultural nurse-family conflicts during critical medical situations in hospital. Method: Strategies are based on an ethnographic study by Van Keer et al., other literature, and expert opinion. Results: Sufficient structural measures are needed. First, institutions must create appropriate ward policies, such as including nurses in end-of-life communication. Second, nurses should be coached in the workplace. Third, institutions must provide adapted, visual, ward information to families. Additionally, education and research are needed. These measures should be actively stimulated by nurse managers and reflect a multicultural program supported by the hospital. Discussion: Intercultural nurse-family conflict prevention or mitigation should take into account organizational aspects, on hospital units and in hospital as a whole, and the crucial role of education and research.

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study.

OBJECTIVE: During critical care, physicians are frequently confronted with bad-news communication because of patients' frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context. METHODS: Ethnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients' medical records. Data were thematically analysed. RESULTS: Bad-news communication was primarily dominated by physicians. Patients' and relatives' input and other professionals' involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out. CONCLUSION: Delivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved. PRACTICE IMPLICATIONS: The challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.

Mental well-being of patients from ethnic minority groups during critical care: a qualitative ethnographic study.

OBJECTIVES: To investigate the state of the mental well-being of patients from ethnic minority groups and possible related risk factors for the development of mental health problems among these patients during critical medical situations in hospital. DESIGN: Qualitative ethnographic design. SETTING: Oneintensive care unit (ICU) of a multiethnic urban hospital in Belgium. PARTICIPANTS: 84 ICU staff members, 10 patients from ethnic-minority groups and their visiting family members. RESULTS: Patients had several human basic needs for which they could not sufficiently turn to anybody, neither to their healthcare professionals, nor to their relatives nor to other patients. These needs included the need for social contact, the need to increase comfort and alleviate pain, the need to express desperation and participate in end-of-life decision making. Three interrelated risk factors for the development of mental health problems among the patients included were identified: First, healthcare professionals' mainly biomedical care approach (eg, focus on curing the patient, limited psychosocial support), second, the ICU context (eg, time pressure, uncertainty, regulatory frameworks) and third, patients' different ethnocultural background (eg, religious and phenotypical differences). CONCLUSIONS: The mental state of patients from ethnic minority groups during critical care is characterised by extreme emotional loneliness. It is important that staff should identify and meet patients' unique basic needs in good time with regard to their mental well-being, taking into account important threats related to their own mainly biomedical approach to care, the ICU's structural context as well as the patients' different ethnocultural background.

Conflicts between healthcare professionals and families of a multi-ethnic patient population during critical care: an ethnographic study.

BACKGROUND: Conflicts during communication in multi-ethnic healthcare settings is an increasing point of concern as a result of societies' increased ethno-cultural diversity. We can expect that conflicts are even more likely to arise in situations where difficult medical decisions have to be made, such as critical medical situations in hospital. However, in-depth research on this topic is rather scarce. During critical care patients are often unable to communicate. We have therefore investigated factors contributing to conflicts between healthcare professionals and family members from ethnic minority groups in critical medical situations in hospital. METHODS: Ethnographic fieldwork was done in one intensive care unit of a multi-ethnic urban hospital in Belgium over 6 months (January 2014 to June 2014). Data were collected through negotiated interactive observation, in-depth interviews with healthcare professionals, from patients' medical records, and by making notes in a logbook. Data were analysed by using grounded theory procedures. RESULTS: Conflicts were essentially related to differences in participants' views on what constitutes 'good care' based on different care approaches. Healthcare professionals' views on good care were based predominantly on a biomedical care model, whereas families' views on good care were mainly inspired by a holistic lifeworld-oriented approach. Giving good care, from the healthcare professionals' point of view, included great attention to regulations, structured communication, and central decision making. On the other hand, good care from the families' point of view included seeking exhaustive information, and participating in end-of-life decision making. Healthcare professionals' biomedical views on offering good care were strengthened by the features of the critical care context whereas families' holistic views on offering good care were reinforced by the specific characteristics of families' ethno-familial care context, including their different ethno-cultural backgrounds. However, ethno-cultural differences between participants only contributed to conflicts in confrontation with a triggering critical care context. CONCLUSIONS: Conflicts cannot be exclusively linked to ethno-cultural differences as structural, functional characteristics of critical care substantially contribute to the development of conflicts. Therefore, effective conflict prevention should not only focus on ethno-cultural differentness but should also take the structural organizational characteristics of the critical care context sufficiently into account.