Sharing stories: Indigenous alcohol and other drug workers' well-being, stress and burnout
- Ann M. Roche PhD, Professor, Vinita Duraisingam Master Org Psych, Allan Trifonoff Grad Dip Leg Stud, Samantha Battams PhD, Toby Freeman PhD, Amanda Tovell Master Soc Work.
Correspondence to Professor Ann M. Roche, National Centre for Education and Training on Addiction (NCETA), Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia. Tel: +61 08 8201 7535; Fax: +61 08 8201 7550; E-mail: firstname.lastname@example.org
Indigenous alcohol and other drug (AOD) workers' roles are often exhausting, poorly paid and under-recognised. There has been relatively little examination of work-related stressors on their health and well-being. This national study identified Indigenous AOD workers' experiences and perspectives on well-being, stress and burnout along with strategies to improve worker well-being.
Focus groups were conducted with 121 participants (70 Indigenous, 20 non-Indigenous, 31 unspecified) from metropolitan, rural and remote locations around Australia, selected via a purposive sampling strategy. Audio files and interview notes were analysed to identify key themes.
Main themes identified included excessive workloads, extensive demands and expectations, workers' proximity to communities, loss and grief issues, lack of recognition, inadequate rewards, stigma and racism, and Indigenous ways of working. Stressors were compounded by workers' complex personal circumstances, profound levels of loss and grief, and lack of culturally safe working environments.
Discussion and Conclusion
Indigenous workers' stress was exacerbated by close links and responsibilities to their communities and a ‘dual accountability’, being constantly on call, playing multiple roles, complex personal and professional lives, and needing to interact with multiple agencies. Many Indigenous AOD workers had developed mechanisms to deal with work-related pressures and received valued support from their communities. The study identified the importance of workforce strategies to improve Indigenous workers' well-being and reduce stress, including: mutual support networks, training in assertiveness and boundary setting, workloads that take account of Indigenous ways of working, adequate remuneration, supervision and mentorship, and cultural sensitivity training for non-Indigenous workers. [Roche AM, Duraisingam V, Trifonoff A, Battams S, Freeman T, Tovell A, Weetra D, Bates N. Sharing stories: Indigenous alcohol and other drug workers' well-being, stress and burnout. Drug Alcohol Rev 2013;32:527–535]
A complex array of environmental, social, economic, cultural and historical factors affect the social and emotional well-being of Indigenous people . They include: unresolved loss and grief, trauma and abuse, domestic violence, physical health problems, identity issues, cultural dislocation, discrimination and social disadvantage. Compared with other Australians they are twice as likely to experience psychological distress  and associated poorer health outcomes, violence, smoking, risky drinking and illicit substance use . Prevalence of harmful alcohol and illicit drug use among Indigenous people is approximately double that of the non-Indigenous population  and contributes to socioeconomic disadvantage, mental disorders, family breakdown, violence, poorer physical health, hospitalisation and mortality [5, 6]. Further contributors are historical trauma, ‘the cumulative emotional and psychological wounding, over the lifespan and across generations’  and colonisation . However important protective factors have also been identified, including social cohesion, a sense of positive well-being and resilience, and connection to land, culture, spirituality and ancestry .
Correspondingly, Indigenous people seeking care and treatment for alcohol and other drug (AOD) issues require workers with specialised skills and knowledge and an understanding of Indigenous concepts of health and well-being . Results from our previous national survey of AOD workers in Indigenous communities found that they can play a crucial role in offering clinical and cultural support to their community . However, achieving this is not without significant challenge.
While estimates of the generic AOD workforce have been established [10, 11], the demographics of the Indigenous AOD workforce are uncertain. Proportionally, few Indigenous people are employed in health and human services, comprising 1% of the health workforce, but 3% of the population . Notwithstanding initiatives such as ‘Close the Gap’ , a shortfall exists in the Indigenous health-care workforce . The small size of the workforce, combined with high community need, exacerbates pressure on workers .
Indigenous human service workers are often overworked and offered limited training and support . Correspondingly, services and provision of basic programs, such as alcohol screening and brief intervention, reflect workers' knowledge and skills [17, 18]. Lack of experience and organisational support, as well as working in remote communities, can contribute to increased risk of violence . Living and working within the same community can also result in conflicts of interest and a potential threat to the well-being of Indigenous staff .
Worker well-being impacts on the capacity of agencies to respond effectively. Best practice in Indigenous-specific AOD programs has been examined. Common elements include clearly defined and effective management structures and procedures, staff training and ongoing staff development programs, collaborative approaches, strong leadership and adequate and continued funding .
The impact of work stress and burnout on mainstream AOD workers' well-being has been established [22-25]. One in five AOD workers experience high stress levels and low job satisfaction, increasing likelihood of turnover . Like others involved in emotional labour, they are subject to compassion fatigue , experience high levels of psychological morbidity and burnout [25, 27, 28] and have high levels of post-traumatic stress disorder stemming from vicarious trauma .
Few studies have specifically considered the experience of Indigenous AOD workers. The current study explored Indigenous AOD workers' experiences and perspectives of work-related well-being, stress and burnout in the context of workplace conditions and community, cultural and spiritual well-being.
Sample and study design
Focus groups (FG) were conducted with Indigenous AOD and general health workers. Participants were recruited using purposeful, maximum-variation sampling  through non-government and government-funded services in metropolitan, rural and remote locations. FG invitations were promoted through Indigenous research information networks.
FGs were conducted from September 2008 to June 2009. Questions reflected key issues that emerged from our earlier online survey conducted with Indigenous AOD workers [7, 31] and from relevant literature [14, 32-34]. Participants were asked about the nature of their work and issues their clients faced; aspects of work that were rewarding, challenging or stressful; the relevance and adequacy of training received; clinical supervision; working conditions; workplace racism; work–life balance; Indigenous ways of working; acceptance by clients; and clients' loss and grief issues.
FGs involved five to 10 participants; ran for approximately 90 min; were led by a facilitator/s, including an Indigenous researcher; and were confidential and audio-recorded with permission. A note-taker recorded observations on the setting, context and issues raised.
Ethics approval was obtained from the Flinders University and Southern Adelaide Health Service Social and Behavioural Research Ethics Committee, the Aboriginal Health and Medical Research Council (New South Wales), the Aboriginal Health Research Committee (South Australia) and the Western Australian Aboriginal Health Information and Ethics Committee.
Data collection and analyses
Data included audio recordings of FG discussions and facilitators' and note-takers' comment sheets. Thematic analysis was used to find repeated patterns of meaning, generate analytic categories and identify emerging themes . Multiple coders discussed emerging themes and codes [36, 37] in order to apply a common coding system and to determine the main themes. The main themes were also checked against each other and the original data . Provisional data interpretation was checked with key stakeholders through a series of interactive workshops and feedback on complex and/or sensitive issues incorporated into the final analysis. NVivo (QSR International Pty Ltd, Doncaster, Victoria, Australia) qualitative data analysis software was used to aid data management and analysis. Audio files were coded directly from the file.
Seventeen FGs were conducted (n = 121; 70 Indigenous, 20 non-Indigenous, 31 unspecified). Participants were aged from early 20s to mid-50s, with 52% (n = 63) being female; came from most states/territories (except the Australian Capital Territory and Tasmania); worked in metropolitan, regional and remote areas; and were mainly employed in community-controlled or government organisations. Workers' roles included Aboriginal health workers (AHWs), AOD workers, managers, supervisors and nurses.
Key themes to emerge from the data included: (i) sources of stress; (ii) individual stress management strategies; and (iii) workforce development strategies.
Sources of stress
Common sources of stress included excessive workloads, juggling multiple responsibilities, community proximity and expectations, loss and grief issues, lack of resources, and racism (Table 1). Specific stressors included the nature of drug and alcohol work; low staff numbers, complex client needs; inadequate services to support clients; being the ‘catch-all’ worker for Indigenous clients or the sole isolated worker; and lack of backfill, support and a ‘voice’ within an organisation.
Table 1. Ten principal contributors to work-related stress among Indigenous alcohol and other drug workers
|Workloads||High workloads were not commensurate with the resources available to meet the needs.|
|Expectations||Workers consistently demonstrated high levels of personal commitment to their work role and community obligations.|
|Boundaries||Being available 24/7 was part of a cultural obligation; some workers were learning to place appropriate limits and boundaries in culturally secure ways.|
|Recognition, respect and support||Recognition or respect was often not afforded workers. Solo or isolated workers had insufficient support.|
|Working conditions||Difficult and stressful working conditions were common, especially among workers in rural and remote settings.|
|Racism and stigma||High levels of stigma were associated with alcohol and other drug work and the Aboriginality of the clients and the workers. Racism was commonly experienced from co-workers and the mainstream community.|
|Complex personal circumstances||Many workers had complex personal/family circumstances. Family members were also often alcohol and other drug clients.|
|Loss and grief and sorry business||Traditional bereavement leave was rarely adequate. The importance of ‘sorry business’ and loss overall was often not understood by non-Indigenous people.|
|Culturally safe ways to work||There was a significant lack of understanding about ‘Indigenous ways of working’, resulting in conflict and clashes with mainstream colleagues and services.|
|Funding, job security and salaries||Short-term funding and short-term appointments with low salaries contributed to high stress levels and high turnover rates.|
Workloads and demands
Heavy workloads were common and derived from juggling multiple roles and a lack of clearly defined roles: ‘As Indigenous … we're the health worker, we're the counsellor, we're the doctor, we're the auntie, and carer sometimes’ (FG 9). Indigenous workers also often acted as community leaders: ‘Lots of workers have multiple roles, often natural leaders, and get to the point where they are doing so much other stuff’ (FG 9).
The complexity and gravity of issues dealt with was a significant source of stress. This was inextricably linked to workers’ proximity to their communities: ‘The hardest part being a woman AOD worker is working with women and they got children and their children have been taken away [by the Department of Human Services (DHS) ] … we're AOD workers and we're in at DHS all the time and courts … can be sister girls, they can be friends that we have grown up with, they can be even relations, and it's very hard’ (FG 16).
Demands from a range of professionals and services were also identified: ‘To have that stuff that you're talking about … with the community and putting your boundaries in is really difficult when you're talking about a community like [X] when you're it … the hospital are calling on you, on top of the community health service, on top of the police, on top of the ambos, on top of your family and the community as well!’ (FG 9). As a result many workers felt overwhelmed and were considered at risk of burnout: ‘… we are snowed under with work’ (FG 2).
Complex work and difficult employment conditions (including perceived lack of professional advancement) increased worker turnover and discouraged new recruits. This further impacted on workloads and stress levels of existing staff.
Proximity to and expectations of communities
Associated with stress and burnout were workers' enmeshment within their communities and community expectations and obligations. Indigenous workers experienced a ‘dual accountability’: ‘You have to be accountable as a department employee, but also to your community’ (FG 13); ‘Obligations are different between white and black people—that's the difference’ (FG 13); ‘… what causes burnout? Frustration, overload, and the community's expectations’ (FG 4). Communities/families had proprietary views of these workers, such that continually being available (‘24/7’) was seen as an immutable cultural obligation: ‘Sometimes, informally, they get torn between community expectations and health expectations’ (FG 9). Others described difficulties in establishing culturally appropriate limits and boundaries in order to prevent burnout. Some felt their behaviour outside work was constantly under scrutiny, which in itself was a source of stress.
Loss and grief
Most workers had complex personal circumstances and were single parents or responsible for dependent children, elderly and extended family members. Many had experienced significant bereavements, domestic violence and personal or family problems with alcohol or drugs. The high prevalence of premature deaths and suicides in communities resulted in profound loss and grief among both workers and clients: ‘That's a big one, the grief and loss. It's so big! We all suffer trauma as workers’ (FG 16); ‘… high levels of grief in the community. This can become overwhelming’ (FG 9). From an Indigenous perspective, loss and grief encapsulates ancestral, intergenerational, suppressed and unresolved grief often not well understood by mainstream colleagues. The difficulty of explaining the impact of loss and grief to managers/colleagues was highlighted. The cultural requirement to attend funerals and deal with ‘sorry business’ (i.e. bereavement and the cultural expression of grief, e.g. through traditional funeral and mourning practices) was a common source of friction, especially when workers were employed in mainstream services.
Work conditions and remuneration
The tenuous funding status of many community-based services contributed to poor remuneration, job insecurity, and lack of career pathways and professional development opportunities, which in turn were key sources of stress: ‘The restriction on career structure—that is a major stress on a lot of our health workers’ (FG 9). Workers maintained that they received inadequate remuneration, not commensurate with their skills and efforts: ‘They just pay you a mere pittance’ (FG 15). Comparisons with workers in similar roles were made, and Indigenous workers' salaries fared poorly: ‘Our awards are a joke really, compared to other people in the community working in the same positions, same roles and same needs who are on wage brackets of treble of what we earn’ (FG 16). Poor pay rates were juxtaposed with exceptional demands, including extensive unpaid ‘after-hours work’. Participants reported that low wages in remote communities contributed to poor health and acted as a motivator for workers to move to locations offering better remuneration.
Status of indigenous AOD workers, respect for indigenous ways of working and management support
Lack of understanding about Indigenous ways of working could also create friction within mainstream services and undermine client and worker well-being. There are appropriate ways of working with Indigenous people in Australia, as illustrated in the South Australian Iga Warta principles aimed at improving service delivery for Indigenous people, which include ‘respecting Aboriginal time and space’ . Similarly, Indigenous and non-Indigenous people have varying concepts of time. In Aboriginal communities, there is often no sense of urgency and an acceptance that important things will be attended to in due course . Such concepts of time, the need for flexibility and the importance of collective involvement were evident in this study.
Indigenous AOD work was often described in positive terms when sufficient time had been allocated: ‘We have more licence to address … complexities’ (FG 9); ‘Being an AHW you get to work in a different way—might spend a whole day with a client in our world, helping them out—wouldn't be able to do that in a different setting … you can adjust yourself to the person, not make the person adjust to the service. You can take time out [to help] … we're not there just to do the job, we care!’ (FG 10).
Negative experiences included lack of recognition; lack of respect for workers, their clients and the Indigenous ways of working mentioned earlier; and insufficient support from co-workers and management: ‘People get burnt out because no-one gives them the congratulations’ (FG 6). This was especially evident among solo and isolated workers. Lack of support and lack of awareness of Indigenous culture and society from managers, few Indigenous managers and inappropriate clinical skills of managers were other stressors. The absence of clinical supervision and similar forms of structural professional development were also reported.
Remoteness and lack of resources
Working in remote locations with limited resources, travelling long distances and inadequate transport further exacerbated worker stress. Workers also described inadequate office/counselling amenities. Isolation was a concern given workplace aggression and violence: ‘And it's the aggression side of things that you have to put up with. It gets a bit stressful. That's a big thing for me at my work’ (FG 2).
Stigma and racism experienced by clients and workers
Stigma was associated with AOD clients in general, as well as with the Aboriginality of clients, which in turn impacted upon AOD workers: ‘… even just being an AOD client without being Indigenous as well, we've really battled, haven't we … with attitudes to our clients’ (FG 9). There was often reticence to discuss personal experiences of racism. More often it was relayed in terms of the experiences of clients: ‘[I] feel bad for the people [i.e. the clients faced with racism], especially when you see their faces’ (FG 12); ‘It's hard enough to get people to address their health needs without having to battle that [racism] as well …’ (FG 9).
When asked about the impact of racism on themselves, some workers described it as ‘all-encompassing’ and ‘all-pervasive’. Examples of racism included subtle, but nonetheless profoundly negative, experiences and encounters with mainstream co-workers: ‘… walk into reception in my region and you say “how you going?” And all of a sudden they put their head down, they're not writing anything’ (FG 2). Often it was basic courtesies that workers noted were lacking in their colleagues and co-workers. For instance, ‘… little things like saying g'day’ that were expected and meant a lot were sometimes non-existent.
Racism and discrimination did not always manifest in stereotypically negative ways. In some instances, people spoke about ‘reverse racism’, which was similarly distressing: ‘The kind of racism I see is a bit different. It's a bit reversed … Like if I do something I get ten thousand emails saying thank you so much you're so wonderful. … But it's really outwardly embarrassing because they don't do it to anybody else and I am the only Indigenous worker in this mainstream organisation. … It's as if they are surprised you can get your work done.’ (FG 2).
Individual stress management strategies
Many workers appeared resilient in the face of extreme pressure. They highlighted the importance of knowing themselves, recognising symptoms of stress, understanding stress triggers and applying preventive strategies. Strategies participants used to minimise stress comprised five domains: traditional (e.g. going home to community), recreational (e.g. passive and active leisure activities), social (e.g. spending time with friends and family, laughter and humour), domestic/personal (e.g. gardening) and work-related (e.g. debriefing). Close family and community bonds, sharing Indigenous culture and stories with younger community members and teaching cultural ways were sources of strength and resilience and spiritual well-being: ‘Workers get strength from their shared experience, having support groups, getting involved with community, families, friends, colleagues’ (FG 9).
Rewarding aspects of work
Rewarding aspects of work included opportunities to help individuals, build relationships with their communities, draw upon spirituality and promote Indigenous ways of working, and reconnect with language and culture: ‘You're there because you want to be there for your people. You want to try and make a change …’ (FG 10). Advocating for clients and contributing to client success afforded a sense of pride and fulfilment: ‘The most rewarding bit for me is when clients exit a program, knowing you've made a difference to their lives, and they feel good about that’ (FG 4). A primary motivation for working in the AOD field was to help people, enhance community services and improve Indigenous health outcomes: ‘First thing, always, for me, is to help my people’ (FG 12).
Seeing health services become more responsive to Indigenous clients’ needs and ways of working was a source of satisfaction, as was being part of solutions to improve Indigenous health and access to services: ‘We've really got it happening. More services are now available in the community. In the 1990s mental health services came out once a month, now services come every day, and child and youth [services] are there, dual diagnosis come weekly, and they have alcohol and drug rehab services as well, and the workforce has increased there as well’ (FG 9).
Workforce development strategies
Participants emphasised the wider role of workforce development strategies in reducing stress and burnout and making workplace practices more Indigenous-sensitive (Table 2). Clinical supervision, mentoring and debriefing were recognised as important, but they were not always available or were poorly executed. Other workforce development strategies included allowing more flexibility for workers to engage with clients on their terms (i.e. outreach, out-of-hours meetings, longer time spent with clients), recognising and addressing workers' own complex personal experiences, resourcing ongoing professional development and networks, consultation with Indigenous staff regarding workforce development policies and procedures, incentives and resources to manage and reduce stress, redressing systemic inequalities, effective coordination with other services, streamlining administrative/clinical processes, adequate leave provisions to participate in cultural obligations (e.g. ‘sorry business’ and bereavement leave), the provision of additional Indigenous workers to reduce job demands and stress, and staff recognition practices. Indigenous AOD workers reported insufficient AOD knowledge and/or inadequate access to training compared with mental health workers.
Table 2. Workforce development strategies
|Increase the number of Indigenous AOD workers|
|Build the AOD skills of Indigenous health and human services workers|
|Build the cultural sensitivity of non-Indigenous workers|
|Expand the capacity of Indigenous communities to address community AOD issues |
|Build strong mutual networks for Indigenous AOD workers for support and debriefing|
|Raise awareness of burnout, anxiety and depression to enable identification in oneself and colleagues|
|Provide assertiveness and ‘boundary-setting’ training for AOD workers, and promote awareness of and skills in self-care strategies|
|Provide access to culturally appropriate counselling/support services (particularly for loss and grief issues)|
|Empower workers and facilitate Indigenous AOD workers' input into organisational processes|
|Introduce mentoring and clinical supervision |
Participants were cognisant of workforce shortfalls and expressed support for workforce capacity-building initiatives at multiple levels, including individual health workers, community-controlled organisations, mainstream organisations and local communities. Adequate funding was highlighted as fundamental to recruiting sufficient workforce numbers, implementing appropriate workforce planning, addressing the lack of physical space to accommodate extra staff (particularly in rural/remote locations) and offering health traineeships and management training programs.
This study identified Indigenous AOD workers' sources of stress and their strategies for enhancing social and emotional well-being by drawing on their stories and experiences. It is one of few studies to examine this issue, in spite of growing awareness of its importance [32, 40, 41]. Findings were consistent with our national survey of workers in Indigenous AOD services , which found that 1 in 10 Indigenous workers experienced emotional exhaustion, and more Indigenous workers reported lower levels of mental health and well-being than their non-Indigenous counterparts .
There has been little research on Indigenous AOD workforce development strategies in Australia. Indigenous AOD workforce development research in New Zealand has called for the following: increased recruitment, retention, training and development; supportive working environments; evidence-based practice and evaluation; and increased workforce development infrastructure . The general lack of health workforce infrastructure in rural and remote Indigenous communities has also been raised as an important issue .
While some challenges identified here echo findings of other studies of AOD workers (such as remuneration and affordable and available accredited training, recruitment and retention) , others are specific to Indigenous workers, such as wage disparities, high community expectations  and workers' enmeshment within their communities. There was often little separation between work and other aspects of life, and Indigenous AOD workers played multiple roles within communities. However, close proximity to community was a source of both stress and support for workers. This also helped Indigenous AOD workers to have a deep understanding of their communities. Indigenous workers' input into services is paramount to their status and empowerment and the responsiveness of services to Indigenous communities.
Two outstanding characteristics of Indigenous AOD workers identified in this study were their strong motivation to improve the health and well-being of their community and the work satisfaction derived from this despite the pressure, demands and poor conditions often encountered.
Loss and grief issues were ubiquitous, and our findings indicate that workers need concomitant support from their organisations. Time off for ‘sorry business’ and identification of AOD Indigenous workers ‘at risk’ of burnout is necessary. Indigenous AOD workers identified strategies they used to minimise stress (traditional, recreational, social, domestic/personal and work-related) that could be shared among colleagues through mutual support networks. In addition, we suggest that strategies that provide emotional support, access to culturally sensitive employee assistance programs, mutual support networks and training in assertiveness and boundary setting are also required.
Our findings also suggest that accommodation is needed of ‘Indigenous ways of working’ that involve more time being spent with individual clients and working in a more holistic way. The findings indicate that Indigenous workers also take on multiple roles beyond AOD issues. This has organisational implications when planning workloads. However, we see a potential tension between holistic Indigenous ways of working and the need for ‘boundary setting’ in regard to individual workers' roles and ‘being on call’ for community/family members. Holistic, cross-sectoral ways of working need to be appropriately resourced to ensure individual workers are not overburdened.
Despite high expectations and demands, Indigenous health workers have endured low status and remuneration compared with many other health and community service professions [44-46]. While participants in this study were clear that remuneration was not a prime motivation, inadequate remuneration nonetheless contributed to physical hardship and impacted health, morale and self-esteem. Based on the findings from these FGs and the previous survey , we suggest that strategies to address salary parity are pressingly needed, as are employment benefits, professional development and career progression. Previous studies have similarly suggested that Indigenous health workers also require registration, professional associations, specialised training and empowerment for their status to be improved [47-52].
Indigenous AOD worker well-being can also be enhanced via workplace support mechanisms, such as clinical supervision, which can contribute to job satisfaction and retention and improved client outcomes [53, 54]. Mentoring can also provide vital peer support for isolated workers and increase collaboration . Better resourcing, qualified supervisors and culturally appropriate clinical supervision guidelines are essential.
These results also suggest that in order to address racism, understand the lived experiences of Indigenous workers and foster change, it is necessary to focus on non-Indigenous workers and managers. Training to build the cultural sensitivity of non-Indigenous workers across sectors is paramount. Culturally aware non-Indigenous AOD workers and managers are a major potential source of support for Indigenous workers.
Indigenous AOD workers are enmeshed within their communities, always ‘on call’, deal with a range of issues and agencies and play multiple roles. They experience a ‘dual accountability’ to their employing services and their community. This can lead to high levels of stress, burnout and turnover. While many Indigenous AOD workers have developed personal mechanisms to address stress and burnout and promote personal well-being, the complexity of their work and distinctive nature of the stressors and constraints they confront require organisational and systems-level attention. This study identified a number of workforce development strategies to reduce the burden on Indigenous AOD workers and address stigma and racism towards their clients.
This study was funded by the Australian Government Department of Health and Ageing. Thanks are extended to participants and the Project Reference Group: Ms Amy Cleland, Dr Colin Dillon, Ms Sharon Drage, Mr Mick Gooda, Mr Don Hayward, Ms Jacqui Malins, Ms Coralie Ober and Mr Scott Wilson. The support of the full project team and Ms Tania Steenson are also acknowledged.