Reducing tensions in the waiting room

Participants during a role play exercise, Tyre, December 2014Healthcare workers in Lebanon have been on the forefront of tensions stemming from the presence of over 1.1 million Syrian refugees in the country. International Alert assessed how they were coping with the increased workload and, between December 2014 and March 2015, provided training to enhance their understanding of conflict and improve their communications skills and ability to deal with stress.

Ahead of the training courses, two in three health workers (69%) reported that they were able to manage their workload with difficulty. Less than a third (30%) were handling the workload without difficulty.

After the training, 38% reported they were now able to manage their workload without difficulty – 7% more than before. The impact of the training was most noticeable in Beirut and Mount Lebanon, where the tensions between Lebanese host communities and Syrian refugees are most pronounced. After the training, one in three respondents was able to complete their tasks without difficulty – 20% higher than before the training.

“We are usually tired and bored,” said one participant. “The training helped us to find our motivation and commitment to our work. It energised us – we feel renewed.” Another participant said: “The training was an opportunity to meet colleagues from other centres, to talk about common issues and to share some problems outside of the work setting.”

Health workers also changed the way they understand the causes of the existing tensions. For example, the number of staff who reported harassment by patients decreased from 40% in December to 33% in March. This might be a result of a change in the way health workers see their patients. “Now, we are focusing on patients’ needs and not on their behaviour,” said one participant.

At the same time, frictions among patients were reported as a cause of tensions by 21% in December and only 16% in March, marking a possible increase in the awareness and ability of healthcare workers to address such frictions.

Following the training, health workers used milder language to describe the communication problems in working with refugees. In the pre-training assessments, comments referred to refugees “not respecting the rules”, being “ignorant”, “stubborn” and “lacking awareness”.

By comparison, in the post-training assessment, the comments were more comprehensive, demonstrating a better understanding. “It is not always easy to understand the patient especially because he is from a different background and has a different educational level,” said one participant. Another commented that working with “people from different backgrounds makes the communication more difficult”.

A range of further actions can be taken to decrease tensions in the workplace, according to health workers. Suggestions include expanding the waiting rooms, hiring additional staff and improving the organisation, enhancing cooperation and teamwork.

Nurses and receptionists also wanted to see higher levels of moral and psychological support by their colleagues and supervisors. Notably, almost half of the respondents said moral support and appreciation would help them manage stress and workplace difficulties.

A large number pointed to a need for financial support as well, with some referring to funding for the centre to increase the number of employees, and others seeing a need for financial compensation for employees.

In May, two months after the end of the course, Alert’s Head of Training and Learning Vesna Matovic visited seven primary healthcare centres and one mobile clinic to identify key lessons learned from the capacity-building work in conflict-sensitivity. Based on conversations with healthcare staff who attended the trainings and patients present in the clinics, change was visible at three levels.

Individual change

  • Cognitive changes (learning new models, tools, skills, etc.): Improved communication and listening skills; increased understanding of others, conflict and problems, stress and stress management techniques;
  • Emotional changes: Increased control of one’s emotions, especially anger, aggression and frustration; understanding that it is okay to feel a certain way; understanding why one feels in a certain way and how to manage it; less fear from facing conflicts and problems; and ability to deal with one’s stress and frustrations; and
  • Behavioral changes: Treating patients differently and being more attentive; allowing more time for explanations; trying different techniques in managing conflicts; using stress management techniques; being more confident to try different approaches and to respond to conflicts in a different, more creative way.

Relationship change

  • Between staff and patients: Patients responded to changes in staff behaviour by becoming more tolerant and polite; patients changed their way of talking to staff; and
  • Among staff: Improved communication among staff; developed trust among staff who attended training; better teamwork; more mutual support.

Social change

  • Improved team work in healthcare centres; improved mutual support among staff;
  • Developing a network of colleagues across centres in the region who are now able to share their experience and problems, and advise each other;
  • Increased cooperation between centres;
  • New policy on how to deal with angry patients in one of the centres; and
  • Change of practice in dealing with too many patients in waiting rooms by trying different options.

The lessons extracted by Alert’s training and learning specialist confirmed the impact at the individual level registered through the evaluation questionnaires and assessment forms. The examples of change at the level of relationships and social change were present in many of the centres Matovic visited, however the centres were selected from those with a high number of trained staff. It can be assumed that the likelihood of the training resulting in relationship and social changes is higher in centres where a larger proportion of the staff was exposed to learning and networking opportunities.

The trainings were organised as part of our work on conflict-sensitive aid, under the EU-funded project on conflict reduction through improved healthcare services, led by the Lebanese Ministry of Public Health and implemented by UNHCR, WHO, UNICEF and Alert. Find out more about the project here.