Approximately one-third (31%) of Australians face social and psychological challenges related to living and working in rural (29% of the population) or remote (2% of the population) environments1. People residing in sparsely populated or isolated environments can experience a contextually unique impact on mental health, and access to health care can be qualitatively or quantitatively reduced compared to urban populations2. They and their families have lower social support from friends and family, as well as fewer opportunities for recreational pursuits3. Remote workers are more likely than the general population to work non-standard hours, under difficult environmental conditions, and to commute regularly. The health workers who support this population, therefore, have needs related to this context. Many of Australia's industries (eg mining) involve rural, remote, fly-in fly-out, or challenging work environments, a testament to the need to continue to support these client and helper groups4.
Challenging occupational environments involve extreme physical conditions that also contain the potential for danger to life and traumatic exposure5. When at work in a remote environment, personnel are highly likely to work significantly longer hours, for more days in the week, than at home6. This means that the potential for workload and other occupational stressors increases. Locating into and out of a work-intensive environment also has an impact, something shared by the nation's now large population of fly-in fly-out workers. Relatively little research exists on this workforce7,8. Rapid changes in work-life environment disrupt a worker's motivation for the job, retention in the workplace and their mental health9,10. And while the level of sophistication in recruitment and the psychological training involved to maximise wellbeing in workers varies markedly11, there is no selection criteria or training program for the families of rural/remote workers.
There should be a concerted effort to share information between professions that supports these types of living and working contexts. Sharing many attributes of a rural/remote lifestyle is the one imposed on members of the Australian military. Shared attributes include mobility of the job, varied and unpredictable working hours, and physically intense work, and the concomitant impact on physical and psychological wellbeing12. This article argues that the military client group and the health workers that support them face similar challenges and have developed interventions or approaches that it would be of benefit to share.
Issue: how a military lifestyle compares and military research may help
With nearly 100 000 members of the Australian Defence Force13, the force is a prominent and well-acknowledged 'challenging' or 'distance' work environment. For this reason, the military has a well-established reliance on psychologists to select, train and psychologically maintain its force. It is well known that the inception of psychological testing for job selection occurred within the military during the First World War14. For a time the transfer of military knowledge to the civilian field was rapid. We suggest that in the contemporary workforce, far less application of military psychological practice occurs in selection, performance, health, safety and lifestyle matters.
Military psychologists work within a specific climate and cultural context that challenges the application of psychological strategies and encourages innovation. The military is a team-intensive work environment, contains significant chronic stressors (interpersonal, environmental and psychological), requires a focus on psychological hardiness and a performance-based culture. Some other psychological factors include mobility of the job, varied and unpredictable working hours, and regular physically intense work. All of these ecological factors impact on mental health, performance, human factors, leadership and teamwork15-17. There are many areas of potential overlap and the following sections will describe three of the more well researched and most contextual: human factors in high-risk occupations; management of the fly-in fly-out work lifestyle and professional competence for remote health workers (in particular, psychologists).
The first area of commonality is in the field of human factors, the study of humans as components of complex systems made up of people and technology. Human factors research is now well established in some occupations, especially those at the highest risk end of the spectrum, such as mining18. Introduction of new technology and more stringent safety procedures reduces risk, but recent researchers have pointed to the need to more thoroughly implement human factors or systems approaches to address the high rate of human factors associated with accidents19.
The relationship between human operators and their weapons and communication systems is a critical one in the safe use of potentially lethal force20. The aviation and transport industries have seen the largest transfer of military knowledge into the civilian realm, particularly in the use of threat and error management (TEMS) and fatigue risk management systems21. More lateral application remains rare. Recently the author of TEMS has led a move to transfer a threat/error model into the medical profession. Other researchers have applied the Human Factors Analysis and Classification System, developed within the United States military, to mining operations22. Another contemporary research development is in the area of situation awareness, an operator's ability to hold in working memory a number of moving parts in a dynamic system23. In the military this may apply to the soldier on foot patrol or the pilot operating an aircraft. Situation awareness has been shown to be equally as useful in reducing accident rates in challenging civilian work environments, such as offshore drilling crews24.
An obvious current focus, particularly for fly-in fly-out and roster-based workers, is the management of sleep cycles and fatigue due to environment and time factors. Recent military research makes use of physiological monitoring devices such as wrist-watch technology to monitor heart rate, skin and core body temperatures25. This allows for supervisors to manage and plan for hydration needs, work-rest cycles, work strain constraints, and reduce the likelihood of environmentally related injuries such as heat stroke. Monitoring technology appears to be a rapidly growing industry relevant to civilian shiftwork, fly-in fly-out and physically challenging work environments26.
Finally, the care of personnel in high-risk environments suggests a preparedness to care for mental health in the case of critical or potentially traumatic incidents. Military psychologists necessarily prepare workers for exposure to trauma and work to build resilience27. Multiple models of critical incident support in a military environment exist, and acknowledge the often isolated nature of the workers involved. For example, some interventions make use of strong team cohesion (both task and social cohesion) to buffer against negative reactions28,29. Some make use of peers to provide both workplace and social adjustment to an unfamiliar living environment30. Much research has been conducted on the importance of leadership in remote work environments. Leadership has been proven to protect against mental health problems under traumatic conditions, and it reduces stigma in work environments that value hardiness (and thereby can tend to increase mental health stigma)31,32. Preparation, expectation and a sense of group effectiveness also increase resilience33.
Managing an itinerant workforce
The second area of commonality is related to the domain of psychological adjustment to the chosen lifestyle. Military exercise and deployment is a time of physical, social, emotional and psychological change for a member. Whilst deployment may be for extended periods, many military personnel engage in continuous short exercises, courses and temporary assignments away from their home location. Such work schedules therefore resemble a fly-in fly-out workforce in many ways. A number of theoretically driven psychological processes commonly occur. There are considered to be four basic stages of adaptation to a different long-term work environment and each stage carries different levels of risk in regards to error rate, safety and psychological wellness34. Moving in and out of this cycle is something for which relatively little research exists, but now applies to a large section of the population. This disruption impacts the worker's happiness with the job, their retention in the workplace35, and potentially their mental health8,36. The literature on the deployment cycle suggests that cognitive flexibility is the key indicator of a person's ability to manage the culture shock cycle appropriately37. Recent military research along with civilian research provides substantiation to that claim38,39. Military research also suggests that a sense that the organisation has the worker's wellbeing in mind can impact a person's ability to deal with a home-away adjustment cycle6.
Training the remote healthcare profession
There is a government focus on the development of higher levels of health care in the rural/remote areas of Australia40, and much research demonstrates the barriers to physical and mental healthcare provision in those areas41-43. The focus on telehealth and other internet-based options is strong in both civilian and military research44,45. Less research looks at the barriers to working in remote settings for the health profession. Some recent research looked at the knowledge, skills and attitudes required of remote and rural psychologists46. They considered the following rural-specific competencies:
- a diverse knowledge base as well as a good knowledge of one's limitations of practice. They refer to this as being a 'generalist-specialist'
- technology, networking and multidisciplinary relationship building skills, including the ability to treat the community as a whole as well as individuals.
- ability to set boundaries, strategies for managing boundary crossings, and an ability to compartmentalise
- a higher emphasis on self-care skills.
Other Australian and international researchers concur that the issue of ethics and boundaries is prevalent, and more prominent, in rural settings47-49. In small communities, a healthcare provider interacts with workers as professional, friend and community member50.
A number of these issues have been addressed in the military healthcare training model, particularly in the supervision and training of military psychologists. Dual relationships and boundary crossings are par for the course in a small, deployed unit with only one doctor, psychologist or nurse. The health provider has two clients - the organisation and the individual - each with sometimes competing demands, and clients who often refer under coercion51. Military health workers sometimes report greater pressure than civilian workers to engage in dual relationships52. The development of models of practice based on boundary crossings versus boundary violations and of navigation of the dual-client workload53 would help the rural workforce.
In the rural/remote workforce in Australia, particularly in the fly-in fly-out work environment, the application of psychology to manage worker wellbeing, improve human systems performance and support work-life balance is yet to be fully exploited. Training leaders in a proactive approach to the management of human systems may result in lower rates of separation from such environments. In the fields of clinical, organisational and human systems psychology, military research has much to offer outside of its current application.
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