Guidelines for Remote MHPSS Programming in Humanitarian Settings: Cross-Cutting Components

4.1 Cross-Cutting Component: Ethical Considerations

4.2 Cross-Cutting Component: Capacity Building

4.3 Cross-Cutting Component: Monitoring and Evaluation

4.4 Cross-Cutting Component: Staff Well-being and Self-Care

4.1 Cross-Cutting Component: Ethical Considerations

All staff must adhere to the laws in place in their area of work, their organizational/institutional code of conduct and any quality standards, safeguarding policies, as well as their relevant professional code of ethics when providing services to clients regardless of whether they are provided face-to-face or remotely, from home or a service delivery point.

The rights and priorities of the client must remain paramount and considered at all times. The core concepts of informed consent and self-determination, confidentiality and privacy, recordkeeping and competence require additional attention. Specific recommendations on expectations for the provision of remote MHPSS are outlined in the Confidentiality Agreement in Appendix E. All staff providing remote MHPSS services must read and sign the Confidentiality Agreement.

4.1.1 Informed consent

• Whether the client is new or has been receiving services and will transition to face-to-face care, a consent form to receive remote support should be provided and signed prior to commencing remote care. Clients should be informed of the decision to provide remote support and the reasoning should be explained, with space to ask questions. Where possible these discussions should be provided during a face-to-face prior to the measures being implemented. See Informed Consent Form for Remote MHPSS in Appendix F.
• When presenting remote support as an option to provide ongoing care, the different modalities available must be discussed, including any related privacy issues.
• Clients must verbally agree to receiving remote support over an agreed modality. If the client agrees, then this agreement must be documented. Preferably an agreement should be documented on an informed consent form signed by the client (see Appendix F). Where this is not possible, the staff member must read aloud the content of the informed consent form and make a dated note of the verbal agreement using client codes rather than names and store this record of consent securely. If the client is a minor or has a caretaker due to a severe MNS disorder, the caretaker must provide the consent.
• Clients (and/or caretakers, where appropriate) must be informed that they have the right to withdraw their consent to treatment at any time.
• Respecting clients’ rights includes discontinuing services if refused, or discontinuing the remote modality of services and resuming face-to-face services when possible. If a client doesn’t feel comfortable receiving remote support and/or doesn’t give their consent, make sure that they are aware on how they can contact the team to request services at a later time. Clients should have access to the phone number of their MH focal point, and any hotline set up for the project, or contacts of other services that the team is made aware of.
• For children or others who do not have capacity to provide consent, their caregiver must agree to giving consent on their behalf in line with the steps described above.
• If sessions are to be audio or video recorded with the client’s consent for the purposes of supervision, an informed consent form detailing this must be signed (See the Supervision section for further details).

Possible reasons of refusal of the remote model and how to address them

4.1.2 Ensuring Privacy

4.1.2.1 Staff Space

• Remote support must be provided from a private space. A private space is a confidential place where there is no risk of being overheard, and limited distractions. If necessary, inform others in the home/workplace that a confidential call is taking place to prevent any disruption.
• If a client cannot be contacted from a private space this must be discussed with a supervisor to identify any alternate solutions before proceeding.

4.1.2.2 Client Space

• A client must also have private place in which they can talk without fear of being overheard or interrupted by anyone who may be nearby, including neighbors, friends or family members.
• It is best to arrange a time to talk using a messaging service so that a client can be prepared and has time to find a private space. When they are contacted at the agreed time, they must be asked to confirm that they are in a private space and are comfortable to talk. Confidentiality must be assured during every contact.

4.1.2.3 What to Do If a Client Is Not Able to Talk Without Being Overheard?

Problem solve/brainstorm with the client:

• Is there another day or time when they would be able to talk privately?
• With respect to the movement restrictions in your particular context and measures to reduce physical contact, can your client find an alternative place where they can talk, e.g. garden?
• Is there another modality of remote support that you could use to check in, i.e. if they can’t talk on the phone could a check-in be done via messaging or email?
• Can the client join the remote session from the nearest safe/private space in their area?

Consult the IOM Internal Guideline for Remote MHPSS Working Modalities (pages 6-8) for additional tips on setting up the physical and technological space for remote service delivery.

4.1.3 General Principles of Data Protection

• Clients must give their permission before their information is collected.
• Client information should not be used except for the purpose in which it was given. Data should not be disclosed to a third party, without the prior consent of the data subject, unless legally or contractually obliged to do so.
• Only information about a client that is relevant to providing care should be collected.
• All reasonable steps should be taken to ensure that client information held is accurate and up to date.
• Client information should not be kept for longer than is necessary. All out of date or redundant data should be destroyed in a secure and confidential manner.
• Security and confidentiality measures should be in place to protect personal data. All electronic data must be password protected. All paper records should be securely stored in a locked cabinet or room.
• Emails and messaging services:
  • Only share emails or messages containing client information with people when a client has given their consent and where possible remove all identifying information
  • Only share emails with colleagues containing client information when absolutely necessary and remove all identifying information. Password protect all documents sent by mail and send the password to the document in a separate email.

4.1.4 Recordkeeping and storage

Details/notes of all interactions with clients should be completed on the same day of the consultation, and if possible, directly after the contact. This includes all remote interactions, no matter how brief the interaction or what method of remote interaction was used. For those who have appropriate systems already implemented and access to the necessary technologies, digitized recordkeeping is preferable with the necessary safety and data protection measures in place. For those who are interested in developing a new digitized recordkeeping system, this should be discussed with IT and technical unit.

4.1.5 If Working from Your Organization’s Facility/Office with Access to Client Files:

• Notes should be completed and added to the client file in accordance with standard organizational procedures.

4.1.6 If Working from Home/Outside Your Organization’s Facility/Office:

• No client files should be stored at home.
• Notes should be made in a notebook specifically designated for client notes.
• Notes should be kept in one notebook to prevent multiple pieces of information being created that can be easily misplaced.
• No identifying information about clients should be entered in notes that are kept outside of an organizational facility. Client codes should be used to identify clients.
• All notes should be locked away and stored safely. If remote support is being provided from home and there is not a safe place where notes can be locked away, this information must be shared with a supervisor, who should provide a lockable box.
• Client files should be updated using the notes when the MHPSS facility can be safely accessed again.

4.2 Cross-Cutting Component: Capacity Building

4.2.1 Training

All staff providing remote support to clients should receive training on the practical steps and procedures presented in these guidelines, adapted for the context in which they are working. Supervisors supervising service providers should also be trained to adapt their supervision to remote delivery. Training of staff prior to transitioning and throughout remote implementation should be prioritized, and procedures put in place to offer remote training where required. Training sessions and related materials should be developed in close collaboration with technical advisors and based on the needs of trainees.

4.2.1.1 Considerations for Training Related to Public Health and Other Emergencies

Providing clear, factual information on public health emergencies, such as COVID-19 or Ebola, or other disasters that may create uncertainty and fear, as well as providing advice on staying safe and employing positive coping strategies can significantly improve well-being. Staff and service providers should be trained to provide psychoeducation to clients and communities about relevant public health or other emergencies. MHPSS providers should develop an updated list of links and psychoeducational.

4.2.1.2 Best Practices for Conducting Remote Training

Undertaking training remotely presents a unique set of challenges related to level of engagement by participants, information retention, time management, etc. Adaptations and special considerations must be made when conducting remote training.

• Maintaining active participation and engagement over long periods can be difficult in remote training. If possible, consider spreading the training agenda over several days with a smaller number of hours allocated per training day.
  • Consider sending out reading materials before the training starts so that participants can come to the session with background knowledge.
  • Consider incorporating questions and answers (Q&A) from previous in-person or remote training into a document, to be provided to participants prior to the training, which may reduce the time required for Q&A during the session.
  • Make the necessary adjustments to the training agenda, including building in more frequent breaks and energizers.
• To account for poor internet connection, consider supplementing real-time training with offline learning participants can undertake on their own time by sharing additional reading and exercises via email or other available file sharing platforms (e.g., Dropbox, Google Drive, SharePoint, etc.), or by post/courier.
  • Consider recording remote training sessions and sharing recordings with participants who may have missed parts or entire sessions due to connectivity problems.
• Plan how interactions will take place during training; ad-hoc communications can be difficult to manage, especially with many trainees. For example, consider using the hands-raise icon and taking questions one at a time, or asking participants enter questions in the chat/messaging section to be answered at a specified and allocated time.
• To enhance engagement and participation:
  • Balance knowledge-based learning and practice. For example, assigning participants to prepare and deliver brief presentations on a specific topic can solidify acquired knowledge.
  • Incorporate other participatory methods, such as role plays (and assign roles and provide instructions to participants ahead of time).
  • Allow space for questions and feedback.
• Choose a communication platform that is easily accessible by all participants.
• Utilize interactive platforms where available (such as Teams and Zoom breakout rooms), and conduct the training using video capability, where possible.
• Send regular reminder invitations to all participants before the remote session to reduce absences.

4.2.2 Supervision

Effective supervision is essential to enhancing and maintaining clinical staff competencies, increasing fidelity to evidence-based treatment models, and reducing unnecessary interventions (e.g., MHPSS staff making referrals to multiple services when contraindicated or failing to disengage services when goals are achieved), and thereby reducing waitlist times and healthcare costs. All staff, whether working from home or at an organizational facility/office should continue to receive regular supervision in line with their organization’s quality standards and standard operating procedures.

• During the initial stages of implementing a remote support system staff will need additional support. Managers and supervisors should check in regularly and conduct supervision at least once a week. Inquire about staff well-being on an ongoing basis and look out for signs of stress and burnout (Refer to Cross-Cutting Component: Staff Well-being and Self-Care).
• If providing remote support to clients, it is helpful to receive supervision by the same method of communication that is used with clients, to gain direct experience of the strengths and limitations of the chosen way of working. Also consider practicing delivering sessions remotely and applying the existing guidance and good practices.
• Supervisees should discuss and troubleshoot with supervisors the challenges encountered with remote service delivery, such as logistical problems and challenging client interactions.
• In the absence of on-site supervision, audio/video recording of the supervisees’ sessions with clients can be helpful in reviewing and providing feedback on the supervisees’ skills as long as the client is comfortable and provides consent. A signed consent form should be on file for every session that is recorded.

4.2.2.1 Methods of Supervision

Supervision can take place through ad-hoc and more structured methods. For example, supervisors and supervisee may agree to hold regular (i.e., weekly) individual or peer supervision sessions over video conferencing or phone or meet on a need basis. The structure and frequency of supervision sessions need to be adapted to supervisees’ needs. Supervisors may utilize a sample version of supervision protocols available in Appendix G, which include:

Knowledge and Skills Building

1. Case Presentations (telephone calls and video conference calls) See Protocol 1.
2. Offering bite-size information through WhatsApp and SMS text messages. See Protocol 2.

Improving Attitude/Motivation

• Supervisor support (through SMS text messages and WhatsApp messages). See Protocol 3.
• Peer support (through SMS and MMS messaging groups WhatsApp). See Protocol 4.
• Reflective discussion (telephone calls or video conference calls) See Protocol 5.

4.2.2.2 Supervision Plans

Once the supervisor has chosen the relevant protocol(s) they should create a supervision plan. The plan needs to be shared with the supervisee(s) to ensure the content accurately reflects the needs and goals of the supervisee(s). The plan needs to include the preferred supervision methods, protocols, duration and frequency of supervision and (where possible) the dates of supervision for the first 6 months. Supervisors should ensure that feedback from the supervisee(s) is included in the plan to keep the supervisee(s) engaged and motivated to gain as much as possible from supervision. Any standardized forms to be used during supervision can be shared with the supervisee (s) at this initial meeting to familiarize themselves with the documents.

The supervisor in agreement with program management teams needs to decide how supervision will be monitored and evaluated. This could include looking for opportunities to bring in an outside expert to evaluate the skills of the supervisee(s) by conducting at least one face-to-face, observational supervision sessions during the first 6 months to evaluate the progress of the supervisee (s) and/or evaluate the progress of the supervisor/supervisee relationship. Alternatively, supervisor and supervisee(s) may agree to meet every 6 months to re-evaluate the goals and aims of supervision, reflect on their professional relationship, review and adapt the remote supervision methods and protocols to match the changing needs of the supervisee(s).

4.2.2.3 Remote Case Conferences

When MHPSS services are provided for individuals by a number of different providers or as part of a multidisciplinary team, it is recommended to conduct regular case conferences, to ensure that service providers address clients’ needs as a team and all aspects of required care are discussed and agreed, and the clients’ condition and care plan are monitored and adapted by the team as necessary. Case conferences also indirectly provide a useful form of capacity building for staff, who have the ability to learn from each other.

It is recommended, for these reasons, to ensure continuation of case conferencing through remote means, if in-person meetings are not possible. Supervisors should ensure to establish and maintain a means of and framework for remote case conferencing, utilizing suitable and confidential platforms that enable multiple service providers to participate. If case conferencing is already taking place in-person, consider trying to keep to same schedule or routine as the team or group of service providers normally use, and ensure to request feedback from participants on the method of remote case conferencing in order to gain valuable information to improve its functionality.

4.3 Cross-Cutting Component: Monitoring and Evaluation

Monitoring and evaluation (M&E) is necessary to assess whether the remote MHPSS program is achieving its desired results, provide measures of the quality of the services provided remotely, and document lessons for consideration in future remote programming. Indicators already included in the common monitoring and evaluation framework should be disaggregated by remote vs. non-remote type.

Reference International Medical Corps COVID-19 MEAL Guidelines (For non-International Medical Corps staff, the Guidelines can be made available upon request via meal@internationalmedicalcorps.org) for an example of M&E methods can be adapted to remote implementation during public health emergencies and ensuring infection, protection and control protocols are in place for these activities.

4.3.1 Documentation of Remote MHPSS Sessions:

Clients’ information can be recorded using hardcopies or digitized recordkeeping tools, putting in place necessary data protection measures noted earlier in the guidelines. Recordkeeping tools need to be adapted for use in remote modalities, with the following considerations in mind:

1. Specify if the session is conducted in person or remotely.
2. If remote, specify the communication type (e.g., video conferencing, audio call, etc.).
3. Include information on client’s preference for the model of service: in person, remote or combined.
4. If the session is planned in advance or conducted as an emergency call.
5. Mention the needed assessment and management interventions that could not be conducted remotely.
6. Note logistical challenges and good practices.

4.3.2 Using Satisfaction Surveys

Satisfaction surveys can be used to evaluate clients’ and caregivers’ levels of satisfaction with the remote MHPSS services and solicit feedback for further improvements. The survey may assess efficacy of remote services (including perceived improvement in functioning, well-being and symptomology); client preferences, including if alternative modalities need to be implemented; challenges or barriers as well as positive developments encountered during remote services. Try to mitigate for bias by making the satisfaction reporting as anonymous as possible, such as using postal service or online link to anonymous feedback mechanism, while protecting the identity and confidentiality of respondents. A sample satisfaction survey is included in Appendix H.

4.4 Cross-Cutting Component: Staff Well-being and Self-Care

The well-being of staff is of utmost importance always—and especially so during emergencies and global crises. All organizations have a responsibility to provide the best working environment for their staff this includes the prioritization of the health and well-being of all staff.

Staff and service providers who work in emergency settings are at an elevated risk of developing burnout, which often result from chronic workplace stress that has not been successfully managed and may manifest in the following symptoms (World Health Organization, ICD 11):

• Feelings of energy depletion or exhaustion;
• Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
• Reduced professional efficacy.

Working remotely and in isolation can exacerbate stress. Setting clear boundaries and practicing self-care can reduce staff and service providers’ risk of developing burnout and increase the ability to maintain a healthy work/life balance.

It is the responsibility of the organization to prioritize health and mental well-being of their staff. Below are some crucial steps the organization must take to do this:

• Update staff welfare policies to include promoting staff well-being during remote service provision.
• Ensure that staff are given the technologies and tools needed to implement remote services such as phones, laptops, tablets, chargers, enough phone and internet credit to ensure they incur no out of pocket expenses.
• HR and Senior Management teams should ensure that staff are only working within their contracted hours.
• HR and senior management teams should ensure that staff do not feel isolated and are involved in regular team discussions, social events and opportunities. They should be regularly reminded that they are part of a team and an organization and not feel as if they have to struggle alone.
• HR and senior management should implement policies that show staff how to take sufficient and regular breaks from their screens in order to stretch, move and take fresh air through their working day.

Below are some tips that staff can use on how to protect and maintain psychosocial well-being while providing remote MHPSS services:

• Schedule the remote sessions only in working hours.
• Set expectations with clients during the initial session of when you will be available and when clients can call. Hold to this boundary if they call outside of hours.
• Wherever available, use the business accounts of applications, such as WhatsApp, which help reinforce professional boundaries and provide automated reply options outside of business hours, letting the person know when they can expect to receive a response.
• Make sure clients know where to go or whom to contact if they need urgent assistance or care. Consider providing clients with referrals for such instances during the initial session.
• Plan ahead and prepare how you will let a client know you cannot talk if they call outside of working hours. Convey empathy, respect and warmth.
• Stay consistent with appointment times.
• Ensure your caseload is manageable, both in terms of the number of clients as well as intensity of any complex cases.
• Seek support from your supervisor when managing cases. Discuss any challenges or difficulties that affect your performance at work.
• Maintain a healthy lifestyle such as sleeping enough hours daily and eating enough and healthy food and including physical activity.
• Maintain a daily routine that includes enjoyable or stress-relieving activities.
• Maintain social contact with family and friends.
• If you can’t manage your work-related stress alone, ask for support from a staff care focal person or your supervisor.

See WHO Doing What Matters in Times of Stress for additional guidance on how to maintain your psychosocial well-being.