Nursing Refugee Women

Australia has a large and expanding population of people from a refugee background – referred to as 'refugees'. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper will explore the need for cultural safety in nursing. It will then analyse the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees and refugee women. Finally, it will discuss how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

The Nursing Council of New Zealand (2002: p. 7), which developed the concept of cultural safety, defines it as "the effective nursing … [care] of a person or family from another culture, [as] determined by that person or family". Fundamentally, culturally safe nursing practice focuses on supporting diverse people to effectively access and engage with mainstream 'biomedical' health systems, and so reducing the high rates of poor physical and psychological mental health outcomes in these populations (Johnstone & Kanitsaki, 2007). Culturally safe nursing practice achieves this by attempting to deconstruct the inequitable power relationships between patients and health providers and systems, which are a significant barrier to health access and engagement for socio-culturally vulnerably groups (Anderson et al., 2003; Woods, 2010). This is achieved through a focus on culture. However, culturally safe practice does not involve nurses learning others' cultures; indeed, diversity both between and among cultures is too significant to allow a nurse to do this meaningfully (Woods, 2010). Instead, culturally safe nursing involves a nurse reflecting on their own culture and on the legitimacy of others' cultures in the context of the nursing care they provide (Mortensen, 2010). Belfrage (2007) notes that 'cultural safety' underpins the provision of the most effective health practice and systems for diverse groups in Australia. This is particularly true in the context of refugee health.

The United Nations' 1951 Refugee Convention, Article 1(A)2, defines a refugee as any person residing outside their country of nationality or residence due to fear of persecution (UNHCR, 2015). As a signatory to this Convention Australia has an obligation to assist with the resettlement of refugees, including a special category of refugees referred to 'women at risk' (Australian Law Reform Commission, 2015; Parliament of Australia, 2015b). In 2013-14, Australia resettled a total of 6500 refugees, approximately 3.2% of its total migrant intake (Parliament of Australia, 2015b). The majority of these refugees were from Afghanistan (39%), with significant numbers also from Myanmar (18%) and Iraq (13%) (Parliament of Australia, 2015b). In response to the Syrian refugee crisis, in 2015-16 Australia will significantly increase its intake of refugees within existing humanitarian quotas (Parliament of Australia, 2015a). Under the Migration Regulation 1994 Australia allocates 12% of its humanitarian quota to 'women at risk', and in 2013-14 granted over 1000 visas to women at risk (Parliament of Australia, 2015b). This program highlights the fact that refugee women are particularly vulnerable to the effects of conflict and persecution (Federal Minister for Women, 2014).

Refugees in general, and refugee women in particular, have "unique and diverse health profiles" (Hadgkiss & Renzaho, 2014: p. 157). Though refugees make up a very small part of the overall Australian population, it is essential that nurses are aware of refugees' health needs and their complex sociocultural determinants if culturally safe health care is to be provided. In a seminal work on refugee health in Australia (examining the health of refugee children specifically), Davidson et al. (2004) report that a significant number of refugees arrive in Australia with complex health needs. The psychological issues experienced by refugees are well-recognised. Exposure to trauma leaves many refugees – up to 60% in one Australian study – with complex psychological sequelae, including impairments to memory function and debilitating dissociative reactions (Alvin Tay et al., 2013). Nickerson et al. (2014) reports that up to 25% of refugees receive a psychological diagnosis of Post-Traumatic Stress Disorder (PTSD), and 16% of these people also have disorders related to grief. Costa (2007) highlights that refugee women in particular face an increased risk of psychological morbidity related to trauma underpinned by conflict, persecution and forced resettlement. For example, one study found that the gender discrimination experienced by a large number of refugee women is positively correlated with increased incidence of traumatic disorders (including PTSD) and increased risk of suicidality (Kira et al., 2010). It is important to note that issues related to gender, including roles and access, may also limit a refugee woman's health-seeking behaviours related to mental illness (O'Mahony & Donnelly, 2013).

In addition to mental illness, a large number of refugees – up to 77% in some reports – also experience physical illness; indeed, Hadgkiss and Renzaho (2014) note that poor mental health is strongly correlated with poor physical health in refugee populations. Physical illnesses which are particularly prevalent in refugee populations include dental disease, non-specific migraine, musculoskeletal pain and disorders of the integumentary, respiratory and gastrointestinal systems (Hadgkiss & Renzaho, 2014). There is also a high prevalence of infectious disease in refugee populations, including human immunodeficiency virus (HIV), active tuberculosis, Hepatitis B and C and chronic gastrointestinal infections (Hadgkiss & Renzaho, 2014). Costa (2007) notes that refugee women are disproportionately affected by nutritional deficiencies and anaemia, and a sequelae of physical and psychological issues related to gender-based violence. Refugee women experience higher rates of complex gynaecological and obstetric conditions, are more likely to have been sexually assaulted and are more likely to have had an unwanted pregnancy and / or abortion than other women in host countries (Goosen et al., 2009; Kurth et al., 2010).

The myriad of complex health issues faced by refugees highlights the importance of host countries' health systems being responsive to refugees' health needs through the provision of culturally safe care and services. However, there is evidence to suggest this is not being achieved in the Australian context; indeed, Johnstone and Kanitsaki (2007) conclude that cultural safety is both poorly understood and lacks currency in Australia's mainstream health contexts (Johnstone & Kanitsaki, 2007). This leads to culturally unsafe nursing practices. The Nursing Council of New Zealand (2002: p. 7) define this as "compris[ing] any action which diminishes, demeans or disempowers the cultural identity and wellbeing of an individual", either overtly and intentionally or otherwise.

There are many examples of culturally unsafe practice relating to refugees in the Australian context. For example, many refugees, both in Australia and elsewhere, perceive themselves to be discriminated against by health staff in their host countries – a key aspect of culturally unsafe practice. Multiple studies report on such issues – including refugees' perceptions of denial or provision of poorer-quality care on the basis of race and / or immigration status (Bhatia & Wallace, 2007; O'Donnell et al., 2007; O'Donnell et al., 2008; Wahoush, 2009; Bernardes et al., 2010; Kokanovich & Stone, 2010; Asgary & Segar, 2011). This is particularly problematic in terms of the provision of mental health services for refugees in Australia; indeed, Newman et al. (2008) highlight that Australian health workers frequently devalue and deligitimise refugees' experiences of mental illness – for example, by dismissing the self-harm behaviours of refugees in immigration detention as being politically-motivated. Hadgkiss and Renzaho (2014) report a high level of 'medical mistrust' among refugee populations, underpinned by issues such as a fear of financial exploitation and that health information will be used to inform decisions about asylum status (Kokanovic & Stone, 2010; Asgary & Segar, 2011). Covert institutional racism is recognised to be a significant problem in Australian health settings, and this is underpinned by the prejudicial and discriminative attitudes towards refugees which are pervasive in wider Australian society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008). This 'systemic trauma' compounds the health issues of refugees settled in Australia, and is a particular problem for women. Indeed, one Australian study found that women with vulnerabilities related to social adversity were substantially more likely to experience inequalities in health access (in this study, in the context of perinatal care specifically) (Yelland et al., 2012).

In addition to culturally unsafe nursing practices, the provision of culturally unsafe health services is a particular problem for refugees in Australia. As noted by Renzaho et al. (2013) the health systems in host countries are often poorly-equipped to manage the complex health, linguistic and cultural needs of refugee populations (Renzaho et al., 2013). It is well-recognised that Australia's mainstream biomedical health system is highly Eurocentric, disempowering because of its exclusivity and repressive of the fundamental social dimensions of health (Willis & Elmer, 2007). Additionally, the biomedical model of health may be incompatible with refugees' diverse perceptions of health, focusing instead on a limited 'pathological' definition of disease and a reductionist distinction between physical and mental health (Willis & Elmer 2007). Again, this is particularly problematic in terms of the provision of refugee mental health services; for example, Savy & Sawyer (2008) present evidence for the considerably limited culturally safe treatment options in Australia for refugees suffering acute mental illness. These issues may result in refugees' exclusion from or disengagement with health services (Correa-Velez et al., 2013). Indeed, there is evidence to suggest that refugees' engagement with health services is poor; in a European study, Bischoff et al. (2009) found that refugees attend far fewer than the average number of consultations, and that their cost to the health system of their host country was just half that of others in host countries. There is minimal current data available on the engagement of refugee women specifically with health services; however, one study suggests that refugee women are 40% less likely than other women in host countries to attend health screening (in this case for Papanicolaou testing, a common screen for cervical cancer) (Rogstad & Dale, 2004). Refugees' exclusion from and disengagement with health services feeds into the cycle of poor physical and mental health outcomes in this population.

Woods (2010) notes that nurses have a critical role to play in deconstructing the power imbalances which exist between patients and health providers, and which often result in the provision of culturally unsafe care – thereby promoting refugees' access to and engagement with health services in a culturally safe way. The Nursing Council of New Zealand (2002: p. 7) highlights that culturally safe nursing practice is underpinned by nurses "hav[ing] undertaken a process of reflection on [their] cultural identity and … recognis[ing] the impact that [their] personal culture has on [their] professional practice". Here, the notion of 'culture' extends beyond the traditional definition of the term as a system of worldviews, value systems and lifestyles based on shared race or ethnicity, and instead 'culture' is considered as a complex, changing concept underpinned by factors such as individual experiences, gender and social position, etc. (Woods, 2010). It is important to note that achieving culturally safe nursing is an ongoing process of continuous reflection (Ogunsiji et al. 2007). Given the covert but pervasive negative views of refugees in Australian health systems and wider society (Henry et al., 2004; Davidson et al., 2008; Johnstone & Kanitsaki, 2008), reflecting on one's own culture in this way is a particularly important aspect of providing culturally safe health care to refugees.

In addition to reflecting on their own culture, a nurse must also reflect on the cultures of others – but should do so in the context of cultural relativism. Cultural relativism is a sociological theory which posits that all cultures are, and therefore must be recognised as, equally valid and legitimate forms of human expression (Kottak, 2004). Cultural relativism is particularly important when caring for refugees, including refugee women, who engage in unfamiliar and challenging health practices, one example of which is ritualised genital cutting (also referred to as 'female genital mutilation'). Many refugee women from parts of Africa and the Middle East perceive genital cutting to be an important cultural practice and fundamental to their identity, role and beliefs, however the mainstream biomedical health system in Australia denounces and reproves the practice (Ogunsiji et al. 2007). If such issues are not dealt with sensitively and approaches – from both nurses and the health system – balanced through the application of principles of cultural relativism, refugee women may disengage from health services (Ogunsiji et al. 2007). As noted, disengagement drives the cycle of poor physical and mental health outcomes for refugees in Australia.

Australia has a large refugee population which is predicted to increase significantly in the coming years. Refugees in general, and refugee women in particular, have distinctive and diverse health needs which require complex and conscientious responses from nurses and health systems. In the context of nursing refugee women in Australia, this paper has explored the need for cultural safety in nursing. It has also analysed the negative impacts of culturally unsafe nursing practices and health systems in Australia on refugees, with a focus on refugee women. Finally, it was discussed how culturally safe nursing practice can (and should) be achieved in Australia to improve the health outcomes of refugee women and others of diverse backgrounds.

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