Fluctuating power in refugee health nursing: a focused ethnography of the Refugee Health Program in Victoria, Australia
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Date
01/12/2021Author
Hughes, Emma Caitlin
Metadata
Abstract
Background
The Refugee Health Program (RHP) is a nurse-led initiative which was introduced
in 2005 with the aim of responding to the complex health issues of refugees arriving
in Victoria, Australia. Refugee Health Nurses (RHNs) provide a coordinated model of
care, specifically addressing health needs of resettled refugees in the community
setting.
Refugees are positioned within the health literature and policy context as a
vulnerable population, with RHNs expected to support this vulnerability and meet their
needs. Refugees are painted in the literature as a passive group, with a narrative of
presumed power imbalance in the nurse/refugee relationship. However, little is known
about the cultural phenomenon of refugee health nursing and the impact of dedicated
refugee healthcare.
Aim
This study explored the experiences of RHNs, Refugee Health Managers and
refugees within the RHP, gaining insight into social and professional relationships and
the complexities of offering a specialised health service for resettled refugees.
Methodology and Methods
A focused ethnographic approach incorporated semi-structured interviews with five
RHNs, two managers and eight refugees, two focus groups with refugees and
participant observations within the RHP between April 2017 and December 2017. Data
collection was undertaken across two sites and interviews, focus groups and
observations were transcribed and thematically analysed.
Findings
Findings show that rather than a power imbalance in refugee health nursing, power
is everywhere, exercised by all actors. Indeed, Foucault (1980) suggests that power
is relational and fluctuates within social contexts.
Findings highlight that RHNs operate as street-level bureaucrats in this progressive
discipline of contemporary nursing practice (Lipsky 1980). They are gatekeepers to
specialised refugee healthcare, providing and rationing access for refugees and
powerful in their professional stance. Nevertheless, RHNs are susceptible to
weakness, with findings elucidating how their inherent power dissipates. RHNs
contend with bureaucracy as put forward by managers, halting their path of autonomy;
and they must deal with vicarious trauma and the threat of ‘burnout’ in caring for
refugees. While findings portray how nursing power is destabilised, this study also
demonstrates the rise of refugees in laying claim to their own power during
resettlement. Foucault (1980) argues that power relations cannot exist unless there is
resistance, and refugees employ defiance and negotiation strategies within the
nurse/refugee relationship. In this way, power is omnipresent and fluctuating within
refugee health nursing.
Conclusion
This study concludes that in a nurse-led refugee health service, power is exercised
by RHNs, managers and refugees as all actors lay claim to elements of control.
Although autonomous practitioners, RHNs experience loss of power due to
managerial surveillance and contend with secondary trauma through the care of
refugees. While construed as vulnerable, refugees can be resilient and perceptive;
showing resistance to RHNs or negotiating prolonged specialist care when they
recognise the benefits.
Overall, this study has implications for refugee health nursing in improving
healthcare delivery for resettled refugees. RHNs are not as powerful as they seem,
and require ongoing emotional, psychological and educational support in developing
therapeutic relationships with refugees and managing complex, sensitive refugee
health issues. Targeted refugee healthcare is beneficial during early resettlement to
address specific refugee health issues. However, a supported discharge process
should be incorporated, encouraging refugee integration through assimilation into
mainstream community health services, while reducing the ongoing workload of RHNs
and preventing burnout.
All newly arrived refugees in high-income host countries could benefit from
proactive health support during the first year of resettlement, with culturally competent
nurses providing health assessment and early intervention, health promotion and
education, orientation of the health system and onward referrals.
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