Fluctuating power in refugee health nursing: a focused ethnography of the Refugee Health Program in Victoria, Australia

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.