Nurses—Making a Difference in Global Health

GOAL 8: Develop a global partnership for development

Displaced and dispossessed: Caring for the world’s refugees

Afghan women refugees in Pakistan
© 2008 The Associated Press

By Shela Akbar Ali Hirani

Refugees are among the world’s most vulnerable populations. They suffer from various threats to their mental health throughout their migration and resettlement. The physical, psychological and emotional traumas that refugees face, before and during migration, are compounded by sociocultural issues they encounter when they finally find shelter. They are often regarded as a burden on the host country’s resources, so these issues are not addressed adequately. Consequently, they experience various mental health problems.

The three major sociocultural issues among refugees are culture shock, loss of status and role, and family disruption, all of which need attention from nurses. Restoring the mental health of refugees by addressing their sociocultural issues is a major responsibility and challenge for nurses.

I have encountered many refugee clients in hospital and community settings and, because of language and cultural barriers, have found it difficult to competently deal with the issues they face. I have also observed gaps in care provided by other health team members due to lack of cultural sensitivity and competency.

Culture shock, “the severe anxiety generated by being in a new culture with unfamiliar language and social norms,” greatly affects a refugee’s mental well-being (Carson & Arnold, 1996, p. 308). When physically and psychologically tortured refugees enter a new land, they find themselves in an alien culture where the environment, climate, language, grooming and societal norms are much different from their own. They are expected to settle in and adjust to the new culture, which leads to stress and gives rise to maladjustment. “The greater the sociocultural difference between the country of origin and the country of migration, the more pronounced will be the stress and the resulting mental illness” (Furnham & Bochner, 1986, p. 105).

In addition to other stressors, refugees often encounter racism in the host community. Frequently labeled as alien, they are ridiculed because of differences in grooming and behavior, which negatively impacts their self-concept, self-esteem and self-worth. As one nurse observes: “These people find it difficult to adjust. They are stared at because of the way they dress” (Hampshire, 2001, p. 17).

Often, health care workers wrongly perceive refugees as mentally ill, based on their behavior. As While (1992) observes, “Unusual behavior is all too easily attributed to mental illness when it is in fact an expression of justified distress or anger” (p. 281). This lack of cultural sensitivity among health workers can further exacerbate poor physical and mental health among refugees. In addition to predisposing refugees to cultural conflict and social isolation, lack of sensitivity by health workers can make refugees reluctant to seek medical help.

Language barriers often contribute to culture shock. Refugees find it difficult to express their concerns and needs to others. They face employment problems and encounter educational challenges that increase stress levels and lead to frustration and maladjustment. Language barriers also discourage refugees from seeking and receiving medical help, which negatively affects their mental health. To improve the mental health of refugees, nurses need to develop cultural competency and sensitivity, address clients and their cultural norms with respect, offer psychological support and be non-judgmental when interacting with them.

Loss of status and role also negatively affect the mental health of refugees. “Refugees,” observes Wiggs (1994), “come from all walks of life—teachers, businessmen, farm workers, ex-government ministers—and yet all have to cope with the umbrella label of ‘refugee’” (p. 18). Previous qualifications are not recognized in the new land, so refugees may have to accept employment that is beneath their qualifications and incompatible with their personal values. Consequently, they suffer from feelings of disappointment, inferiority, decreased self-concept and role conflict.

I have personally seen many Afghan refugees in Pakistan who were previously wealthy, respected businessmen and merchants. They used to live in big, beautiful houses but now, because they are laborers, vegetable sellers, cobblers or unemployed, live in camps or rental housing. As a result, they suffer from role conflict and societal indifference to their previous status. These role-conflict issues are exacerbated for males when the females in their lives get jobs but they remain unemployed. This situation sometimes leads to drug addiction or even suicide.

“Status and role loss is particularly important to men,” observes While (1992), “and downward social mobility has been found to be a factor in the incidence of mental illness among immigrant groups” (p. 281). In contrast, retaining their previous identity contributes to refugees’ mental health.

Many refugees continue to live stressful lives in their host country because of their illegal status, suffering from loss of control and feelings of powerlessness and uncertainty (Baxter, 2000). They are sometimes reluctant to seek help from health workers, thinking it would involve questioning and disclosure of information that might cause them to be stigmatized or rejected.

Even if refugees seek help, they often don’t share necessary information about illnesses or openly discuss past experiences in which they were exploited, tortured or raped. In such situations, restoring the mental health of refugees is one of the biggest challenges nurses face. It is the responsibility of nurses to establish and sustain partnerships with refugees by learning about their bitter experiences and their physical and emotional consequences (Downs, 1997). Nurses can help and support refugees by encouraging them to tell their stories, accept themselves, to let go of their past, and move on with focused and achievable goals. A positive attitude by nurses toward refugees can help them overcome problems associated with role conflict and status loss.

Finally, refugees encounter family disruption. Migration inevitably involves separation of refugees from familiar places, family members and relatives. “All political refugees are different, but all will have experienced the extreme trauma of enforced uprooting and the misery of permanent separation from loved people and places” (While, 1992, p. 281). Refugees feel uncertain. They don’t know whether family members they became separated from are alive or not. I have encountered many Afghan refugees who suffer feelings of guilt for leaving relatives behind.

Many who had witnessed the deaths of close relatives now suffer from depression, post-traumatic stress disorders and somatic complaints. Five years after South Asian refugees migrated to the United States, 81 percent were seriously distressed about their separation from missing family members; 67 percent had recurring painful memories of war and their escape from it; 59 percent were homesick; and 58 percent were experiencing stress caused by difficulty communicating with relatives remaining in South Asia (Fox, Cowell, & Johnson, 1995). Maladjustment caused by family disruption among refugees often leads to further isolation. As a result, they find it difficult to cope with major life changes in a new society and culture, making them more prone to mental illnesses.

Studies suggest that refugee women are more prone to mental health problems caused by family disruption, whether from loss of parents, spouses or children. It is important that nurses address such issues competently. By learning to detect and understand unrecognized grief among refugees, nurses can help them deal with issues of loss and painful memories. Nurses can also offer support to refugees by designing intervention programs that encourage social support networks, family viability and ethnic community development. In addition, nurses can help refugees develop culturally appropriate coping strategies.

To deal effectively with refugee sociocultural issues, nurses must become aware of values they hold that hinder effective care. Nurses should make use of available media to address these issues and their impact. They need to strongly emphasize implementation of culturally sensitive approaches to meeting refugee needs through mental health services, referral centers and hospitals. Nurses also need to convince government workers and policymakers to allocate funds and other resources for refugee needs, including resettlement.

As refugee advocates, nurses should encourage governments to provide mental health services, recreational facilities and career guidance services, and help empower refugees by promoting training programs that advance language, education and professional skills. In hospitals, nurses should ask management to provide cultural competency training to staff members. Within refugee communities, nurses should establish support groups and identify, recruit and help train health workers. They should also take the initiative in arranging for refugee counseling.

If nurses do not effectively deal with culture shock, loss of status and role, and family disruption, the physical, mental and social well-being of refugees is at risk, which can trigger additional maladjustment problems. By demonstrating cultural sensitivity and competency, and helping establish support networks, nurses can minimize maladjustment and reduce mental health problems for refugees. RNL

Shela Hirani
Shela Akbar Ali Hirani, RN, BScN, instructor at Aga Khan University School of Nursing in Karachi, Pakistan, is secretary of Rho Delta Chapter.                                             

Baxter, C. (2000). Antiracist practice: Achieving competency and maintaining professional standards. In T. Thompson & P. Mathias (Eds.), Lyttle’s mental health and disorder. Philadelphia: Bailliere Tindall.

Carson, V.B., & Arnold, E.N. (1996). Mental health nursing: The nurse-patient journey. Philadelphia: W.B. Saunders.

Downs, K., Bernstein, J., & Marchese, T. (1997). Providing culturally competent primary care for immigrant and refugee women. Journal of Nurse-Midwifery, 42(6), 499-507.

Fox, P.G., Cowell, J.M., & Johnson, M.M. (1995). Effects of family disruption on Southeast Asian refugee women. International Nursing Review, 42(1), 27-30.

Furnham, A., & Bochner, S. (1986). Culture shock: Psychological reaction to unfamiliar environments. London, New York: Routledge.

Hampshire, M. (2001). Out of reach. Nursing Standard, 15(51), 16-17.

While, A.E. (1992). A text book of psychiatric and mental health nursing. New York: Churchill Livingstone.

Wiggs, L. (1994). Meeting the needs of refugees. Nursing Standard, 8(51), 18-20.

RNL - Reflections on Nursing Leadership - Published 11/21/2008 , Vol. 34 No. 4