Nurses as a global force to advance equitable healthcare among women impacted by forced migration

Author: Shahin Kassam

Situating women impacted by forced migration within nursing
Over 50% of the global workforce in health are nurses. Guided by nursing science, nursing knowledge is unique and integrates principles such as health prevention and promotion and social justice into their diverse care provision roles. While we often think of nurses as immersed within clinical settings across acute and community care environments, nurses are also leaders in education, research, health systems management and policy. Nurses are also guided by global health initiatives, including the United Nations Sustainable Development Goals, which promise to ‘leave no one behind’ in delivering care to all populations, regardless of their social positioning, including class, race and gender. Critical to nursing roles is the identification of populations that are marginalised by structural violators, including antiquated policies rooted in colonialism, racism, sexism and classism. Women impacted by forced migration is one such population that is rising in numbers daily, yet is relentlessly exposed to human rights violations and social exclusion.

The International Organization for Migration defines forced migration as people who need to leave their homes to escape persecution, war, conflict, human rights violations or environmental disasters. However, forced migration also affects those in less visible and insidious circumstances, such as gender-based violence, including human and sex trafficking. While we know that over 108 million people are currently experiencing forced migration, we also know that this number is forecasted to rapidly climb to one billion people by the year 2050. A deeper look at these numbers reveals the over 50% of those impacted by forced migration are women. Women face disproportionate rates of exploitation and gender-based violence and the subsequent health sequelae, including post-traumatic stress, HIV, hypertension and depression. Women also persistently encounter barriers to accessing timely and appropriate care. Women of colour face even more layers of inequity where overt and subtle forms of racism contribute to social isolation, hopelessness and diminished trust.

What do nurses do within their care provision roles focused on women impacted by forced migration? Here is what we know.

Communicating effectively and safely: We talk, and nod and smile and you get some kind of communication
Nurses have the capacity to be aware of the diverse ways in which health is conceptualised and understood across varying cultures. This includes how health issues, such as post-traumatic stress and gender-based violence, can be communicated differently. Centring care around women’s descriptions of their health fosters the learning of new ways that appropriately express issues related to women’s well-being. Communication through interpreters can be situationally beneficial, however, caution is advised. For example, paying attention to the interpreter-woman dynamic to ensure the woman’s comfort with the interpreter’s background and approach is important to provide a trusting and comfortable space to engage in health discussions. Ethical issues are also concerning when family members are used as interpreters, as it can create inadequate and inappropriate communications, leading to mistranslation and risks of breaching confidentiality and quality of care.

Prioritising women within care delivery: Find out what their normal is before trying to change it
Nurses address multiple issues related to difference through prioritising women within care. Essentialist prejudices can exist within nurses’ care delivery; however, many nurses described looking beyond differences and focused listening as strategies used to promote culturally sensitive care. Differences also exist within belief systems and interpretations of spiritual well-being, where women often avoid mental health care, especially during grief and loss experiences. Prioritising women’s belief systems over their own is a core approach used by nurses. This includes being open to women’s spiritual and cultural practices.

How can systems contribute?
While many nurses are expected to shoulder the responsibilities of ensuring care is provided in a safe and ethical manner, the focus on systems to support these responsibilities seems to be minimal. In order for nurses to be well-positioned to provide appropriate and effective care to women impacted by forced migration, health systems have a responsibility to support nurses in the following ways:

• Integrating migration as a health determinant that shapes women’s well-being in training: Provide ongoing professional education across acute and community care environments focused on how to assess migrant status and its contribution to women’s experiences of diminished access to appropriate health services.
• Providing continuous professional support on trauma and violence-informed care with a focus on how women living with forced migration are impacted by gender-based violence and racism: Develop policies that foster continuity of care among nurses toward building trusting and safe relationships that promote engagement between health systems and women impacted by forced migration.
• Critically examine clinical care pathways to ensure inclusion of women impacted by forced migration as a population with complex health issues: Questioning current protocols on how timely health follow-up and monitoring is being provided and how interdisciplinary partnerships with nurses are being promoted to facilitate access to services.
• Exploring creative approaches to communicating across language barriers: Evaluating what visual aids are currently in place to promote communication and how well they work from nurses’ perspectives and the women they serve.
• Examining policies and practices that promote exclusion of discrimination: Including nurses in research that critically analyses institutional policies targeting care provision among women affected by forced migration.
• Exploring nurses’ experiences of providing care to women affected by forced migration within acute care settings: Questioning what promotes and hinders care provision within rural and urban settings, including emergency rooms and intensive care units, as well as what nurses understand about how migrant status shapes women’s health.

Mapping out next steps
The phrase ‘leave no one behind’ means many things. However, an overarching goal of this idea is to ensure inclusion, which is a socially just and ethical principle. These involve at least two areas of further thought and action-oriented inquiry.

The first is including nurses within health system decision-making. Nursing knowledge is distinctive and well-positioned within health care systems worldwide to provide effective care for women affected by forced migration. However, current knowledge is limited is many ways. While nurses are a core pillar within many interdisciplinary teams, their voices and stories are often pooled into disciplines that do not recognise the capacities nurses hold, especially in providing action-oriented care among complex populations. Outcomes of including nurses within interdisciplinary decision-making structures include identifying how populations that are systemically marginalised are being overlooked, and strategies to mitigate pervasive exclusion of these populations.

The second area is engaging and integrating the experiences of women impacted by forced migration. There is an urgent need for research that focuses on understanding prejudice and discriminatory policies and practices that are further marginalising women impacted by forced migration. Implicit and explicit racism continues to be rampant within health systems. Unsettling and dismantling these harmful structures can be approached through research that centres women’s experiences of health and health care. Outcomes of such research include informing practice, programming and policies with women’s narratives. Approaching such research through an intersectionality lens that identifies inequities within multiple axes of oppression, including gender, race, migration status and class, has the potential to highlight overarching ideologies that persistently exclude groups of women from narratives. In addition, integrating a community-based research approach holds promise of engaging with expertise that is often overlooked within non-profit sectors.

Additional resources

Editorial in motion
Short video summarising published editorial, ‘Leave No One Behind’

Editorial
Leave no one behind: how nurses are building capacity within health systems to respond to global forced migration
Kassam, Shahin; Marcellus, Lenora; Butcher, Diane
JBI Evidence Synthesis 20(11):p 2605-2606, November 2022. | DOI: 10.11124/JBIES-22-00384

Systematic Review
Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review
Kassam, Shahin; Butcher, Diane; Marcellus, Lenora
JBI Evidence Synthesis 20(11):p 2609-2655, November 2022. | DOI: 10.11124/JBIES-21-00181

Best Practice Information Sheet

A summary of the evidence reported in the systematic review in available in a JBI Best Practice Information Sheet, which is available for download

Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.