In the past several decades, many U.S. communities have opened their arms to refugees fleeing conflicts around the world. But once refugees arrive here, they typically must adapt to many things most Americans take for granted, such as public transportation, telephones, and indoor plumbing. The complex infrastructure supporting life in this country, for example, which comprises banking, employment, and health care, can be even more baffling.
Many refugees are unfamiliar with American culture and American medicine, and relocation may be confusing and frightening. Nurses can help them navigate health care, as well as other systems vital to their well-being. Working with patients adjusting to a new society can be challenging and may sometimes seem overwhelming.
Many refugees have had to leave their homes as a result of a disaster, which is likely to have had physical or psychological consequences to which nurses should be sensitive. Some have been tortured; they may carry physical and psychological scars. Some have lived in poverty or been dislocated and have lived in refugee camps for decades. Finally, their poverty, when combined with other factors, sets them apart from even the poorest patients a nurse is likely to encounter.
A number of organizations and resources offer support to nurses caring for refugees. Some of these exist for specific communities but may also be helpful to nurses. Others are wider in scope. Here we will highlight theoretical and practical tools for helping nurses better understand the needs of refugees, how to care for them, and how to connect them with other needed services.
TRANSCULTURAL C.A.R.E. ASSOCIATES
Josepha Campinha-Bacote, president of Transcultural C.A.R.E. Associates, has developed what she calls the "process of cultural competence in the delivery of health care services," a model of transcultural nursing that's useful not only to those who provide care to refugees, but to all health care providers. The Campinha-Bacote framework translates transcultural knowledge into five areas: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. She describes these competencies as interdependent and able to provide the desire to enter into the process of becoming culturally competent by genuinely seeking cultural encounters, obtaining cultural knowledge, conducting culturally-sensitive assessments, and being humble to the process of cultural awareness.
Nurses may find this tool useful in their attempts to empathize with refugees from unfamiliar cultures.
THE AAN: CARING FOR VICTIMS OF TORTURE
In 2001 the American Academy of Nursing (AAN), which makes policy recommendations to the nursing profession, convened an expert panel on violence. The panel produced Policy Recommendations for Nurses Caring for Victims of Torture, which provides background information on torture, its forms, and its consequences. It also provides recommendations on how nursing can address the needs of and provide care to torture victims. The guidelines include both goals and recommendations on how to achieve these goals, which range from broad ("Nursing . . . will speak forcefully and compassionately in all appropriate venues denouncing torture as a serious health threat") to specific ("Nursing research initiatives will aid in establishing the prevalence of torture and measure treatment outcomes"). The recommendations on how to meet these goals are more specific (for example, "Support a conference or institute on the subject of torture and survivors of torture").
THE HMONG HEALTH INFORMATION PROJECT
c/o Northern Wisconsin Area Health Education Center (NAHEC)
719 North 3rd Avenue Wausau, WI 54401
(715) 675-7899
Sharon K. Johnson, in the April 2002 issue of the Journal of Transcultural Nursing, describes Hmong refugees in the United States as "continu[ing] to suffer the sequelae of war injuries, including chronic nonhealing bullet wounds, exposure to biological and chemical warfare, and psychological conditions such as posttraumatic stress disorder and major depression." The characteristics Johnson describes are found in many refugee groups, such as those from Somalia or Cambodia.
Originally from Southern China, the Hmong (pronounced "mung") are members of a Southeast Asian ethnic group believed to have migrated to Laos about 200 years ago. Their mountainous environment isolated them from other cultures for many years; consequently, the Hmong culture remains distinct from that of greater Laos.
After the 1975 Communist takeover, the new Laotian regime branded the Hmong as collaborators with U.S. forces in the country. Many of the Hmong fled to Western Europe and North America; some spent as long as 20 years en route, stalled in refugee camps in Vietnam and across Southeast Asia. The flow of Hmong into the United States was heaviest between 1980 and 1995, says Johnson in the same article. The largest Hmong communities in the country are in California and the upper Midwest.
In response to the needs of the Hmong community in America, the Hmong Health Information Project (Hmong HIP), which is partially funded by the National Library of Medicine and the Northern Wisconsin Area Health Education Center (NAHEC), is developing a Web site, http://www.Hmonghealth.org, aimed at increasing the health and health literacy of the Hmong community in America. Me Lee Thao believes that it can serve a dual purpose: to promote health and wellness among members of the Hmong community, and to teach health care providers about the community's unique needs. Thao is the content adviser to the Web site and says that her goal is "not only to educate the Hmong people, but also to educate the providers."
According to Thao, public health and home health care nurses can use the site to provide better care as well as to educate their patients. The language barrier is one issue the Web site can help resolve. Currently, because few home health care nurses speak fluent Hmong, translators are often needed when they go to Hmong homes. But translators cannot always effectively handle medical literature and instructions. In situations where no interpreter is available, the Hmong-English glossaries on the Web site may help Hmong readers who don't understand medical English. The site's translation glossaries can support the work of public health nurses and give the Hmong tools to better manage their health care. The Hmong HIP also provides access to videos and CD-ROMs, either free or at cost. Margaret (Peg) Allen, NAHEC library consultant, says that in order to reach a wider audience, Hmong HIP may begin distributing audio files as well, possibly in both digital and analog formats (since many Hmong may have tape players but not Internet access).
THE CENTER FOR VICTIMS OF TORTURE
717 East River Road Minneapolis, MN 55455
(612) 436-4800
The Center for the Victims of Torture helps bring healing to torture victims, primarily refugees and people who have sought asylum in the United States, and to their communities. The center also works for the cessation of torture around the world and as advocates of torture victims in matters of public policy; it also provides training to health care professionals.
The center operates out of a Victorian farmhouse, the Minneapolis Healing Center. The house has been renovated to provide therapeutic comfort to those who come for counseling. Natural light and artwork contribute to a sense of well-being. Local gardeners volunteer time at the home's Healing Garden.
For nurses, local and remote, the center provides a number of resources, including a bibliography on torture, videos, and reading material. Some pamphlets are available on the center's Web site, but other items must be ordered through the mail. The center also coordinates visits from speakers and roundtable discussions on topics related to refugees and torture.
ETHNOMED
Harborview Medical Center
University of Washington
The Seattle area has experienced an influx of refugees from many countries, including Ethiopia and Cambodia. In response to the health care needs of this growing population, the University of Washington's Harborview Medical Center created EthnoMed. This Web site, a collaborative project of the University of Washington Health Sciences Library and the Harborview Medical Center's Community House Calls Program, offers information for health care providers and patients.
EthnoMed provides patient education materials in different languages, allowing patients to find health information themselves, despite language barriers. Audio resources are a recent addition and may come in handy for those who don't speak English.