‘I hear you’: Nursing in refugee health

Refugee health nurse Kate Spanner provides refugees and asylum seekers access to healthcare and the vital support needed on their new journey

“You’ve got to be able to listen to the person who’s talking and just validate their story and their journey without an end point to anything, except to say ‘I hear you, I want to give you some kindness and I want to celebrate the journey you’ve had so far’,” says refugee health nurse Kate Spanner.

A clinical nurse in Refugee Health, Kate works at South Australia’s Refugee Health Service (RHS), a specialist statewide healthcare service for newly arrived refugees and asylum seekers.

“We’re not a long-term health service, our aim is to provide that immediate arrival health assessment and follow-up care, treatment and referral with the idea of doing a really soft and supported transition into mainstream services when the client and the family are ready for that.”

Kate spent her early career working in a variety of clinical roles in paediatric nursing. The seed to working with clients from a refugee background was planted during a role as a clinical nurse consultant in respiratory medicine.

“I realised that the part of nursing I really enjoyed was the holistic care of a client group rather than the idea of looking after one disease state or one healthcare issue,” she recalls.

Working overseas in a variety of nursing roles for several years but then having children meant a short break from nursing.

After contemplating her next step, Kate decided to follow her passion and head into primary healthcare.

Her first role was with a primary healthcare service in the western suburbs of Adelaide working with a variety of vulnerable groups from a refugee and asylum seeker background.

It was a natural stepping-stone to specialising in providing healthcare to refugees and asylum seekers with the Refugee Health Service, where she has worked for the past 15 years.

The RHS has been providing primary healthcare services for refugees and asylum seeker clients for more than 20 years, focusing on newly arrived families and individuals with complex health and psychosocial needs. The RHS multidisciplinary team includes nurses, social workers, psychologists, GPs, multilingual bi cultural workers, visiting specialists and administration staff.

Kate’s role as a refugee health nurse encompasses providing comprehensive health assessments, clinical management of complex conditions, referrals, health literacy education and support, and immunisations, including COVID-19 immunisations. A daily nurse-led ‘drop in clinic’ offers clinical assessment and management.

As the service’s dedicated child health nurse, Kate also runs a weekly paediatric clinic, carrying out growth and development assessments and working with families with children with special needs to support timely access to the National Disability Insurance Scheme (NDIS).

Newly arrived refugees and asylum seekers typically spend a year to 18 months accessing healthcare via the service. Some clients transition to mainstream health services earlier, while other complex cases may need help from the service for several years.

“Sometimes it can be a really validating experience for someone to see that they don’t need the specialist service anymore,” Kate says.

There is no specific training course to become a refugee health nurse. However, Refugee Nurses Australia (RNA), a national organisation founded in 2016 to connect nurses who work with people from a refugee or asylum seeking background and provide a forum to highlight professional issues, developed a set of professional standards and competencies for what is broadly required in the role. RNA provides national leadership in refugee nursing by promoting clinical best practice and advocating for improved equity and access to healthcare for people from a refugee background.

The team of six nurses at the Refugee Health Service boast diverse areas of clinical experience, such as women’s health, mental health, and midwifery. All nurses hold portfolios depending on their area of specialty.

“The other thing that you need to work in this space is a really good understanding and that constant awareness of global geopolitics,” Kate explains.

“You can’t work with refugees and asylum seekers if you don’t have an understanding, politically and geographically, of where they’ve come from. You don’t need to know all the details and the politics and history of a particular country but you need to have an understanding of what is happening in that space that have forced people to leave it.”

The majority of newly arrived refugees and asylum seekers who land at the Refugee Health Service have been granted humanitarian visas by the federal government. In South Australia, settlement agency AMES meets individuals and families at the airport and transports them to houses, or in more recent COVID times, medihotels, hotel quarantine, and apartments scattered across the city.

“We have very different groups of refugees that come into the health service from very different parts of the world,” Kate says.

“There will be surges of people. At the moment, we’re dealing with groups of evacuees from Afghanistan. Prior to that, we had a large group of people coming from South and Central America. A few years ago, we had a large influx of people from Syria. And there’s always people coming from other areas of need including Burma, Nepal and Africa.

Healthcare needs are invariably complex and challenging. Many refugees arrive with nutritional deficiencies. Some have an undiagnosed or untreated disability. Physical, emotional and mental trauma is common.

“We are working with a group of people that have normally found it very difficult to access healthcare, whether that’s because of war or the fact they’ve been living in a refugee camp for 20 years. They might have had access to healthcare, but it was only available on a user pay system.” Kate says.

There’s a lot of undetected and untreated chronic diseases, as well as infectious diseases.”

For Kate, a typical day on the job includes everything from screening of newly arrived clients, including their physical, emotional and mental health needs, to blood tests, administering COVID-19 vaccines, and working at the nurse-led drop in clinic or the child health clinic. All care provided is assisted by an accredited interpreter.

While most clients who access the service have been granted humanitarian visas, a small cohort originally arrived via offshore detention on Nauru, then community detention in Adelaide, before securing temporary protection visas. Some have Medicare, some do not. None have Centrelink.

This cohort will not be settled permanent in Australia as refugees and are unfortunately in a state of limbo with no endpoint, Kate laments.

“It’s really difficult to work with this amazing group of people because they had to make really difficult decisions to leave the lives they had to get in a boat. They’re very strong, very brave people and now all that they need is that idea of a hopeful pathway. You can listen and you can provide care for them right now, and advocate on their behalf, but you can’t ever say it’s going to be fine.”

The Refugee Health Service experienced a reduction in arrivals for about a year amid the ongoing global COVID-19 pandemic.

However, in recent months it has registered over 200 Afghans who fled the country and were flown to Australia under the federal government’s evacuation mission from Afghanistan after Kabul fell to the Taliban.

“We suddenly had all these planes landing and all these people in a variety of medihotels here and then in apartments and hotels around the city because there was no housing available, all with amazing stories of how they got on planes and got out of what was a horrible situation. We’re still hearing those stories now as we’re slowly triaging and doing health assessments in this group of clients.”

Kate says adapting to a new country has been challenging for the Afghan refugees, especially as they are still in contact with close family back home and constantly re-traumatised by the situation unfolding.

“It’s been more the sudden dislocation,” Kate explains.

“The fact that they left with nothing, no clothes, no records, trying to even work out ‘do u know how old u are? There are no birth records, there are no immunisation records.”

Kate says people from a refugee background should be entitled to access mainstream healthcare, just like everyone else. Yet barriers remain.

“There’s always that system failure of recognition in tertiary sectors that refugees and asylum seekers are a vulnerable group and need extra support,” she says.

“For a whole variety of reasons, they find accessing mainstream healthcare, especially the tertiary health sector, quite difficult. They don’t feel heard there due to language issues, lack of use of interpreters. Clients find it difficult to access care because of transport. We had a big issue when families needing COVID swabbing and they were told ‘oh you just go through a drive through service’ but you can’t really do that on a bus, and most of our clients don’t have driver’s licences or cars.”

Kate says listening is often a key part of refugee nursing.

“Quite often as nurses, we’re listening for a point of referral or what is this person going to tell me that I can use to support their health needs. But sometimes as a refugee health nurse, you just have to listen so someone can feel for the first time that they’re being heard. That their story is being shared. Sometimes it’s an amazing and great story and sometimes it’s a really tragic story. But you still must give them that right to be heard.”

When Kate completed her nursing degree in the late 1980s, she says could not have imagined ending up as a refugee health nurse. But she considers the role the most enjoyable of her career, and says it reflects the unique diversity of nursing pathways.

The refugee health nurse community is small and tight-knit. It needs more nurses with resilience, big hearts and a passion for social justice, Kate says, when asked for her advice to students and new graduates considering the speciality.

“Go and get some clinical experience in whatever area pathway. Hold onto the passion. Seek to learn about other people, seek to experience to work in other cultures where you can, and just look for opportunities to be involved in primary health nursing and then that will lead to refugee healthcare.”

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