Nursing practice and global refugee migration: initial impressions from an Intergovernmental-Academic Partnership

Abstract

Aim:

This report from the field describes impressions of the initial impact of bilateral, multi-sectoral field-based activities undertaken to strengthen International Organization for Migration/United Nations Migration Agency and US-based nurses’ capacity to address complex clinical, social and cultural challenges experienced by refugees in resettlement. Authors comment on the defined and thorough health assessment process that refugees go through prior to resettlement, and focus on the essential nursing role in the health assessment process and continuum of care. The development of the interdisciplinary and collaborative partnership is described as well as next steps to move the partnership forward.

Background:

In 2017, International Organization for Migration/United Nations Migration Agency and the University of Minnesota, guided by experts from the United States Centers for Disease Control and Prevention, began a unique bilateral Intergovernmental-Academic partnership to enhance the health care of refugees. A key component was to strengthen nursing care of refugees through the standardization of clinical practice and nursing leadership.

Sources of Evidence:

Listening sessions, direct interaction between International Organization for Migration/United Nations Migration Agency and US-based refugee resettlement stakeholders, patterns in resettlement.

Conclusion and Implications for Nursing and Health Policy:

The report highlights the potential public health impact of a bilateral and collaborative initiative that develops and bridges key points in the migration and health trajectory of people with refugee status. Separated by geography, context and scope of work, health professionals in different roles in varied worldwide settings with a spectrum of resources may not fully understand the work of each other. Project activities were a platform through which US-based and internationally based nurses established mutuality, reciprocity and equity as partners. By strengthening systems and resources, the partnership reinforces the abilities of nurses who engage in this important work, to optimize health and wellbeing of people with refugee status.

Introduction

The scale and complexity of global refugee migration necessitates nimble, high-quality healthcare networks that are sustainable in and responsive to dynamic refugee migration patterns. In this article, we describe the activities of one such healthcare network. In 2017, the International Organization for Migration/United Nations Migration Agency (IOM) and the University of Minnesota (UMN), guided by experts from the United States (US) Centers for Disease Control and Prevention (CDC), began a unique intergovernmental-academic partnership to enhance the health care of refugees. A key component was to strengthen nursing care of refugees and nursing leadership with an emphasis on IOM clinical nursing activities relevant to the pre-departure period, the final series of refugee medical screenings completed prior to resettlement. The primary objectives of the nurse-centred initiative include:

1. Build relationships and partner to grow through the sharing of knowledge, resources and best practices in refugee migration and US resettlement;

2. Reinforce the IOM nursing workforce with additional skills, knowledge and resources necessary to manage complex clinical and public health work;

3. Develop international collaborations to strengthen the health of people with refugee status along the resettlement trajectory;

4. Promote and protect the health and wellbeing of refugees;

5. Elevate the role of nursing through leadership development and the promotion of standardized clinical practices.

To meet these objectives, IOM engaged a team of Minnesota-based nurses actively practicing, teaching and/or conducting research with refugee populations. This collaboration was fostered through international exchanges of nurses. IOM nurses visited Minnesota for formal leadership training including observing the domestic refugee programmes and clinics. US-based nurses, in turn, visited IOM field sites to better understand the pre-departure system and clinical management of refugees. Through the collaboration, IOM sought to strengthen nurses’ capacity to address complex clinical, social and cultural challenges experienced by refugees in resettlement and foster bilateral project ownership and mutual understanding. The project team continues to develop and implement strategies aligned with these objectives (Fig. 1).

Fig. 1.

Summary of IOM nursing workforce capacity building activities.

Evolution of the collaboration

As a first step, the project team engaged nurses practicing in major IOM resettlement operations in listening sessions designed to identify capacity building needs and to determine where partner strengths could be utilized for mutual benefit. Listening sessions were held in Dar es Salaam, Tanzania and Kuala Lumpur, Malaysia with nurses representing IOM operations in Africa and Asia.

The listening sessions were an opportunity to elicit the perspectives of representatives of the 500+ member workforce, in terms of how nurses viewed and approached their work (IOM 2017). IOM performs health assessments for refugees, and migrants identified for resettlement to various countries. IOM nurse professionals are responsible for standard nursing cares associated with the basic clinical procedures of those migrants completing their required health assessments prior to departure. The nursing activities they provide are in the context of the larger cluster of activities that manage both individual and public health needs of travel and resettlement. As an integral part of a multi-disciplinary team, nurses play an important role in delivering quality services to their population of concern. In some locations, nurses work as members of a larger team of nurses and panel physicians, and in other locations, they work independently with non-IOM physicians or partners in the completion of the health assessment process. Whichever the setting, accurate medical information collected by the nurse is essential for the physical examination and follow-up activities.

Nurses framed their roles within the context of nine high-level public health/nursing competencies (Table 1) (Schoon et al. 2018). As nurses positioned their work with refugees within each of these high-level domains, they referenced skills and knowledge with which they performed essential roles, responsibilities and functional core competencies tied to health outcomes in resettlement, including health assessment and evaluation of fitness to travel. Spaces for growth were discussed, where nurses perceived additional support, information or structure would facilitate the quality of care they provided to clients as well as their own professional development as nurses (World Health Organization [WHO] 2016). These early phase discussions produced the framework for the ongoing collaboration.

Table 1.

IOM nursing competency domains

*Communication	*Clinical Assessment and Practice
Teamwork and Collaboration	Critical Thinking and Clinical Judgment
Leadership	Problem Solving
Technology Resources	Advocacy
Education

^*Current project focus areas.

During the listening sessions, IOM nurses discussed their roles in ways that facilitated US-based nurses’ understanding of the scope and impact of the IOM nurse role. IOM nurses described their positioning and engagement with refugees preparing for travel to their final destination in the United States, ‘Nurses are among the first health encounters and continue to interact [with the refugee] until they depart for a receiving country.’ Repeatedly in these sessions, nurses expressed the notion of being ‘everywhere’ and that ‘we ensure that the migrant is healthy…with readiness to meet their fate on arrival’. These ideas figured prominently into the expressed value of ‘do no harm’ that IOM nurses brought to their work as they carried out the mission of IOM.

A second early phase priority was to facilitate direct interaction between IOM and US-based refugee resettlement stakeholders. Individuals and families with refugee status go through a carefully developed, thorough, and defined US Refugee Admissions Program (USRAP) health services process of medical screening and management for resettlement (CDC 2012, 2016, 2017a, 2017b, 2019; United States Citizenship and Immigration Services 2019a, 2019b). The process begins in the host country 4-5 months prior to departure and continues in the United States (USRAP 2018). Separated by geography, context, and scope of work, health professionals in different roles in varied worldwide settings with a spectrum of resources may not fully understand the work of each other (IOM 2019a; WHO 2010). Upstream identification of health conditions, and management of those conditions, has a critical impact on refugee health care following arrival in the United States and can significantly decrease costs, improve individual health and promote community integration (IOM 2019b). An example of seemingly discrete actions that can improve the care of refugees across this continuum of care is the standardization of the clinical approach and documentation across this huge organization and the globe. Standardizing documentation allows US refugee programmes and clinical providers to understand the process and to more successfully utilize the documentation of previous care (e.g. vaccinations, screening tests, health conditions identified; IOM 2019c).

Additionally, through bilateral exchanges, project partners have identified protocols for the detection and management of health conditions that can put refugees at risk before, during or following arrival in the United States. An example of this activity is the development of a protocol for identification of refugees, particularly children, who have malnutrition. Although seemingly obvious, malnutrition can be quite subtle and can have devastating consequences if not identified and appropriately monitored (e.g. children who have severe anaemia and are malnourished may not tolerate the altitude and physical demands of international air travel; IOM, 2019c; WHO, 2018). Once identified, it also allows the US-based care teams to provide more targeted services within their clinical time constraints at new arrival screening and medical visits.

Capacity building results from direct experience (Matovu et al. 2013; Ward et al. 2019). As nurses from Minnesota and IOM travelled to observe the work of their colleagues and the health systems that serve refugees, they were better informed regarding their own work and that of their colleagues. Exchanges between US domestic and overseas health providers have a ripple effect, as nurses share their perspectives with colleagues upon their return (quasi train-the-trainer effect). The effort to bridge US-based and internationally based nurses to build mutuality, reciprocity and equity remains a central tenet of the project. For Minnesota nurses caring for refugees post-arrival in the United States, these exchanges facilitate understanding of the complexity of the pre-departure assessment process, as well as systems differences that necessitate additional patient support, such as the US appointment model. On the IOM side, nurses better understand the health processes and services available to refugees after their arrival. This facilitates more effective counselling to refugees with significant medical conditions. A team approach to refugee care is essential, and because nursing practice is integrated at a number of points in the refugee health assessment process, these bilateral interactions are necessary (Matlin et al. 2018).

Building out the partnership

Led by IOM nurse leaders from several major refugee operations in Africa and the Middle East, the project team next narrowed a focus to two competency domains (Table 1) which represented high priority areas for project partners: Communication (with a focus on interprofessional communication and the use of medical interpreters) and Clinical Assessment and Practice. Two in-person trainings for IOM physicians and nurses were organized and held in IOM regional hubs (Bangkok, Thailand and Kampala, Uganda). Interprofessional sessions as well as sessions developed specifically for nurses were structured around these priority areas.

Communication

The project team embedded communication structure and strategy with interprofessional collaboration models to support the continued development of a community of practice (Bridges et al. 2011; Cleary et al. 2019). Learning activities introduced during the in-person trainings stressed and reinforced approaches to communication to strengthen the work of teams, influence patient safety and health outcomes and facilitate the evolution of organizational culture (Cooke 2016; Jeffs et al. 2013; Jones et al. 2013). Coaching, feedback, provider team debriefing and conflict resolution were specific tools that the project team identified as priority areas. These were then integrated throughout the training curriculum. Curriculum delivered during the in-person trainings was structured around IOM case studies to facilitate meaningful reflection and discussion (Breytenbach et al. 2017; Bryan et al. 2009; Mukhalalati & Taylor 2019). Members of the project team conducted field observations following in-person trainings as elements of the curriculum were disseminated regionally by IOM nurses and physicians. This served as a formative evaluation as the project team considered regional differences in the dynamics of healthcare teams across IOM regions.

Clinical Assessment and Practice

Core areas of the health assessment focus of the project include the evaluation and management of infectious diseases and/or chronic conditions and associated symptoms that would impact the ability to travel safely or contribute to a public health concern in the country of arrival. Training sessions focused on aspects of the multi-step health assessment process conducted by nurses with refugees immediately prior to departure for resettlement in the United States. Emphasis was placed on health education and counselling that IOM nurses provide to refugees pre-departure. The training approach was interfaced with updates on vaccination protocol, use of medical interpreting and basic clinical nursing skills used routinely in health encounters by IOM nurses. Where possible, nurse and physician trainings were conducted together or in concert to promote interprofessional collaboration between IOM providers (Bridges et al. 2011; Cleary et al. 2019). A key aim of the activities was to promote optimized refugee health care.

Moving the partnership forward

The clinical development of the IOM nursing workforce encompasses multiple key considerations. The structure envisioned for the next project phase incorporates the following steps: promoting a standard, baseline clinical practice expectation for all IOM nurses; determining a system of implementation of new knowledge and skills; and implementing a learning platform, to facilitate uniform training and implementation across the large organization.

Standardizing practice

The project team conducted a subsequent, multi-faceted needs assessment to determine priority clinical areas. The assessment included IOM nurse surveys, discussions with IOM leaders and an examination of patterns in clinical care data (CDC 2013, 2018). Priority areas that emerged included standardization of nursing health assessment based on IOM protocol and maximizing the nursing role in the assessment of paediatric growth and development. The development of learning and practice support tools in paediatric growth and development will function as a template for the design and implementation of future work aligned with project objectives.

Implementation system

The project team is considering implementation systems through which training, education and professional development can be effectively disseminated through the nursing workforce. A Training of Trainer model (ToT) was an early focus in these discussions and a mirror ToT is being conducted on the physician side (Mormina & Pinder 2018). The in-person trainings for IOM physicians and nurses (Bangkok, Thailand and Kampala, Uganda) allowed the project team to pilot project ToTmaterials and assess the feasibility of implementing this model for nurses in the organization. The project team evaluated strengths of the model that included cost efficiency and a professional development pathway for nurses in the organization — an ask in early listening sessions (Yarber et al. 2015). Solutions to potential challenges to implementing a ToT model included developing strategies to access smaller missions where there are few nurses, as well as determining a system to conduct trainings across the extensive IOM nursing workforce which is decentralized and spread globally, sometimes in very remote areas (Mormina & Pinder 2018).

Learning platform

The project team is exploring the development of a multimodal platform where training materials can be accessed for multiple purposes by a diverse set of users (Flahault et al. 2017; McIntosh et al. 2017). The project team will leverage online training and resources, and integrate with in-person modalities to enhance efficiency, hands-on training and to access nurses working in more remote placements. As new nurses enter IOM, there is a period of shadowing, structured supervision/mentorship and then independent practice with continued oversight. Missions implementing new health programming might have the opportunity to shadow or observe the way a programme is implemented at a different location (Matlin et al. 2018). Senior nurses serve many roles, one of which is that of a resource for best practice. Expert nurses are responsible for assessing the learning needs of their trainees and adapting orientation and training accordingly (Benner 1982) Scope of practice varies across IOM missions, as does clinical scope and the frequency with which specific skill sets are implemented. In these varied roles and contexts, the ability to access reliable, evidence-based content from a streamlined source is essential (Flahault et al. 2017; Matlin et al. 2018). Content experts on the project team have developed comprehensive pilot modules that are housed on the academic partner’s online learning system. Through a formative evaluation process, the modules are being vetted through stakeholders and revised based on user feedback.

In the coming months, the project team will integrate a University of Minnesota nurse fellow into the project work who will be based full-time in Uganda. A focus of the fellowship will be the implementation of a pre-departure health and hygiene curriculum for refugees in resettlement programmes. Communicated messages will be consistent with those that refugees receive post-arrival in the United States. A second focus will be assessing an approach to standardize nursing clinical skills and practice in the settings of IOM transit centres. This constant on the ground presence will be an important next step in evaluation and will inform future phases of the described initiatives.

Conclusion and Implications for Nursing and Health Policy

Nurses routinely integrate and synthesize the dynamics of culture, health, illness and community. While people with refugee status repeatedly demonstrate resilience and adaptability, their health and dignity remain at risk. By strengthening systems and resources, this initiative reinforces the abilities of nurses who partner in this important work across the continuum of migration to optimize health and wellbeing. In the end, the bilateral and reciprocal project focus leads to better care for a vulnerable and marginalized population. New understandings will be disseminated across domestic resettlement spaces to influence national entities and partnerships, thus broadening the impact. The programme is in its early phases, and we have set medium and long-term goals with concrete and measurable outcomes. To evaluate successes to date, the project team is focused on implementation processes, such as satisfaction and confidence of nurses who participate in trainings and international exchanges, which suggest high project impact. Upcoming assessments will include platform usability and assessment of conceptual knowledge acquisition and retention through the standardized learning platform. Given the multi-level structure of IOM (local, regional and global levels of operation), and the focus of this project thus far, we are emphasizing an expansion of opportunities for nurse training and education, to improve standardization of clinical practices at the local and regional level. In line with structural changes within IOM, we anticipate the project will support policy prioritizing the standardization of clinical procedures for nurses at the global level. Key IOM nurse project leaders will facilitate local and regional implementation and dissemination in partnership with academic partner nurses. Advances in clinical practice and education/training will result from the sustained presence and accountability of nursing in the initiative.

Over the past decade, in alignment with the Institute of Medicine’s Future of Nursing report (2011), the American Association of Colleges of Nursing (AACN) and American Organization of Nurse Executives (AONE) Task Force on Academic-Practice Partnerships has focused on promoting the development and enhancement of academic-practice partnerships, defined as ‘a mechanism for advancing nursing practice to improve the health of the public’ (Beal et al. 2012, p. 328; Beal & Zimmermann 2019). This task force, and ongoing steering committee, has developed guiding principles, strategies, tool-kits and an online academic-practice community, among other resources, aimed at facilitating such partnerships (Beal et al. 2012; AACN 2020). The AACN-AONE collaboration was developed for academic-practice partnership at the local, state and national levels in the United States (Beal & Zimmermann 2019). While there are fewer descriptions of implementation at the international level, we experienced broad relevance and utility of the outlined strategies within our cross-national partnership development.

The IOM screens all refugees resettling to the United States. Project activities in the last fiscal year impacted services to more than 18,000 refugees and refugee families. To promote and protect the health and wellbeing of refugees is the overall goal of the interagency partnership. Staff capacity and system building is an integral element of the University of Minnesota support in this overall goal. To achieve this, the project leadership team maintains a strong focus on the bilateral nature of the project, mutual understanding and promoting equity across resource variable sites in a way that highlight distinctive, though equally critical, contributions nurses across the continuum make in refugee migration (Crisp et al. 2008). The intergovernmental organization and academic/community nursing relationship is a unique and powerful initiative with important public health and professional impact.