School Nurses' Experiences Working With Unaccompanied Refugee Children and Adolescents: A Qualitative Study.

School nurses are one of the first health-care professionals to meet unaccompanied refugee children and adolescents and therefore have an important impact on health outcomes. The aim of this study was to describe school nurses' experiences working with unaccompanied refugee children and adolescents. Semistructured interviews were conducted with school nurses (n = 14) who worked with unaccompanied refugee children and adolescents. The interviews were analyzed via qualitative content analysis. The results fell into three themes: (a) knowledge of trauma-informed care, (b) knowledge of intercultural nursing, and (c) importance of self-awareness. School nurses require the development of tailor-made skills that focus on crisis, trauma, and cultural awareness to meet the complex needs associated with working with unaccompanied refugee children and adolescents.

Introduction

Children and adolescents below 18 years who seek asylum in Sweden without their parents or other legal guardians are referred to as unaccompanied refugee children (Regulations Regarding Asylum Seekers, 1994). School nurses conduct their first health checkup when these children and adolescents start school and follow their physical and emotional health during the school years (Clausson & Morberg, 2012). School nurses therefore are in a unique position to provide support to refugee youths during the transition process (Ciaccia & John, 2016; Johnson, Beard, & Evans, 2017). Transcultural nursing is a humanistic and scientific area of study and practice focusing on differences and similarities among cultures with respect to human care, health, and illness based on the cultural values, beliefs, and practice of the individual (Leininger & McFarland, 2002).

Background

In 2018, 68.5 million people were estimated to be fleeing from dangerous conditions in their homeland (UNHCR the UN Refugee Agency, 2018). According to the Swedish Migration Agency (2018), 35,369 unaccompanied children and adolescents sought asylum in Sweden in 2015. Almost one third of them originated from Afghanistan with significant numbers from Somalia and Syria (Swedish Migration Agency, 2018). A refugee is defined in accordance with the UN Refugee Convention and Sweden's Aliens Act (The Sweden's Aliens Act, 2005) as a person who has moved from his or her country on the grounds of a well-founded fear of persecution due to race, religion, belonging to a particular community or political viewpoint—and in regard to the aforementioned fear—cannot or will not return to their home country.

Children migrating from other countries have often done so under dangerous traveling conditions but form a heterogeneous group of individuals with unique histories and care needs. It is not uncommon, however, that their experiences are marked by traumatic events such as torture, poverty, witnessing and participating in war, and the loss of family members. These experiences may, in turn, contribute to a variety of mental illnesses (“National Guidance for Child”, 2017). Previous research in Belgium has shown that between 37% and 49% of participants in a study of unaccompanied refugee children and adolescents had psychiatric diagnoses such as depression, anxiety, and posttraumatic stress disorder (Derluyn & Broekaert, 2008). In a Swedish study conducted at a group residence (Brendler-Lindqvist & Larsson, 2004), all resident unaccompanied refugee children and adolescents had varying mental health symptoms such as difficulties with sleep, concentration, mood swings, decreased appetite, and suicidal thoughts. In addition to psychological symptoms, these newly arrived refugees also suffer from somatic complaints that are commonly found in Swedish nonrefugee youths such as eczema, asthma, and dental problems.

Refugee children arriving on their own are an extremely vulnerable group because they must endure uncertainties in the asylum-seeking process alone—this produces significant psychological stress on young people, whereas for refugees accompanied by adults, refugee youths who are alone suffer from more negative health symptoms such as anxiety, sleep difficulties, and depression (Angel & Hjern, 2004). Furthermore, many children and adolescents are questioned by the prosecutor and social workers about their age, which places further stress on the child who is held responsible for proving his or her birth year (Hopkins & Hill, 2010).

Discussing health and lifestyle with children and adolescents is a challenge for school nurses (Golsäter, Enskär, & Harder, 2014; Golsäter, Lingfors, Sidenvall, & Enskär, 2012). School nurses in Sweden have a master's degree in public health nursing or pediatric nursing and they encounter students aged 6 to 19 years on regular health checkups, immunizations, and drop-in visits (Garmy, 2013). One of the tasks included in school nurse assignments is the regular health dialogues with school-aged children and adolescents. The students are offered these visits every 3 years during their schooling in Sweden. The children and adolescents want to be prepared for this meeting, and they also expect that the school nurse is compliant with what the student wants to discuss. If the school nurse focused on what they found to be important based on his or her professional knowledge, the students often tended to stop listening (Golsäter, Sidenvall, Lingfors, & Enskär, 2010; Magnusson, Hulthén, & Kjellgren, 2009; Mäenpää, Paavilainen, & Åstedt-Kurki, 2007). However, students also expected the school nurse to share his or her professional knowledge with them (Clancy & Svensson, 2010; Golsäter et al., 2010). The challenge is to create a constructive discussion about the multiple health aspects, without making the student feel blamed or ashamed. If the school nurse succeeded in creating a trustful dialogue, it was possible for the student to reflect about the pros and cons with possible behavioral lifestyle changes (Golsäter et al., 2010).

School engagement has been found to have a significant impact on positive youth development among culturally diverse populations (Koller & Verma, 2017). In a report from the Ombudsman for Children in Sweden (2017), school nurses throughout Sweden have identified mental health as one of the most serious health problems exhibited by newly arrived refugee children and adolescents. However, while traumatic events in the originating country are a major consideration for identifying refugees' current and future mental health status, the conditions of the destination country also significantly contribute to their long-term psychological well-being (Ascher, 2009). Through proper support and treatment, the effects of previous traumatic experiences such as the risk of developing posttraumatic stress disorder can be mitigated (Ascher, 2009). However, the National Board of Health and Welfare (2013) reports that the knowledge about which methods are most effective in preventing or mitigating mental health problems among unaccompanied refugee children and adolescents is insufficient. Attention to and prevention of mental health problems within this population should be of primary concern for school nurses because educational factors including the ability to take on an education and the desire to learn are strongly associated with health and well-being (Morberg, Lagerstrom, & Dellve, 2012; Ombudsman for Children in Sweden, 2017). Thus, it is important to clarify the role of school nurses in the promotion of health and the prevention of future physical and psychological issues in unaccompanied refugee children and adolescents to best establish the most favorable conditions to achieve long-term health in this population.

Aim

The purpose of the study was to describe school nurses' experiences working with unaccompanied refugee children and adolescents.

Methods

Design

This research was an empirical qualitative study. Qualitative research methodologies aim to describe and understand subjective experiences (Polit & Beck, 2016). The selection of research design was dependent of the nature of the issue being addressed. A semistructured interview format was used to provide answers to questions concerning school nurses' experiences working with unaccompanied refugee children and adolescents. Qualitative content analysis was then performed because this method describes variations of experience and distinguishes between their differences and similarities (Schreier, 2012). Before the recruitment of informants, a research ethics application was submitted and approved by Kristianstad University.

Procedures

Initial contact was made via telephone and e-mail to the management responsible for school nurses in possible municipalities to describe the purpose of the study both in writing and verbally. Contact information of eligible school nurses who have experience working with unaccompanied refugee children and adolescents were provided, and they were invited to participate in the study. Eligible nurses were also informed that their participation was voluntary and that confidentiality would be respected (i.e., all data collected will remain anonymous, and they may withdraw from the study at any time). Written consent was obtained before the interview.

Sample

The survey was conducted with school nurses who worked at schools with children and adolescents aged between 6 and 19 years in five municipalities in southern Sweden. To address the purpose of the study, an appropriate selection of school nurses was made to incorporate as broad a variety of options as possible (Polit & Beck, 2016). Thus, the school nurses were drawn from different geographical areas within the included municipalities. The inclusion criteria were that the participants should be school nurses within the municipality who had workplace contact with unaccompanied refugee children and adolescents. The motivation for the choice of the number of participants (n = 14) was based on the wish to collect sufficiently varied data while still remaining manageable with respect to thorough qualitative analysis (Graneheim & Lundman, 2004).

Five municipalities in southern Sweden with rural and urban areas were included. In interviews with school nurses in two of these municipalities, the informants were asked if they had colleagues willing to participate in the study. This resulted in the inclusion of six more participants. Snowball sampling such as this is a complementary and efficient technique in a qualitative study that aims to build a reasonably large selection (Polit & Beck, 2016). The median age of the school nurses was 45 years (range, 31–60 years), and the median work experience as a school nurse was 9 years (range, 1–25 years). The school nurses experience of encounter with unaccompanied refugee children and adolescents varied from several encounters every week to a few encounters every year.

Data Collection

Data were collected through individual semistructured interviews with each participant that lasted 40 to 60 minutes. The interviews were conducted by the first two authors and took place from September 2017 to January 2018. Interviews were recorded and transcribed in full by the first two authors. Before the interview began, the informants again received written and oral information on the purpose of the study and were informed that the interviews would be recorded. The school nurses were reminded that participation was voluntary and that they could withdraw at any time. This is especially important because the topic might be sensitive. The choice of location for the interviews was at the discretion of the informant so long as the environment was quiet and free of distractions and interruptions (Polit & Beck, 2016). All school nurses opted to have the interviews at their place of employment.

A semistructured, open-ended interview technique was used to give the informants a free space in which to provide their answers. The same questions were posed to all respondents (Polit & Beck, 2016). The questions are as follows: How do you experience the meetings with unaccompanied refugee children? Which knowledge do you find is important when meeting with unaccompanied refugee children? What do you think makes it easier for you to build a trustful relationship with the children? How is your workplace organized for working with unaccompanied refugee children? Please tell us about the barriers or strengths that make it more difficult or easy to perform well as a school nurse working with unaccompanied refugee children and adolescents. To obtain a more in-depth description of the participants' experiences in working with unaccompanied refugee children, various follow-up questions were asked (e.g., Could you tell me more? How do you mean? How?). This approach is an encouraging directive to get participants to expand on their initial answers (Polit & Beck, 2016). The interviews were transcribed either on the day of the interview or the following day.

Analysis

Conventional qualitative content analysis was used, which means an inductive approach (Hsieh & Shannon, 2005). Interview material was analyzed using qualitative content analysis focusing on both the manifest content and latent content because the purpose of the study was to describe and understand school nurses' experiences (Graneheim & Lundman, 2004). This approach is appropriate when describing differences and similarities in a textual format. The analysis was initiated by all authors reading the transcribed interviews several times to obtain a sense of comprehension (Graneheim & Lundman, 2004). The meaning units that responded to the purpose were condensed by the first two authors by summarizing the content without losing its core meaning; this was subsequently entered in a computer template to render the analytical process more transparent. A special column was then created that comprised the labeling of the meaning units in the form of codes. Such a codification method enables the understanding of context through its relation to the text. All authors met to compare their codifications thereby identifying similarities and differences. Similar codes were highlighted and most formed subthemes while three formed themes (Table 1; Graneheim & Lundman, 2004).

Table 1.

Description of Themes, Subthemes, and Quotes.

Themes	Subthemes	Quotes
Knowledge of trauma-informed care	Importance of trauma-informed care	“You should know what wounds you wake up when meeting with unaccompanied refugee children, what wounds are pulled up and how to handle it. If I do not know … I'm here, but then the student walks home and lives with their thoughts.” (No. 11)
	Lack of trauma-informed care	“I would like to know what's more, we'll go for such training in trauma wise care, and I hope we get a little more. I know that I would like more tools.” (No. 7).
Knowledge of intercultural nursing	Importance of a broader cultural knowledge	“It feels more important to have broader cultural knowledge while working to understand what they have for expectations about how things will work.” (No. 10)
	Striving for learning more about other cultures	“I have read about, for example, Afghanistan and the different cultures and peoples found in Afghanistan, to understand when conflicts between different students arise and that they come from different peoples.” (No. 8)
Importance of self-awareness	Personal development	“It is necessary to dare to meet people in difficult situations; I think that when you are 23–24, you are not well prepared for it. You may not have enough in your own backpack, not enough experience to dare to listen …” (No. 4).
	Professional development	“You must be very receptive and positive to working with unaccompanied refugee children. Sometimes you have to think in many three-dimensional ways. You must think about why they say so, why they behave so, and why they react so.” (No. 9)

Results

The analysis showed that school nurses' experiences working with unaccompanied refugee children and adolescents could be segmented into three themes: (a) knowledge of trauma-informed care, (b) knowledge of intercultural nursing, and (c) importance of self-awareness.

Knowledge of Trauma-Informed Care

The school nurses described a need for knowledge and guidelines about care for children and adolescents who had been exposed to chronic adversity and trauma. Having knowledge regarding care for young people who have been exposed to trauma has great importance to ease the communication and to be able to provide adequate health care for the students such as health checkups and immunizations. Unaccompanied children and adolescent refugees who have had devastating experiences often mistrust adults and authorities. These experiences could be challenging in several situations. For example, noise can trigger anxiety or information about an upcoming immunization could also lead to unexpected reactions. Some school nurses received this training in their current position. However, other nurses mentioned a lack of such skills. School nurses described their lack of sufficient skills and methods available at their disposal during difficult encounters with unaccompanied refugees. Other school nurses described how proper skills are important to respond to and support unaccompanied refugee children and adolescents:The school nurse wished that everyone at school had some basic training and understanding of posttraumatic stress disorder. A few school nurses described how this education had been implemented successfully at the schools, and that the collaboration between the school nurse and the other school staff worked well; other school nurses felt isolated in their concern regarding the needs of unaccompanied refugee children and adolescents. To provide trauma-wise care, the school nurses also highlighted the importance of adequate collaboration with stakeholders and organizations outside of the school such as residents, child and adolescent psychiatrists, social workers, and primary health-care providers.

You should know what wounds you wake up when meeting with unaccompanied refugee children; what wounds are pulled up and how to handle it. If I do not know … I'm here, but then the student walks home and lives with their thoughts. (No. 11)

Knowledge of Intercultural Nursing

The school nurses found that working with unaccompanied refugee children and adolescents was an opportunity for learning about intercultural nursing. Striving for knowledge about different cultures to better understand the refugee child's culture was considered important for the school nurses. They agreed that this required increased awareness and understanding of how the culture affected the individual refugee child.

Some school nurses sought information on their own to increase their knowledge of cultural differences that could exist between different groups of students. Although the work sometimes meant challenges and difficulties, the school nurses stated that they are significantly satisfied with their work. They further stated that the learning opportunity regarding intercultural nursing and the exchange of emotional feelings is mutual and rewarding. They perceive that refugee youths respect and appreciate their efforts:

The more you hold on, the more you are linked to them as individuals because the unaccompanied refugee youths are incredibly generous with themselves. I feel that I get more back from these young people, and I learn a lot about intercultural nursing. (No. 6)

Importance of Self-Awareness

The school nurses described the importance of being self-aware and being knowledgeable one's own strengths and weaknesses when meeting unaccompanied refugee children and adolescents. This theme reflects the professional and personal development of school nurses in their work with unaccompanied refugee youth. Several school nurses reflected their personal qualities into their profession, and they agreed that courage, strength, and life experience are required to adequately meet the needs of this student group. Even when the work sometimes entailed responding to and supporting traumatized refugee youths, this was counteracted by the reported high levels of job satisfaction and personal development within their professional role. The school nurses pointed out the need for time and space for reflection when working with unaccompanied refugee children and adolescents. For all school nurses, access to clinical group supervision sessions with other school nurses was valuable and important.

The school nurses found it important to have a positive attitude when working with unaccompanied refugee children and adolescents and elaborated that this attitude ensured that they could be open to and accepting of the individual's thoughts, feelings, and behaviors, regardless of their content:Finding the courage and strength to dare to engage with people in complex situations requires life experience. For many school nurses, age was a crucial factor in the measurement of life experience. The older they were, the safer and more confident they felt in their work with this population. One school nurse described how the nature of the work had transformed her way of thinking and working:

No matter how much education you've received, there's still a person who's there with emotions, and you've got your own self, you cannot just cut it off and be a real professional … and then maybe it's an advantage that we're actually people and that in the meeting with unaccompanied refugee children we show humanity. (No. 3)

It's important to keep it professional while daring to be there [in the meeting with unaccompanied refugee children and adolescents], present with my feelings. (No. 13)

… and things happen to yourself when you start work. If I compare myself from before I started working with unaccompanied refugee youths and how I am today, I developed myself in my view of my work. I do not exactly do the same things I did when I started. (No. 2)

Discussion

The purpose of the study was to describe school nurses' experiences of working with unaccompanied refugee children and adolescents. Three themes were identified through the analysis: (a) knowledge of trauma-informed care, (b) knowledge of intercultural nursing, and (c) importance of self-awareness. The overall message from these interviews was a critical need for broader knowledge of cultural differences and appropriate care measures for trauma victims that could be achieved by increased access to continuing education as well as opportunities for school nurses for personal and professional development. This is in line with the three pillars of trauma-wise care: a framework that builds on the concepts of providing trauma victims a healing environment (Bath, 2015). The school nurses also stated that even if communication could be challenging—in line with Squires and Jacobs (2016)—they found their work with respect to this population to be an opportunity for learning about intercultural nursing, which was meaningful and rewarding. Acquiring new knowledge, support, and advice often occurred in conjunction with other school nurses. Furthermore, the nurses emphasized the importance of good synergy between all personnel that plays a role in the care of these refugee children and adolescents both inside and outside the school context.

The school nurses emphasized the importance of possessing the right skill set to handle the traumatic histories that often typify these refugee children. Previously, there has been little research about the experiences of school nurses in relation to unaccompanied refugee adolescents and children in their care. A previous survey found that school nurses in Sweden stated that student health education should be strengthened in the domain of care for psychologically afflicted students (Ombudsman for Children in Sweden, 2017). The poor mental health in this group of refugee students tends to worsen over time, and the Children's Ombudsman suggests that there must be increased efforts to promote the continuing professional development and education of health-care staff, so that they may adequately meet the needs of these students (Ombudsman for Children in Sweden, 2017). However, this requires a basic understanding of the complexities surrounding trauma that demand a wide variety of responses (Bath, 2015). Receiving support to accept what has happened—and to subsequently understand and accept their own emotions—marks the beginning of the healing process. In this context, our research highlights the crucial interplay between the student's mental health and the care given to them in the school setting. The UN Committee on the Rights of the Child (2015) has also expressed concern that Sweden's educational health-care system lacks sufficient resources to properly address the needs of refugee children in a timely and appropriate manner. This was proposed in its recommendations to the State of the Convention that resources should be increased so that the school health-care team can provide adequate support for the psychosocial issues that are endemic to this population.

The school nurses noted the importance of cultural diversity knowledge to gain a deeper understanding of the impact that one's culture has on shaping attitudes and values. According to Carr and Knutson (2015), school nurses have a unique repertoire of skills and should promote cultural development within the school context and apply a nursing perspective that is characterized by tolerance and acceptance to the differences inherent in a population that is culturally diverse. Previous studies have shown that school nurses who strive for and apply cultural skills in their professional activities promote students' academic achievements and contribute positively to the school's health-care system in the long run (Truong, Paradies, & Priest, 2014). Mendonca et al. (2009) reported that school nurses occupy a strategic position within educational settings and should strive for creative implementation and advocacy of increased cultural awareness. This will enable newly arrived unaccompanied refugee students to establish a safe and trusting relationship with the care staff, which will allow students to adapt to and integrate within the host country more successfully (Mendonca et al., 2009). Studies have also found that school nurses are important in the care for students with mental health problems (Haddad, Pinfold, Ford, Walsh, & Tylee, 2018; Jonsson, Maltestam, Bengtsson Tops, & Garmy, 2017).

Strengths and Limitations

To achieve a variety of responses from school nurses, they were selected based on the purpose of the study. By increasing the selection of respondents, the possibility of obtaining nuanced descriptions increases and this enhances the credibility of the study (Graneheim & Lundman, 2004). When difficulties were encountered in achieving the desired number of participants, a snowball method was applied to find new participants. This method is considered effective and time-saving, and participant questions can be relayed to one common reference person who facilitates the formation of a trusting relationship with the new participants (Polit & Beck, 2016). A negative effect of snowball surveys is that participants might suggest other participants with similar traits as themselves that can bias the results.

To avoid the risk of inadequately detailed descriptions, follow-up questions were used at the end of each interview to encourage participants to elaborate on their responses. This increases the study's trustworthiness; the same questions were assigned to all participants (Polit & Beck, 2016). This analysis was conducted and discussed by four researchers, and this further increases the trustworthiness of the study. However, this study is conducted with school nurses in Sweden, and Swedish regulations were referenced. One limitation is that school nurses in other countries should search for regulations relevant to their practice setting.

Implications for School Nursing

This study highlights that many school nurses called for improved cooperation and communication as well as clear guidelines for the care of unaccompanied refugee children and adolescents. The school health-care mission is to work according to the child's best interests, needs, and rights (“National Board of Health,” 2016). Thus, an organized interaction between different authorities and staff working with these refugees is required, and it is important to remember that a lack of adequate support potentially puts the student's well-being at risk (Ciaccia & John, 2016). Building nonperson-based collaboration requires time, and the question “Who does what?” should be asked to reflect on their own and others' responsibilities and roles (Bath, 2015; Kraft & Eriksson, 2015). The UN Committee on the Rights of the Child (2015) recommended that the Swedish government implement a high-level mechanism with a clear mandate to ensure equal access to all rights at both the regional and municipal level, and that the necessary resources be made available. This aligns well with the outcome of our qualitative study on the need for improved collaboration when dealing with unaccompanied refugee children and adolescents.

Conclusion

School nurses require tailor-made skills with a focus on crisis, trauma, and the expansion of cultural knowledge to meet the complex needs that work with unaccompanied refugee children and adolescents entails. The school nurses found their work with unaccompanied refugee children and adolescents to be an opportunity for learning about intercultural nursing, which was meaningful and rewarding. Acquiring new knowledge, support, and advice often occurred in conjunction with other school nurses. Furthermore, the nurses interviewed emphasized the importance of good synergy between all personnel, which plays a role in the care of these refugee children and adolescents both inside and outside the school.