Assessment of Refugee women health
- What are the most important factors for the registered nurse to assess when dealing
with a female refuge who is exhibiting flashbacks from trauma, especially sexual
trauma or physical abuse?
According to the article, it is evident that effective management of the patient will require
the registered nurse to understand the health needs for the patient. Most of the female patient
accessing health care is often facing sexual health complication such as sexually transmitted
diseases, rape, anxiety associated with risks of sexual exploitation. This often results in
trauma- associated with posttraumatic stress Disorders. The most important factors that must
be assessed by registered nurses includes; cause of trauma ( war-related or physical/sexual
abuse); signs and symptoms of PTSD; the pre-trauma factors, the co-occurring disorders; the
social as well as interpersonal factors (Heavey, 2014). - Describe the cultural considerations and language barriers the RN will need to
address to foster therapeutic communication for the female refugee
The registered nurse is required to understand the external forces that influence their health
including poor living conditions, inadequate health resources in the patient countries of
origin, oppression experiences and loneliness. Cultural considerations such as traditional
gender roles are barriers for accessing care. Most refugee women are reluctant to seek care
because they fear to become victimized based to their cultural and religious beliefs.
Communication issues such as language barriers hinder communication. Despite the fact that
the patient could be having qualified translator, healthcare providers non-verbal
communication could make the patient withhold vital information. These issues must be
addressed using compassionate communication; and where necessary, the patient must be
Assessment of Refugee women health
2
helped to achieve at least the basic needs such as food, shelter and medication. This will help
in winning the patient trust (Taylor, Pugh, Goodwach, and Coles, 2012).
- List common triggers for this population and describe how the RN can assist to
decrease the effects.
Registered nurses must understand the common triggers such as medical equipment’s such as
speculums retractors, security details which could be frightening of others. Some of the
anniversary dates especially for the victims could also be triggers that could make the patient
diagnosed with PTSD isolation and avoidance behaviours. Consequently, patient may
experience hyperarousal behaviour, high blood pressure, extreme anxiety and racing
thoughts. This could be managed through disassociation coping strategy. The nurses must
provide extra attention for the patients to establish trust and strong relationship (Heavey,
2014). - Provide two nursing diagnosis statements (each statement must include an actual
nursing diagnosis, related factor and as evidenced by) that might apply to a refugee
patient experiencing trauma flashbacks.
Refugee patient that is suffering from trauma flashbacks could be diagnosed with (Heavey,
2014):
a) Post Traumatic Stress Disorder; the related risk factors include cardiovascular diseases,
musco-skeletal disorders, respiratory disorders, immune dysfunction and suicidal thoughts.
b) Chronic pelvic pain- associated risk factors includes genitourinary disorders, vaginal
fistulae, and the damage anal sphincter.
Assessment of Refugee women health
3
References
Heavey, E. (2014). Female refugees: Sensitive care needed. Nursing, 44(5), 28-35.
Taylor, S.C., Pugh, J., Goodwach, R., and Coles J. (2012). Sexual trauma in women—the
importance of identifying a history of sexual violence. Aust Fam Physician. 41(7):538-
541.
CESARINE* SAT QUIETLY, hunched in a chair in the
waiting room, her gaze cast downward. She walked into
the exam area without resistance, appearing resigned.
She stared at the floor without looking at me or acknowledging my presence.
It was the first time I’d met this patient, who was being seen in a busy public clinic. Communicating through
a qualified medical interpreter, I introduced myself and
asked her if she understood why she was in the clinic
today. Staring at her hands, she said she’d gotten a disease from the men who’d raped her in her native country.
I sat down nearby but didn’t block the door. I told
her I was a nurse-midwife, and I wanted to help her as
much as I could. “Cesarine, if all you want to do today
is see what the clinic is like and then go home, that’s
fine. I’m glad you’re here and I think I can help you, but
sometimes this is overwhelming when you’ve had such
a difficult experience. I want you to be comfortable here
with us. We’re going to take our time, and I’ll ask you
what you want to do next.”
Cesarine appeared to relax a little. I continued,
“Would you like to keep talking, or would you rather
stop for today?”
*The patient’s name has been changed to protect her privacy.
Female
refugees:
Sensitive
care
needed
By Elizabeth Heavey, PhD, RN, CNM
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com May l Nursing2014 l 29
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
30 l Nursing2014 l May www.Nursing2014.com
Cesarine looked up for the first
time, seeming a bit surprised. She
quietly indicated she wanted to keep
talking.
I smiled and said, “Good. It’s okay
to stop whenever you want, even if
it’s just to take a break. Does that
sound okay?” She nodded her head,
and we began to talk.
Casualties of war
Cesarine had immigrated to the
United States after surviving rape
and torture by the military and civilian forces fighting in her country
of origin. More and more, sexual
violence is being used as an explicit
war tactic. Women live in fear of
not only dying or becoming disabled, but being ostracized by their
community.
In some parts of the world, the
terror involves the fear that loved
ones, including children, will be
forcibly recruited into murderous
militia forces or will “disappear”
forever. Almost half of those forcibly
displaced by violence are adolescents
and children with limited means
of providing for and protecting
themselves.1
Before World War II, most wartime injuries and deaths involved
military personnel. During and after World War II, noncombatants,
including many women and children, were injured and killed at
alarming rates, largely in conflicts
or wars within their own country.2
Globally, violence is now one of the
leading causes of death for those
ages 15 to 44.3 Many refugees
who’ve been exposed to violence
and can relocate to the United
States are resettled into low-income
neighborhoods, where they may
experience more violence and discrimination. The displacement,
immigration, and acculturation
experienced can further social
exclusion and economic adversity,
necessitating long-term communitybased responses.4
Impact of posttraumatic
stress disorder
These exposures may result in
posttraumatic stress disorder
(PTSD), a trauma- and stressorrelated disorder that involves reexperiencing the traumatic event, trying to avoid triggers, having negative cognitions and mood, and experiencing hyperarousal signs and
symptoms, over which the affected
individual has very little control.5
In regions with high levels of violence, population rates of PTSD are
estimated to be from 30% to 80%
or sometimes even higher.6,7 Refugees from violent areas are more
likely to experience PTSD than returning combat veterans and are
10 times as likely to experience
PTSD compared with the general
population.6,8
A traumatic event involving an assault on a child or woman is more
likely than one on a man to result in
PTSD and may result in long-term
debilitating consequences.5,9 PTSD
not only affects the mental health
of the individual, but also impacts
his or her physical well-being. (See
Health risks associated with PTSD.)
Exposure to trauma and acute stress
increases inflammation, immune
system dysfunction, and disturbances in corticoadrenal steroid
production, resulting in premature
aging.10
The presence of PTSD impacts
health-related behaviors and the
ability to access healthcare. People
with PTSD are more likely to
smoke and less likely to be physically active, and report higher levels of medication nonadherence,
sometimes due to forgetfulness.
They’re more likely to experience
depression and low income, both
of which exacerbate these issues.11
Refugees who aren’t diagnosed
with PTSD but have a history of
trauma or exposure to political violence also report higher levels of
distress and are more likely to suffer from chronic medical illnesses
while being less likely to use mental health services.4 Women traumatized by violence are more likely
to develop disorders such as heart
disease and sexually transmitted
infections.12,13
Further complicating the situation is the increased likelihood that
women exposed to trauma will
avoid preventive services, such as
Pap smears, clinical breast exams,
and early prenatal care, for fear of
repeated traumatization.14
Wide-ranging effects of rape
Women who’ve experienced rape
and war-related sexual violence are
more likely to develop PTSD than
any other crime victims.7 (See
Health problems associated with
sexual violence.) In many cultures,
women may be unwilling to report
their experience of sexual violence
because losing virginity before marriage, regardless of the circumstances, can make others consider
them unfit for marriage. The loss of
social stature after sexual violation
can lead to a future of subsistence
living, involving either begging or
working in the sex trade.15 The
immediate trauma associated with
sexual violence is frequently also
followed by other long-term consequences, such as unwanted pregnancies, death of the victim’s infants
who have no further source of
nourishment, psychological distress, sexual dysfunction, infertility,
cervical cancer, altered self-image,
and further cultural rejection.16
Health risks
associated with
PTSD10,11
PTSD is a major risk factor for these
problems:
• cardiovascular disorders
• digestive disorders
• musculoskeletal disorders
• respiratory disorders
• cancer
• infectious diseases
• unintended injuries
• suicide, homicide, and drug
overdose.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com May l Nursing2014 l 31
Exposure to highly traumatic
events can lead to changes in
thought and behavior patterns,
either immediately or long afterward.
“Flashbacks” may occur after exposure to triggers or may not be related
to any apparent cause. Victims may
experience intrusive thoughts that
disturb or frighten them.
Nursing challenges
Nurses should be alert to common
triggers that may be experienced
in a healthcare setting, such as a
scent in an exam room; the act
of disrobing; and the presence of
equipment such as speculums,
retractors, or biopsy equipment.
Locked facilities and security may
be reassuring to some patients,
frightening to others.
Anniversary dates or certain times
of the year are particularly difficult
for many survivors of violence. People coping with PTSD develop significant avoidance behaviors to help
control their memories and intrusive
thoughts.
During acute episodes of distress, the patient may display
hyperarousal behavior, which may
include a pounding and rapid heart
rate, racing thoughts, hypervigilance, profuse diaphoresis, hyperventilation, nausea, and extreme
anxiety. It may become difficult
for patients to concentrate or even
maintain awareness and presence
in their current physical environment and condition.5,17
Patients with PTSD may instinctively sit with their back to the wall
facing the door or right next to a
door to feel they have an escape
route. Even with these accommodations, patients may continuously
scan the room and have difficulty
concentrating on what’s actually
happening.
Understanding coping
mechanisms
Disassociation is a coping mechanism that may be evident in patients
experiencing crisis levels of stress.
War-related trauma is associated
with what some cultures call spirit
possession. In this, the patient
experiences an altered state of
consciousness with impairments
in functional indicators beyond
those experienced with PTSD,
with no memory of the experience
afterwards.17
In the United States, this type of
response to extreme trauma is also
seen and classified as a variant of
dissociative identity disorders. These
are very difficult for patients and
providers to manage. In some wartorn areas of the world, up to 18% of
the population experiences this very
debilitating condition, which leads to
both physical and reproductive
health impairments. It’s also associated with frequent trauma-related
nightmares.17
Trauma exposure can lead to
mood changes, which may be extreme; anxiety or depression may
become the baseline emotional
state for extended periods. Eating,
sleeping, and activity schedules can
be easily disrupted, with some patients going days without being
able to rest or eat appropriately.
Fear of recurrence of the event or
even the fear of reexperiencing the
memories and flashbacks to the
event may lead to isolation, provoking feelings of claustrophobia,
agoraphobia, self-injurious coping
behavior, or even suicidal ideation. With appropriate support,
many patients can recover but
others, particularly those with a
history of extreme or multiple
traumas, may have little or no
symptom resolution.1,5
Who fares best?
Not all patients with a history of
trauma develop mental health issues.
Research clearly shows that those
with a limited history of trauma, significant familial and community support, and the presence of positive
coping mechanisms with protective
cultural factors fare better than those
without these traits.1
A higher educational level also
clearly has a protective effect for refugees’ mental health after exposure
to trauma or violence. Education
may empower refugees to prepare
and survive trauma and violence or
protect them through enhanced social status, resources, and benefits
once they arrive in the United
States.14
Communication issues
Nurses are in a key position to
facilitate the elimination of communication barriers, to note and
respond to verbal and nonverbal
communication cues, and to ensure
that the information given is in a
format the patient can understand.
For patients for whom English is a
second language, having a medical
interpreter available before the patient is even brought into the exam
room is extremely helpful. Clear
and compassionate communication
is critical to optimizing nursing
and medical care. Patients who
can normally function without
Health problems associated with sexual
violence16
Victims of sexual violence may have these health issues:
• genitourinary disorders, including urinary difficulties and subsequent infections
• anal sphincter damage
• rectal and vaginal fistulae
• genital and bodily disfigurement, including necrosis of breast tissue resulting in
an inability to breastfeed
• chronic pain involving the pelvic region that makes it difficult to sit or stand for
extended periods
• sexually transmitted infections, including HIV/AIDS.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
32 l Nursing2014 l May www.Nursing2014.com
an interpreter may need one in
these circumstances because the
stress induced by the visit itself
may negatively affect language
fluency.15
Others may be reluctant to have
an interpreter present because of
confidentiality concerns. Nurses
should ask patients if they’d like a
medical interpreter in the room or
would prefer one who’s available
remotely, such as by phone, video,
or Internet connection.18
Overcoming patients’ fears
For patients like Cesarine, even
coming into a clinic for care can be
very difficult. The experience may be
enough to induce frightening psychological responses. You may find a
patient in your healthcare facility
who isn’t prepared psychologically
or physically to participate in an
exam or her own care. Whenever
possible, provide extra time for these
patients to establish a safe and trusting relationship.
Patients with a history of trauma
may respond better to having multiple visits for more complex needs
or procedures. Scheduling multiple
visits with the healthcare provider
breaks the process down into smaller
steps that may be more manageable
for the patient.
The patient should be fully
clothed for the initial patient contact, and meet with clinicians in a
private location that’s ideally not an
exam room. The patient’s consent
to discuss her health concerns as
well as for any subsequent exams
should be obtained. If the patient
can’t participate in an exam on the
first visit, it should be deferred until she’s more comfortable. It may
take multiple visits to obtain a full
health history and perform a complete physical assessment. During
this time, the healthcare provider is
building rapport and a trusting relationship with the patient.
Step by step
When I met Cesarine, she needed a
colposcopy. In her case, several cervical
biopsies would be needed as well. This
is an invasive and uncomfortable procedure for many women, let alone
someone with a traumatic history.
We didn’t do the procedure the
first day she came in; instead, we
talked and she shared her history. I
reinforced that I saw her as incredibly resilient and strong and was
glad she’d come to the clinic. I explained the procedure and reinforced her control over how we’d
proceed. She hadn’t gone to any of
her previous appointments because
of her fear. I could see she’d become
more comfortable with me and the
clinic as I walked her out to schedule our next appointment, which I
assured her would be with me so she
wouldn’t have to start the process all
over again with a new provider.
Continuity and comfort
With patients like Cesarine, continuity of care is critical. A familiar
environment where the patient
works with the same nurses and
provider can make a significant difference in the patient’s comfort level
and ability to participate in her
care.
Traditional gender roles may also
impact when treatment is sought and
what’s shared or disclosed during a
visit. Some refugees may be willing
to see healthcare providers from only
their own ethnic background or of
only one gender.15 Many female refugees are more likely to seek care for
their children or spouse than for
themselves.19
In later conversations, Cesarine
disclosed she was reluctant to seek
care because of her fear of being victimized again and her belief that after
the rape, her own life had no value.
Women who are raped in her country don’t typically report it because
the legal system blames the victim,
who may be raped again by the police if she tries to seek justice. Cesarine had no reason to believe that
things would be any different in the
United States; she was prepared for
us to continue to blame or harm her
as well.
Stopping the cycle
Another challenging aspect of caring
for patients with a history of trauma
is the unfortunate reality that the
cycle of violence is frequently perpetuated.6 Nurses must screen all
patients with a history of violence for
current violence concerns, either as a
perpetrator or a victim. Asking appropriate open-ended questions lets
patients from various cultural backgrounds express themselves using
the culturally appropriate verbal
framework.
For example, nurses may lead
into a safety question with a comment like this: “In this country, it’s
against the law for someone including a spouse to hit or physically
hurt you. Are you ever concerned
that someone will hurt you? How
so?”
If a concern for violence is identified, specifically ask about coercive
sexual practices. In many cultures, a
married woman doesn’t have the
right to say no to sexual contact
Clear and compassionate
communication is critical
to optimizing nursing
and medical care.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.Nursing2014.com May l Nursing2014 l 33
with her husband regardless of the
circumstances.20
Ask about children in the home
being exposed to violence. Frame
the question appropriately; for example, “In this country, we have
support and protection available for
women with children who are experiencing violence. Children can
be protected from violence and can
legally remain with a nonviolent
parent even if that parent is a woman.” In many areas of the world,
women don’t have any legal custody rights, so clinicians should establish the existence of some legal
gender equity in this country before
expecting a mother to report violence against her children. Although many women are reluctant
to report abuse or will minimize it,
they may be more willing to disclose the violence that their children experience if they feel they
can protect them. In many cultures,
women’s roles in maintaining the
family’s integrity may preclude reporting any abuse because this
could cause the family’s disintegration and result in the woman being
shunned and stigmatized.20
Screening for further violence
Because those who’ve experienced
violence may perpetuate it on others,
ask patients about this risk in a nonjudgmental way. For example, say,
“Some people who’ve been hurt find
themselves hurting others when they
become frustrated or upset. Have
you ever felt this way? If so, what’s
happened?”
As with any other patient, use
appropriate nursing assessment
and judgment to identify physical,
psychological, and emotional signs
of abuse. Follow-up should involve
reporting as necessary, according
to facility policy and state law.
Providing support
Identifying risks for violence early
on may enable us to interject familial support and prevent further
escalation. Involving appropriate
resources such as social workers,
psychologists, and child protective
services may provide enough support to help a patient develop better coping mechanisms or may
provide protection for the children
in the home should the situation
escalate. Violence assessments
should be done regularly because
patients and their environments
can change quickly. Also, as patients become more comfortable in
the healthcare environment, they’re
more likely to disclose current violence concerns.13
Ensure that the patient with a history of trauma has access to appropriate psychological treatment. If
you’re working with a recent refugee
with a history of trauma, she may
already be established with a care
agency and have services in place.
For patients who aren’t connected
with support agencies, making these
referrals may facilitate regular and
preventive care.
Caring for oneself
Nurses should also be aware that
having regular interactions with
traumatized patients can affect all
healthcare personnel. Vicarious
trauma, when those who care for
victims of trauma are significantly
affected by hearing and interacting
with the victims, is a real concern
for healthcare personnel. Being
aware of one’s own responses and
limitations is essential when working with these patients. Having a
way to “debrief” after these encounters helps nurses maintain their
own health and longevity in the
field.21 (For more information, see
Preventing vicarious trauma and
burnout.)
On the path to health
I’m happy to say that we could collect the cervical specimens we needed to ensure Cesarine received the
follow-up care she needed. When
she left my office the day of the procedure, she took my hand and
thanked me. “You are kind,” she
said. “You take care of me. I see you
again?” I said yes, she’d see me again
and between the two of us, we’d
help her to be well. For nurses, that’s
what it’s all about. ■
REFERENCES
- World Health Organization. Violence. 2011.
Preventing vicarious trauma and burnout22
Use these tips when caring for patients who have a history of trauma.
• Share the load. Although consistency of care providers should be maintained
for these high-need patients, distribute them among several care teams so the
burden isn’t overwhelming for any one care provider.
• Provide adequate time for visits. These patients will need more time.
Overscheduled healthcare personnel can’t provide the care needed, and
their stress levels will go up when they try to “catch up” after seeing these
patients.
• Maintain as balanced a lifestyle as possible. Try to balance work and
play. Exercise, adequate rest, and breaks from the intensity of work are all
critical. Use vacation time wisely and rejuvenate as much as possible. Seek
and follow through with preventive healthcare for yourself and your family.
Take breaks whenever you can throughout the day, and get away from the
office or your unit even if it’s just to go to the bathroom or step outside for
a few minutes.
• Be aware of your own stress level and responses. Regularly assess your
own feelings and consider outside counseling or support as needed. Meet
regularly with friends and develop a strong social network. Maintain a spiritual
practice that resonates with you. Recognize when your own experiences are
impacting your interactions with your patients. Give yourself the same break
you’d give a patient who needed it. Sometimes we take better care of our
patients than of ourselves.
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
34 l Nursing2014 l May www.Nursing2014.com - Bhutta ZA, Yousafzai AK, Zipursky A. Pediatrics,
war, and children. Curr Probl Pediatr Adolesc Health
Care. 2010;40(2):20-35. - Centers for Disease Control and Prevention.
CDC helps prevent global violence. 2013.orche MV, Alegria M. Political - violence, psychosocial trauma, and the context
of mental health services use among immigrant
Latinos in the United States. Ethn Health. 2008;13
(5):435-463. - American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders. 5th ed.
Arlington, VA: American Psychiatric Publishing;
2013. - Feliciano M. An overview of PTSD for the adult
primary care provider. J Nurse Pract. 2009;5(7):
516-522. - Hustache S, Moro MR, Roptin J, et al.
Evaluation of psychological support for victims
of sexual violence in a conflict setting: results
from Brazzaville, Congo. Int J Ment Health Syst.