Introduction A refugee, according to the United Nation’s definition (as cited in matthewhouse.ca, 2012), is “a person outside his or her country of origin who has a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group or political opinion.” The current number of refugees around the world is 43.7 million, as estimated by the United Nations High Commission for Refugees (UNHCR). Being a refugee is not a choice – they are forced to leave their country of origin to avoid conflicts that could potentially be disastrous, traumatic, or even lead to their death. They begin a long journey of danger and uncertainty on the refugee highway, seeking safety and security (matthewhouse.ca, 2012). Also, as stated in matthewhouse.ca (2012), refugees come to Canada in three different ways. About 7,000 refugees per year are sponsored by the government. Another 3,000 per year are sponsored by private groups, such as churches. Historically, the largest group, which up until recently, numbered more than 20,000 per year, come to Canada with no sponsors and ask for asylum upon arrival. There is no system in place to welcome or assist refugee claimants. They are simply numbered among the homeless, often without resources. Many are forced to look for help in inappropriate city shelters not equipped to meet their needs. Government policies are becoming harsher and there is no structure in place to directly look after their well-being. Despite having reached a safe country, they are at risk of being victimized and traumatized again. The Albanian family, as focused in our case study, is suffering from emotional distress which, if not benevolently managed by nurses, can break the family’s unity and capacity to build a new and better life. Furthermore, their basic needs must be met before they can stand up on their own. Prompt assessment of illnesses and strengths can help the family and nurses create fitting plans and can even engage the two in a mutual and active nurse-client relationship.
A Glimpse of the Kosovar Life Nurses are responsible for identifying general information needed in assessing their family’s health problems, including its causes and consequences. The actions and interventions employed by the nurse must be based on facts and one way of delivering accurate and relevant care is to have background knowledge of the family’s culture, beliefs, education and lifestyle. Gathering historical backdrop of the refugee’s culture and tradition raises self-awareness and promotes consistency in developing appropriate questions during health assessment.
History. Kosovo was an independent federal unit of Yugoslavia until the Serbian government stripped away the basic rights of the Albanians (Kosovars) in 1989 and suspended the Kosovo parliament. Initially, the Kosovars responded with peaceful and passive resistance in 1992 and continued to hold elections, chose their leaders, and utilizes the Albanian language, education, and health care. Peaceful attempts were ineffective and in 1998, the Serbian (former Yugoslavian) government began a campaign of violence (“ethnic cleansing”) against civilians, including women and children, causing over a quarter of a million Kosovars to flee the country (Bongers, Laisure, & Mackling, n. d.). Culture and Social Structure. Extended family is very important to Kosovars. They do not have nursing homes and tend to take care of their own. If the family cannot take care of the elderly or children, neighbors help. Women are considered by men as equals and often function as decision makers. Many of the people live in villages among the mountains. Each village has a unique style and color concerning dress. The men of the villages wear beige hats. These hats are tradition for Albanians and this distinguishes them from other ethnic groups. Many urban Kosovars are educated at the University of Pristina located in the capital of Kosovo (Bongers et. al., n.d.). Language. The Albanian language is one of the original nine Indo-European languages and is not derived from any other language. About 90% of the inhabitants of the Adriatic Coast, primarily in Kosovo and Macedonia, speak Albanian. The official Albanian language, adopted in 1909 was written in a standard Roman orthography and based on the Gheg dialect. Since 1974, citizens of Kosovo and Macedonia speak varieties of eastern Gheg (Bongers, et al., n.d.).
Religion. There is a mixture of religions in Kosovo, especially Islam, Orthodox, and Roman Catholicism. Roman Catholicism was the first religion of Kosovo, but many Kosovar refugees are Sunni Muslims. There is not a strong conservative or radical Muslim movement in Kosovo as there is in the Middle East (Bongers, et al., n.d.). Health Care Practices and Beliefs. Male circumcision is strongly encouraged, but not forced. It is believed to be only a procedure for cleanliness. Female genital cutting or “circumcision” is not a practice and is condemned on an Islamic basis. The younger generation participates in the use of narcotics at an alarmingly increasing rate. The use of alcohol and smoking are endemic and are increasing among the people as a whole. Immunizations are considered very important. The medical professional goes into the villages and cities to provide immunizations (Bongers, et al., n.d.).
Midwives are often used in the villages for labor and delivery. Midwives are often elderly women who have had babies and possess some of the knowledge needed in helping with labor and delivery. A few are medically trained. Hospitals are used by most urban women, but many of the resources taken for granted in Western countries are not widely available. Birth control is hard to obtain and not highly utilized. The younger generations use it more often, but the older generation population desires to have more children to help with the land and the elderly. Many women use the saying “my son for me, my son for land” Reproduction. On the average, Albanian women give birth to 2.7 children and fewer than 10% use contraceptives. The number of abortions is high and many women lose their life following complications. Maternal mortality in Kosovo is the highest throughout Europe and infant mortality is increasing. As life expectancy has increased among Kosovars, chronic illness has increased as well. Hypertension and other cardiac-related illnesses take on increase importance inside Kosovo as well as among refugees. Kosovar refugees have not presented at countries of second asylum with any significant pattern of health problems (Bongers, et al., n.d.). Mental Health. Refugees from Kosovo are vulnerable to mental health problems. Many will suffer from post-traumatic stress disorder (PTSD) and depression as the most common psychiatric diagnosis. Other diagnosis may include somatoform pain syndrome, dissociative disorders, and recurrent panic attacks. Women and girls who were raped often have a difficult time dealing with the long-term effects of the trauma. Pregnancy and STD testing may be needed with new refugees and should be done with sensitivity (Bongers, et al., n.d.).
Care Plan and Recommendations for Interventions Although the family is physically healthy, nurses must also assess the emotional and mental condition of each member. The family in focus experiences emotional distraction and are often quarreling. Our group contrived on developing befitting care plans and recommendations that could be advantageous for the family and help them survive the crisis they are facing:
Ineffective Family Coping
As stated by Guttman (1999) (as cited in factrefresher.blogspot.ca, 2011), difficulties in coping with changes in health care needs can lead to increasing needs for assistance in using the health care system effectively. Case management combines the nursing activities of client and family assessment, planning and coordination of care among all healthcare providers, delivery of direct nursing care, and monitoring of care and outcomes. These activities are able to address continuity of care, mutual goal setting, behaviour management, and prevention of worsening health problems.
Communication. Communication in health care is important for three reasons: exchanging important information about health, promoting ongoing care to restore health after treatment for illness, and relationship building for ongoing health maintenance. Effective communication approaches for providing public health information are particularly important for “hard-to-reach” populations such as forced migrants (refugees) as their usual sources of information and family support are often fractured (Wahoush, 2009). Newcomers who are unfamiliar with the health-care system may interpret relatively innocent events as evidence of discrimination or racism if they are not clearly explained by health providers. Negative experiences may result in subsequent avoidance of seeking health care. On the other hand, if verbal communication is difficult because of language barriers, patients can interpret non-verbal cues and so understand the intent of the healthcare professional (Wahoush, 2009). Facilitate Family Conference. Including all family members as appropriate can provide and reinforce information about illnesses and future family needs. Knowledge can help the family prepare for eventualities and deal with the actual crisis. Likewise, assisting family members to understand “who owns the problem” and who is responsible for resolution can avoid placing of blame or guilt. When boundaries are defined, each individual can begin to take care of own self and stop taking care of others in inappropriate ways (Doenges, Moorhouse & Murr, 2006). Nurses must involve each family member in information giving, problem-solving, and care of member that has illness as feasible, as well as, identifying other ways of demonstrating support while maintaining client’s independence. This process can reduce feelings of helplessness while effectively enhancing feelings of control and self-worth (Doenges et al., 2006). Health care professionals must learn to see the family as a true partner in providing care and to see themselves as health educators whose role is to teach families how to solve problems rather than as the “experts” who solve problems for them (euromed.eu, n.d.). Assess Coping Skills and Strengths. When the family has coping skills that have been successful, they may be used in the current situation to relieve tension and preserve each member’s sense of control. In doing the assessment, nurses must encourage each member to talk about what is happening at the current time and what has occurred to precipitate feelings of helplessness and anxiety. This provides clues to assist the family or its members in developing coping strategies and regaining equilibrium (Doenges et al., 2006). Nurses must also evaluate the family’s ability to understand events, correct misconceptions, and provide factual information. The results of these evaluations can assist both parties in identifying and correcting false perceptions of reality, therefore, initiating problem-solving (Doenges et al., 2006). Referral of Access to Services. The Albanian family came to Canada without money, job, and health insurance. Noting the family’s socioeconomic status, availability, and use of resources can help nurses determine the appropriate healthcare assistance they need from the government of Canada.