Experiences and Suggestions of Nurses Involved in Caring for Migrant Populations in Italy: A Qualitative Study
Abstract
:1. Introduction
1.1. Migrants in Italy
1.2. Determinants of Health
1.3. The Right to Health
1.4. Nursing Care
2. Materials and Methods
2.1. Design and Aim
2.2. Sampling and Partecipants
2.3. Data Collection
2.4. Data Analysis
2.5. Rigor
2.6. Research Team and Reflexivity
2.7. Ethical Aspects
3. Results
3.1. Italian Legislation and Migrants
There are adequate regulations and laws that protect migrant health, such as the Testo Unico for Immigration or Art. 32 of the Constitution, which refers to the individual and not the citizen, resolving the right of health to all. Unfortunately, […] they do not find confirmation and application in reality. Indeed, cases are not uncommon in which many people, especially migrants, find objective difficulties in accessing care.(I/7)
Art. 32 is a great utopia. Then you need utopias to figure out where to go, but we cannot say that Art. 32 is respected. I don’t see around me access to care universally guaranteed. It would be a big lie to say otherwise.(I/2)
I met some young people who came to Italy from Pakistan via the Balkan route, they arrived at least two months ago, and the appointment to apply for asylum was given for a month later. Meanwhile, they could not go to the dormitory because they were undocumented, so, they were forced to sleep on the streets. These people, who are left on the streets, end up in the hands of organized crime, drug dealers, etc.(I/1)
the main constraint is that enrollment in the NHS is tied to a residence permit; thus, a person until he obtains his first residence permit, cannot have a treating physician and does not have access to any specialist assessment or examination, except for emergency character.(I/3)
the Cutro Decree, freshly enacted, further exacerbates the difficulties in obtaining a valid residence permit in our country and consequently, complicates everything else. Unfortunately, as we know access to care is tied to obtaining residency, which is linked to having a residence permit and work in order to have a home. In Bologna we see so many people who have jobs, have documents, know the language, but do not have a home, and being homelessness prevents them from registering with the registry office and so, no assistance. For those who do not even have documents, it is even more complicated.(I/2)
The offices, which issue STPs, granted like 5 STPs per week on one day a week. So that is an absolutely dysfunctional organization both from a bureaucratic point of view and from a health point of view because then people do not have the opportunity to receive any kind of care.(I/12)
3.2. Structural Difficulties in Caring for Migrant Patients
When [national] norms arrive in the Local Health Authority, they are interpreted and there are possibilities to change situations. For example, an ENI code might have exemptions in one region and not in another. So nursing care, especially territorial care, like the one I do, has to set itself according to the administrative dynamics it goes to meet. If you can have exemptions, you can do things; if you can’t have exemptions, you have to find other avenues, either the resources of the individual or the support of the private social.(I/5)
Lack of resources is a universal problem, for example, how long do you wait to have a gynecological examination? The discourse of lack of resources overrides the ethnic issue. However, the problem of difficulty of access only affects migrants and is a political will, just as it is a will to keep them in a continuous limbo between legality and illegality.(I/2)
One limitation is that there are too few places for people to go. Just think about people who live on the mountains or in the lowlands, if they need to go to the GP and they don’t have the GP, the only place they can go is this [the outpatient clinic] and so maybe they are forced to make even improper access to the PS. In the whole territory of the province of Modena, there is only ours as a direct access outpatient clinic for people who are irregular or not registered with the SSN. It is all volunteer-based, except for the nurse.(I/10)
what you see is that definitely the whole hotspot is an overcrowded place. It should have 400 beds, but as a result of so many new arrivals, there are as many as 4000 people. Now the situation has changed a little bit […] But what you observe is that there are 1–2 health professionals for 4000 people and so, basically there are situations that can’t be controlled and so there have been cases of people dying inside the hotspot.(I/13)
The other problem is, if you make the laws then don’t educate the professionals, it’s useless. There has been a new legislation for more than a year that says that minors, children of migrants whether they are documented or not doesn’t matter, are entitled to a Fiscal Code and to assistance. We have experience, until a few months ago, of children who could not do this because, when we showed up at the health services, we were told that they did not knew the law. If you make a law then you don’t do refresher courses and training, it doesn’t work!(I/8)
There is a lot of misinformation and ignorance, within the CAS [Centro di Accoglienza Straordinaria: Center of Extraordinary Reception]: the idea is that STP is only entitled to those who have an imminent medical emergency for which, as a result of hospitalization or urgent need to make a visit, then he or she is issued STP.(I/12)
At the time of discharge however I expected a discharge with STP and instead, it was a discharge sheet with last name/“migrant”/born on the day of the visit and a sort of temporary STP code but that had no validity whatsoever, so unusable for a second access. So, from this point of view, absolute negligence regarding the issuance of valid health documentation.(I/12)
Rather than an absence of structural/clinical/specialist resources, perhaps the lack of resources becomes more manifest in “outline” elements, such as mediation, accompaniment, which are extremely scarce and lacking.(I/3)
3.3. The Influence of Politics
It is a political idea. If you have a budget with 10 percent for military spending and 2 percent on spending on health and services, you’ve also given yourself an answer. Let’s try to do the reverse, 10% health and 2% armaments, it may be that we already find the solution. We invest in professionals, we train them, we give them tools, and we do ‘low-resource medicine’, meaning an equal allocation of resources and a prudent management, as if it were the management of our house, where you try to implement rewarding paths, even in the paths of logistics and redistribution of resources. You’ll find that you limit waste, that you have more motivated professionals and therefore, everything runs as if it were an organism oriented toward a society that gives a look with respect to the determinants of health.(I/5)
The support was there, but I can say that I felt quite alone.(I/11)
3.4. The Work of NGOs and Associations
Clearly, if the resources were there, there would be no need for the intervention of NGOs. There are not there are resources! Some NGOs participate in projects and access public funds, but they partly finance projects privately because what the public provides is not enough.(I/4)
if there were no [associations and NGOs], these people would be completely invisible.(I/1)
Partially the risk is taken, and I also believe it is also a moral dilemma. In the sense that, you know it’s a service that should be publicly and nationally guaranteed, and this guarantee is not there, this service is not provided and you go in some way to plug the hole, to make up for the lack of an entity that should instead take charge of this situation. So certainly the risk is to make policy disregard this problem; on the other hand, the risk would be that of standing by and not taking action and not looking for a solution.(I/12)
I think it’s a big topic that regards all NGOs work that always fills in gaps and provide pretexts for governments and institutions to wash their hands of problems. It certainly happens. I wonder, if there were not all these organizations, would the NHS really be more inclusive? Probably not.(I/8)
I don’t think it can diminish political interest about this issue; on the contrary, by working actively they can raise and highlight the difficulties of access to care for this segment of the population, perhaps being able to support in some way the work done by institutions and the NHS.(I/7)
The attempt must be to set up virtuous models that set an example and that must become replicable. In any case we would do that [assist the migrant population] because, if we didn’t, people would not know where to go, but in doing it we try to set a model that can be disseminated.(I/2)
The idea, indeed, is not to replace the NHS, but it should be to try to supplement and make up for the shortcomings, with the idea slowly to make a handover and then leave the project to NHS.(I/12)
you cannot save people alone, you have to collaborate, and this is something that as a health professional doesn’t immediately come to mind, we don’t see ourselves in the role of policies creators, however, we are and we have the responsibility to collaborate, to be heard, be seen, to get the best care possible and to make those responsible for public health to really take charge of all patients.(I/3)
3.5. Nursing Care
in my opinion we have many more prejudices than what the actual situation is.(I/12)
You get used to it, some French, English, Google translator, however clearly there is a limitation for you that then have to find an answer to the need, but it’s a limit especially for the person himself to express his need.(I/2)
The typical example is trying to treat an animistic epileptic: try to give him medicine when he thinks he has a demon in him and needs to go home to get the amulet. The issue is cultural and is based on the different approach to illness from people to people.(I/2)
I remind of some interviews, at first visits, in family history, “My father died when he was about 40 years old,” “How come? Do you remember? Did he have a particular pathology?”, “Mmm, he was a healer and had accumulated too many evil spirits.”(I/3)
there is a lot of misuse especially of antibiotics. There is no knowledge of the function of the antibiotic which therefore, is used for everything and there is an immoderate demand and use. Almost everyone travels with antibiotic in their backpack without knowing the function. Often then there’s abuse: you give a medicine, you explain it, there’s understanding on the part of the patient, however then, “the toothache didn’t get over it, so I took the whole blister pack.”(I/12)
Moreover, distrust seems to depend not so much on the NHS nor on the Western model of medicine, but on the bureaucracy, which makes migrants exhausted and perplexed.(I/4)
Of course, it is different for those who arrived 40 years ago and have settled here; for them, even the Western medicine has been assimilated. For those who have just arrived, the distrust is enormous.(I/2)
In a totally globalized world, huge masses of people move by plane or on foot and it is desirable to include in academic courses, elements of medical anthropology, ethnopsychology, ethnopsychiatry—this would be the minimum. It is important for a future physician, to know about human trafficking, risks, prostitution, etc. this allows you to understand many things and to avoid asking questions that risk bringing back bad memories and souring the relationship of trust as well. You need a lot of ECTS on these topics!(I/2)
Teaching should not be a “I teach you in this culture how things work” also because it would never be enough. It is true that we can make a prediction of the major communities present in Italy. However, there will always be someone from a small town in Mali that doesn’t fit into your knowledge. It is more a matter of approach, making it clear what is an open approach.(I/8)
As nurses we care for the whole person so we cannot disregard the culture—obviously getting help from the cultural mediators. Certainly, knowing the cultural factor well allows us to achieve certain results at the nursing level.(I/4)
our universities are based on scientific methods so the courses introduced must be proven, this limits the risk. The more you know, the less stupid and simple answers you give. The more you articulate knowledge, the more articulate your answers.(I/2)
3.6. Winning Strategies
The presence of the mediator is crucial in breaking down most of the cultural barriers that might come up. In the sense that when you have created communication, you have created trust and automatically you have created an opportunity to interact, to explain, to act consensually on both sides and with the specific that we never talk about an interpreter but a cultural mediator. It is not a person who simply translates from my language to yours and vice versa, but is a person who creates a channel of trust, a channel of interpretation of the message, who knows your culture and knows how to get the message across in the most understandable way.(I/12)
The strategy that works the most is first of all to give autonomy: whatever you want to do, if you don’t make the person a protagonist in his/her own journey, there will always be a problem. If you don’t give autonomy and don’t make him/her understand what the treatment is, what hospitals are of reference, the fact that, if he does not learn the Italian language there will always be a problem and he will always be a step behind, even for the job search, when you tell him that with a better workplace he will also have a better chance of getting treatment and getting out of the dynamics of “Caporalato” and everything else… so, at the center is a person with a project migration. All the rewarding strategies… what goes into increasing the level of autonomy, awareness and interrelationship between the person and his or her environment is something that is rewarding, whether it is an Italian course or going alone to the doctor or choosing the doctor after qualifying, suing an employer who doesn’t pay… start to use the tools, the few that the state gives, to be a full citizen, this is a winning strategy.(I/5)
There is a tendency not to record, not to write … this makes it more difficult to work, it makes save 3 min not to record an access to the clinic, but then the next time you don’t know what you did or what your colleague did… again we are talking about a logic of safety for us and for the patients. Already they are people who are used to “not existing” on paper, not recording, documenting, writing, providing a piece of paper back after a visit, always seems to me to be neglecting people who have little opportunity to act in their turn.(I/3)
3.7. The Role of the Family and Community Nurse
By settled population I am talking about a population that is assimilated to the Italian population, so, I wonder and ask you: if community nursing is useful for me, it should be useful for my Senegalese neighbor as well, right? There should be no difference between me and him, so yes, for the settled population absolutely yes, but not so much specifically for the migrant person, but as a useful service for all citizens and the whole population present throughout the territory. If, on the other hand, we are talking about the transient population, then it becomes a little bit more complex, how do I access the FCN service? Do I access it through an STP code? How long am I going to stay in the territory? […] Probably for this type of population you ask for a more specific type of service, more focused on what is the trend and transit in Italy. So maybe not, the FCN would not be the ideal solution.(I/12)
For example, there are many FCN in suburban neighborhoods in Bologna, but there are big obstacles, so people end up in our outpatient clinic, because FCN does not have the elements, the resources. There must be created special systems to be able to best ensure continuity of care, etc.!(I/3)
4. Discussion
We do not think to exaggerate by saying that anyone who has had, at least in a professional sphere, encounters with an immigrant or, rather, with multiple immigrant citizens, has wondered, had curiosity, came up against the evidence of a bureaucracy that tends to exclude otherness, in some cases has felt powerless on the relational or clinical, sometimes outraged by reactions and attitudes. Nothing new for those who have chosen to work in helping relationships. But what is new in the relationship with the foreigner, often the realm of shared prejudices, more or less conscious, is that we have measured, and we measure with concrete hand our powerlessness: the communicative linguistic, relational, political-organizational, cultural therapeutic one. Again, there is the awareness that in order to overcome this impotence, we must cross the diaphragm that separates us from each other and share information, impressions, discoveries, strategies. In the mirror-function that immigration forces us, we find our weaknesses but also the motivations to be protagonists of what, with good reason, we can call real pathways to public health and the right to health “without any exclusion”.[30]
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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1. Questions about Legislation |
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2. Questions about Cultures |
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3. Good practices and suggestions |
|
Interviewee | Sex | Age | Degree(s) | Years of Experience as a Nurse | Years of Experience in the Migration Field | Region of Practice | Experience Abroad as a Nurse | Foreign Languages Spoken |
---|---|---|---|---|---|---|---|---|
I/1 | F | 31 |
| 8 | 4 | Tuscany |
| English Spanish |
I/2 | M | 35 |
| 10 | 10 | Emilia-Romagna |
| Spanish (first language) English |
I/3 | F | 27 |
| 2 | 2 | Emilia-Romagna |
| English French |
I/4 | M | 55 |
| 30 | 11 | Trentino |
| English French |
I/5 | M | 40 |
| 20 | 10 | Campania |
| English French |
I/6 | M | 62 |
| 42 | 12 | Sicily |
| None |
I/7 | F | 48 |
| 30 | 5 | Trentino |
| English |
I/8 | F | 45 |
| 6 | 4 | Lazio |
| English Spanish French Arabic Turkish |
I/9 | F | 45 |
| 22 | 3 | Sicily |
| English |
I/10 | F | 30 |
| 7 | 2 | Emilia-Romagna |
| English |
I/11 | M | 39 |
| 6 | 2 | Emilia-Romagna |
| English Spanish |
I/12 | F | 29 |
| 7 | 2 | Calabria |
| English Spanish |
I/13 | F | 26 |
| 5 | 2 | Sicily |
| English |
Themes | Subthemes | Codes |
---|---|---|
italian legislation and migrants | interviewees’ impressions and opinions | Struggle to be optimistic |
See few advantages and many obstacles | ||
Recognize benefits: STP, access to exemptions, primary care, access to counseling, etc. | ||
Be a maze/limiting/dysfunctional | ||
rights guaranteed only on paper | Guarantee, on paper, the right to health and the access to care | |
Not find application in reality | ||
Not comply with the constitutional principle | ||
exclusions and consequences | Exclude people | |
Seek order and rigor but achieving the opposite | ||
Increase the risk of crime | ||
Increase uncertainty | ||
Make complicated to stay/rescue at sea | ||
practical problems | Require excessive documentation/numerous prerequisites | |
Have long waiting times | ||
Struggle to renew documents | ||
Tie NHS enrollment to residence permit | ||
Burden the public system/increase improper accesses in ER | ||
structural difficulties | regional differences | Convert national norms into regional contexts |
Adapt to administrative/organizational dynamics | ||
Have disparities between North and South | ||
unprepared staff | (Not) be up-to-date and educated with respect to legislation/Be ignorant and uninformed/Be negligent with respect to issuing valid health documentation | |
lack of resources | Have limited and insufficient resources for all | |
Disadvantageously manage the little resources available | ||
Not guarantee universal and equitable access to care | ||
Force to use private project funds | ||
Not have sufficient beds or dedicated facilities | ||
Have availability of few healthcare workers compared to the large migrant population | ||
hospital model | Have a hospital-centric approach/Wait for patients in the hospital/Not have resources for the territory | |
Ensure health services but not care about making a service effectively accessible/Not guarantee “side” but necessary services (e.g., cultural mediator within the hospital) | ||
Exclude those with poor health literacy | ||
Be there need for structural change | ||
Be there need to make the distribution of resources more equitable | ||
Be there need to consider all determinants of health | ||
the influence of politics | allocation of resources | Ensure access to care when there is willingness (see Ukrainians’ ad hoc legislation or individuals pathways such as Asylum Seeker and Refugee Protection Service)/Allocate resources according to policy idea |
Allocate resources unequally | ||
Make policy choices that put lives at risk/ Choose where to invest (military spending rather than health spending) | ||
Choose investments for image and votes | ||
instrumentalization | Use the issue of migration in an instrumental and propagandistic way | |
View migration as an emergency and not as a constant and natural human initiative | ||
lha (local health authority) | Not perceive concrete collaboration | |
Have a good collaboration | ||
Ignore people’s initiatives initially then supporting them when they become relevant and strong | ||
Never sign concrete conventions/offer little concrete support | ||
Have person-dependent collaborations | ||
the work of ngos and associations | popular outpatient clinics | Offer services that are not present |
Assist people who are otherwise “invisible” | ||
moral dilemma | Wonder the moral dilemma/Have the doubt | |
relationship with politics | Create an alibi/Provide excuses to disregard the problem | |
Lighten the politics | ||
how to act | Document, analyze and denounce | |
Create tables of dialogue with institutions | ||
Create a network between associations and collaborations with ASL | ||
Create virtuous and replicable models | ||
Strengthen the role of territorial medicine/Reconnect with territorial medicine/Not replace/ Redirect pts to their GPs | ||
nursing | difficulties in assistance | Meet no barriers |
Communicate in different languages | ||
Manifest pain | ||
Give different meaning to illness/ Provide culturally-influenced explanations | ||
Use medications incorrectly/excessively/ Not adhere correctly to therapy | ||
Encounter ethnographic/anthropological barriers | ||
Not understand aspects distant to one’s own culture, such as prevention | ||
Deal with patient contact | ||
Be a woman/Gender relations | ||
Identify/understand rights | ||
Interface with the system | ||
Train the staff | ||
migrant patients’ trust and distrust | Be wary initially | |
Be distrustful due to “cultural distance” | ||
Be wary of the (western) model of medicine more than of NHS/Be more wary of the hospital than of the outpatient clinic (therapies) | ||
Be more distrustful as women | ||
Have trust | ||
Lose trust because of bureaucracy | ||
how to improve | Know the culture to provide quality care/favor migrants’ approaching | |
Embed generic notions (elements of medical anthropology, ethnopsychology, ethnopsychiatry) within the degree program | ||
Break down prejudices with knowledge | ||
Structure new cross-cultural courses in a scientific manner | ||
Incorporating language skills | ||
Act as professionals | ||
winning strategies | within the staff | Involve the cultural mediator (help with language but also with approach) |
Share among colleagues after each intervention/experience | ||
Multidisciplinary teams | ||
Train | ||
with the patient | Establish a relationship of trust/’Attach the person’ | |
Dedicate time/Ask and explain treatment/Dialogue with the patient | ||
Have respect | ||
Don’t get too close, don’t touch the person | ||
Ask for consent before each procedure | ||
Have no judgment | ||
Give autonomy to the person | ||
Offer psychological assistance | ||
Maintain contact | ||
Have elasticity | ||
structural | Raise awareness in professionals and give information to migrants | |
Collaborate with LHA | ||
Document/share among professionals a computerized electronic record | ||
Overcome the dichotomy between outpatient clinics for people who are enrolled in the NHS and outpatient clinics for people who are not enrolled, with STPs | ||
(in the most emergency contexts) Create an operational structure with protocols and lines on how to move | ||
the family and community nurse (fcn) | Potentialities Of the facn | Have a relevant role |
Be able to fill the gap/Overcome the fragmented nature of the system | ||
Provide continuity | ||
Bring the responsibility of taking in charge back within the NHS | ||
Depend on the type of migrant population: useful service for settled citizens and migrants—not a solution for the transiting population | ||
What is still missing | Have an interest in reaching the entire population | |
Specific training | ||
Resources |
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Camedda, C.; Righi, M. Experiences and Suggestions of Nurses Involved in Caring for Migrant Populations in Italy: A Qualitative Study. Healthcare 2024, 12, 275. https://doi.org/10.3390/healthcare12020275
Camedda C, Righi M. Experiences and Suggestions of Nurses Involved in Caring for Migrant Populations in Italy: A Qualitative Study. Healthcare. 2024; 12(2):275. https://doi.org/10.3390/healthcare12020275
Chicago/Turabian StyleCamedda, Claudia, and Maddalena Righi. 2024. "Experiences and Suggestions of Nurses Involved in Caring for Migrant Populations in Italy: A Qualitative Study" Healthcare 12, no. 2: 275. https://doi.org/10.3390/healthcare12020275
APA StyleCamedda, C., & Righi, M. (2024). Experiences and Suggestions of Nurses Involved in Caring for Migrant Populations in Italy: A Qualitative Study. Healthcare, 12(2), 275. https://doi.org/10.3390/healthcare12020275