​Acknowledging people’s journeys

Acknowledging refugees’ journeys by ‘getting to know them as people’ and listening to their stories of dislocation as well as stories of hope and resilience was found to be critical to build relationships respectful of their unique life trajectories. Participants shared an empathetic understanding of refugees’ stories and reflected back on how their complex human trajectories resonated with them, exposing their own vulnerability as healthcare professionals. Participants reflected on the importance of acknowledging what refugees have been through to develop a more nuanced understanding of their complex migration journeys to NZ:

[R]espect them as people … respect what they have been and what they can be … They were lawyers, policemen, doctors, teachers, and they come here and all of a sudden they have nothing… That's something to just always keep in mind. (PN126)

Acknowledging what refugees have been through also meant respecting differences in expectations to avoid unmet needs and allow for trustful relationships to develop. This included managing refugees’ expectations regarding health delivery within a system that operates very differently to what they are used to, but also managing their own expectations as healthcare professionals, with refugee patients presenting to the practice with priority needs that often differed from their own. Establishing dialogue around those contrasting perspectives and providing emotional support to reduce feelings of uncertainty were important to facilitate meaningful engagement.

​Cultural sensitivity and openness to difference

Relational closeness was developed through an openness to difference. Participants referred to the importance of demonstrating a genuine interest in refugees’ cultural practices, norms and values. Setting aside professional assumptions about ‘what is best to do’ and avoiding ‘treating everybody the same’ reflected cultural sensitivity and provided foundation to culturally appropriate care:

​[I]t's no good saying: " I'll just treat them like anybody else”… That's not what equity and justice are all about. You've actually got to recognise that refugees need to be treated differently because otherwise you will not meet their needs, and that's part of cultural competency. (GP827)

Cross-cultural interactions, however, could be challenging at times and participants acknowledged the importance of cultural competency training to build confidence and skills for the relational encounter through cultural diversity. Participants also discussed the importance of understanding the nuances of cultural differences and their potential impact on the health of refugee patients, including impact on health service utilisation. Uptake of cultural competency training, however, remained variable, with a third of our participants not having completed any training relating to refugee health. Furthermore, only very few people at the practice were generally allocated time to attend training sessions due to busy practice schedules.

​Translating experiential knowledge into practice

Participants’ journeys shaped the ways in which they related to cultural diversity in their professional practice. Participants with experience of working in culturally diverse contexts felt that they had a somewhat advantageous perspective on negotiating cultural issues. In particular, participants gave detailed reflections on their own experiences of travelling and working overseas for professional or humanitarian work including with refugees and having to adapt to cultural diversity. Experiential knowledge acquired through exposure to different cultures allowed them to develop an understanding of ‘difference’ in terms of norms of culture and gender which they would then translate into their practice with refugees in NZ. Participants from migrant backgrounds shared their own experiences of relocation, and although contrasting to those of refugees, this helped them with building a connection between what they had been through and the way that they can support their refugee patients resettling locally:

I’ve worked all over the world including with refugees … [I]’ve lived in different cultures myself and I had to adapt. [A]ll the things I have experienced and learned are actually things I can use to help somebody else. (GP200)

​Making a difference

Providing care to refugees was generally perceived as an opportunity to contribute to a ‘bigger cause’, in reference to the humanitarian values underpinning refugee healthcare. Participants’ willingness to help was reflected by an overarching sense of moral commitment and responsibility. Through caring for refugees, participants felt that the work they were doing was worthwhile and that impacting on the lives of their refugee patients, even the slightest, was extremely gratifying:

[I]t's been a fulfilling experience … doing something worthwhile … and that sort of warm fuzziness … [the] constant remembering of what these people have been through, and if you can make a difference, then that's really worthwhile. (GP404)

Providing care to refugees was seen as a transformative experience, with some participants taking on advocacy and volunteering roles in their community to promote a culture of acceptance that celebrated diversity. Overall, participants’ relational experiences reflected a caring approach aimed at nurturing people’s potential, providing opportunities for them to pursue fulfilling lives in NZ and creating a relational space at the practice that is culturally safe for everyone.

​Time commitment

Providing care to refugees through mainstream general practice challenges the time-restricted consultation structure. Participants mentioned needing to dedicate more time to consultations with refugee patients than with most other patients. The time allocated to each consultation was still perceived to be too limited despite financial assistance provided to general practices through the voucher system to cover for 30 min appointments. Participants often mentioned having to compensate for this at the detriment of the experience of care provided to other patients, extended waiting times and sometimes considerable disruption to their work schedule. The longer time required for consultations was sometimes perceived as a burden on the system:

​[Consultations] just are long and that is never going to shift … Theoretically 30 min, but generally much longer, disrupted, and throw the rest of your day out. (GP794)

​Use of interpreter services

The use of interpreter services (interpreters physically present in the consultation) was generally perceived as an enabler to providing high-quality care to refugees. Beyond language translation, interpreters were also considered to be ‘cultural brokers’—helping with understanding the cultural meanings of certain words, cultural behaviours and gender roles during consultations. General practices are free to use interpreter services at no cost and this was seen as an important incentive to interpreter bookings in order to facilitate communication with refugee patients. However, despite the availability of interpreter services at no cost and the positive experiences of interpreted consultations by participants, important variations in the uptake of these services were noted including the use of a ‘make do’ approach with the use of other means such as Google Translate or relying on family members for translation in the consultation room, including children. Those challenges most often occurred when refugee patients would present to the practice without an appointment and needed to be seen urgently, when interpreters had not been previously booked on the basis that a family member speaks English well enough to substitute interpreter assistance, or when an interpreter had been booked but the patient’s visit extended beyond the scheduled timeframe, leaving the remainder of the consultation without an interpreter.

​Interface with other services

Participants highlighted the importance of connecting with other services and facilitating referrals to appropriate resources to facilitate management of refugee care and ensure timely access to services for refugees. Navigation roles (eg, cross-cultural health navigators from the local PHO and Red Cross volunteers) were instrumental in enabling connections between general practices and the other providers in the network and helping refugees navigate the health system. Despite the perceived benefits of navigation support, those roles often relied on very few individuals covering for an entire resettlement region, with concerns expressed about sustainability of navigation assistance in the long run. Participants also reported uncertainty about the role of the different refugee services providers in the network which would sometimes lead to apprehension towards referrals to other services. Participants were more familiar with referring patients to health resources and many struggled with endeavouring to refer refugee patients to the wider range of social and community support services required to meet their needs, including employment and housing. Some participants described a ‘disconnect’ between services and expressed feelings of professional isolation (silo work) in terms of coordinating care across the primary and secondary care interface and beyond the health sector:

[W]e’re just one cog in the whole system. Everybody needs to talk to each other more … to have everyone on the same page so that [refugees’] needs are being met, and that there's no duplication. … We need more communication, there’s a bit of a disconnect. (GP878)

Misunderstandings about refugees’ entitlement to care were also common occurrence, particularly in the early stages of the resettlement programme. The need to clarify refugees’ rights in accessing healthcare led GPs to write justification letters to various services to ensure timely access to healthcare, particularly to secondary care.

​Adapting delivery arrangements

Different ways of adapting healthcare delivery to refugee patients were reported by participants. These initiatives were implemented on a voluntary basis with the intention of making services more efficient and also more responsive to the needs of refugees. Examples of initiatives included the allocation of gender-concordant providers at consultations, the implementation of group appointments for all women or men of a same family, or the establishment of a welcome session outside normal business hours for new refugee cohorts to introduce them to staff at the practice, provide information about the role of general practice, explain how to book appointments and address any other informational needs of refugees, including how to navigate the wider health system. Overall, these initiatives were perceived to be fostering culturally appropriate practice, facilitating relationship building and trust, as well as helping with providing smoother pathways to and through general practice for refugee patients. Despite perceived benefits of adopting flexible delivery arrangements, no formal support was provided to general practices to implement such initiatives.

​Mainstream general practice model: fit for purpose?

The parameters of the current business model of NZ general practice were seen as compromising the system’s responsivity to refugees. The financial imperatives underpinning the business model of general practice, including relatively short consultation times, were perceived to be interfering with value-driven care and tailoring of care to specific groups of patients, raising concerns about the ‘fit’ of mainstream general practice to address the complex healthcare needs of refugees. The business model of general practice was perceived to be in competing demand with moral responsibility in the eyes of many participants.

It’s a private business. It's finding that balance between social responsibility versus financial viability. (GP949)

I'm not sure if [general practice] is where [refugee care] is most appropriately held, because it's a fast-paced short-appointment-time service that's quite busy … it's a lot of work, and it's not fitting in appropriately with the rest of what we do here. (GP202)

​Addressing healthcare needs across the social determinants of health

Refugees were generally portrayed as ‘high needs’ patients, with priority needs ranging from physical, mental, oral health needs, to a wider range of social needs including support for navigating the health system, language assistance, legal aid, help with finding sustainable employment and healthy housing:

Refugees are a relatively high-needs population because of their previous experiences, so they will have both physical and mental health needs … then of course employment is difficult. They've got language barriers … the qualifications they have are not necessarily recognised. They've got social needs and financial constraints as well. … they need help with navigating the system … so we will sometimes go beyond our (typical) role so they can get the help they need. (PN184)

The problems presented by refugee patients were seen to require approaches which go beyond standard clinical practice for both GPs and PNs. In order to address refugees’ needs, participants talked about employing a ‘social approach’ that considers the wider social determinants of health. This involved connecting with various services beyond the health sector and advocating for patients’ rights to access services. Considerable time needed to be invested in strengthening existing community networks and creating new networks and pathways to facilitate navigation to and through services:

[The role] is wider than just your standard general practice role because refugees have a lot of other needs outside of health… it is like being a “communal garden GP”… the role is community focused and more social. (GP949)

​Invisibility of the role and perceived lack of value

Providing care to refugees involved a lot of ‘behind the scenes work’, particularly for retrieving previous health information in the absence of shared information systems, building new referral pathways and connecting refugees to services beyond the health sector. This ‘background work’ would range from more simple tasks of filling out extra paperwork to more complex tasks of developing relationships with other service providers and adapting delivery arrangements to ensure refugee patients are being seen according to their needs. Participants would refer to this as ‘charity work’ and ‘unpaid’ work, with considerable additional burden on reception staff, limited numbers of nursing resources and GPs’ caseloads already at full capacity:

We do a lot of extra work with [refugees] in the consultations, and then there's quite a lot of behind the scenes work that we do as well … it’s like volunteer work, we were aware that we weren't going to get paid for it. (G404)

There was a perceived lack of value for all the efforts that needed to be invested in creating the conditions for ensuring that refugees’ healthcare needs are being met. Invisibility of the role is portrayed by the following quote:

[T]here’s a sense of you're just out there doing things and no one can see you and no one really [cares] … there is not good understanding of the amount of work that’s happening with [refugees] … I don't think [our role] is valued properly. (GP794)

​Disempowerment in response to lack of support

The perceived lack of support and recognition of the role expressed by participants, coupled with the complex reality of refugee healthcare in a system already subjected to significant stress and limited resources, can lead to professional distress. Participants reported feeling quite overwhelmed at times and uncertain about their ability to meet the challenges that providing care to refugees entail. This quote from a GP participant reflects how challenging this can be:

I've found it more difficult than I expected. I've found the health stuff pretty overwhelming. … Feels like more than I can manage … people come to me with these huge lists of diagnoses, referrals everywhere, issues that need to be followed up and no systems in place … I've felt like I've drowned in that really … I've found it unwieldy, hard to manage… the practice has really struggled. (GP794)

The inability to help as they would hope to was frustrating and left participants feeling helpless at times:

[M]y heart would just sink when I saw them on my list … [I]t’s really frustrating … and that frustration comes with not being able to really help them like I’d want to. (PN656)

Commitment to make things work in the face of challenges was driven by a strong sense of moral responsibility, but the ability to sustain these efforts in the long run due to a lack of resources was questioned by many participants:

There's a sort of a practice commitment to do this even if it was going to be a struggle … [we were] well aware that [the support] we were offered was not going to be enough time or resources … and the rest of it would have to come from us. … I just wonder how that will go in perpetuity (GP404)

Many participants also reported dissatisfaction with the disparities between general practices in terms of uptake of refugee patients, and the disengagement of some general practices early on after the implementation of the resettlement programme. This situation was perceived to be adding increased pressure on a selected number of practices already under stress, with participants expressing concerns for the sustainability of PHC delivery to refugees in the longer term.