Ethics of Nursing in a Detention Centre
Barbara Rogalla writes about Nursing behind Razor Wire
There are serious problems with the ethics of nursing in Australian immigration detention centres, where we lock up asylum seekers and refugees. The problems are worse than the problems arising from working as a nurse for organisations such as the Red Cross.
At the Red Cross, your position is protected from being drawn into "partisanship" with either your friend or your foe, for example when you work in a war zone.
In Australia's detention centres the position of nurses is compromised to such an extent that on reflection, you probably can't work: the centres are stacked with party-political interests.
This page provides a short overview of the situation. With many thanks to Barbara Rogalla and Michael Hall.
18 March 2004: Force Feeding Hunger striking asylum seekers - Legal and ethical implications of medically enforced feeding of detained asylum seekers on hunger strike. If called upon to treat hunger strikers, [Australian] medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.
16 March 2004: The Rules: Nursing in a Detention Centre - DIMIA and ACM are now acutely paranoid about human rights and refuge advocacy groups and their influence. Let me illustrate this point. A disabled child arrived one December and I was told by both an immigration and ACM manager to do nothing for him other than what I would do for any able-bodied child as he would probably be released soon.
25 October 2003: A child in detention: dilemmas faced by health professionals - If a government's policy conflicts with ethics of care workers, health professionals, psychologists or psychiatrists, these ethics are undermined if these policies are deemed to be followed or implemented. This paper deals with the dilemma in the case of a child held in detention and faced with serious psychological distress symptoms.
18 August 2003: Two NADA News broadcasts on 3CR Community Radio - Two members of the National Anti-Deportation Alliance, recently formed in Australia, talk on-air at 3CR Community Radio in Melbourne, discussing the highly questionable practice of forced deportations and chemical restraints.
Nursing behind Razor Wire: A Question of Ethics
By Barbara Rogalla
Until recently, RN Barbara Rogalla worked at the Immigration Reception and Processing Centre in Woomera - an area tucked away from public scrutiny behind cyclone fences and razor wire in the desert plains of South Australia. She describes her experiences and offers some advice to other nurses who find their ethical considerations clash with organisational objectives.
'I have practised general and psychiatric nursing at Woomera - in what former Prime Minister Malcolm Fraser dubbed a 'hell hole' when he was awarded the year 2000 Human Rights Medal.
The clientele were some of the most desperate people in the world - people who feared death or torture if they were not granted refugee status in Australia.
Nurses practise wherever people are, because everybody needs nursing care at some time during their life. It is not surprising, therefore, that nurses also work in immigration detention centres built to accommodate the ever-increasing number of asylum seekers. Detention environments exist for the purpose of detaining people. Nurses are not directly employed for these purposes, and there is always a potential clash between organisational objectives and ethical considerations.
Last year I was in an incongruous position - one where I believed Woomera's management did not fulfill its obligations.
Initially I attempted to resolve my concerns 'in-house'. Several months later I went to the media, but only after exhausting less dramatic avenues of reporting. The media quickly informed the public that something was drastically wrong in the refugee camps. Then came an Australia-wide call for a full judicial inquiry.
Nursing in immigration detention centres means moving into unchartered waters - because the concept of locking up people who ask for asylum is new to Australia. Nurses' responsibilities are spelt out in several codes of practice and conduct developed by professional and legislative bodies. But unlike a procedure manual, the code of ethics does not provide a blueprint for explicit actions.
I found the support from a professional colleague absolutely crucial. There also was assistance and free legal advice from the ANF SA Branch office.
I informed representatives of Family and Youth Services, the police, and government departments. Whichever agency a nurse chooses to approach depends on the problem that makes it difficult to sustain their legal and ethical principles.
You cannot rely on colleagues to get the message out. Always assume this is up to you. Just how you do this and how far you take the matter is between yourself and the code of ethics.
Nurses have the same responsibilities toward the patients in immigration detention centres as toward other patients. Their mode of arrival to Australia - even if it is illegal - is of no consequence. Therefore, nurses must speak out whenever they believe patients are disadvantaged or patients' rights are violated. This holds especially true in detention settings where treatment choices are not an option, and usual avenues of complaint and support are restricted.
The code of ethics compels nurses to do whatever is necessary to preserve the integrity of nursing practice. A company employing registered staff with professional obligations should expect nothing less.
The Immigration Minister, Philip Ruddock, suggested early in February that a legal framework be established to allow detention guards to chemically restrain detainees. Mr Ruddock made it clear drugs would then be administered for security reasons. The legal framework for the administration of chemical restraint by nurses already exists, but only on clinical grounds. Current practice parameters constrain nurses from drugging people for the purpose of political expediency.
Asylum seekers are detained by an act of Parliament, not because a judge has sentenced them. Imagine if a detainee was physically restrained, thereby rendered helpless, and forcibly administered a drug to achieve effortless deportation. This could constitute a form of torture that, until now, has had no place in Australian legislation. World politics and the emerging refugee crisis are likely to bring the nursing profession to the threshold of examining and re-defining ethical parameters. This is an active process that involves every RN. It starts with speaking out when human rights are ignored, in order to generate a forum for informed debate. That is part of our job.'
Frontline nursing in detention
Letter to the Editor
A Response to
Thanks to Michael Hall for the thoughtful article. Here are my thoughts, from the perspective of a nurse who has practiced at Woomera.
The whole reason we have detention centres is political, it would be naïve to think otherwise. Let's face it, anybody who works there is employed in relation to the all-embracing goal of locking up asylum seekers. We can't get away from this basic tenet.
The real paradox for health professionals is that Australian detention centres actually cause ill-health to asylum seekers. This has been clearly established by the work of many clinicians, including Amer Sultan, Louise Newman, and Zachary Steel in Sydney.
There is no doubt that nurses who work in the professional, psychological and geographical isolation of immigration detention centres are able to develop a whole range of new skills. I've been there, done it, and seen great problem solving skills emerge in other nurses, under less than optimal working conditions.
The real question is not "can we do it?" but "ought we?" In future, when the political spectrum does its full cycle and swings the other way, it may become difficult to admit that we have ever worked there.
Frontline nursing in detention
Australian Nursing Journal
by Michael Hall
Michael Hall worked at Curtin Immigration Reception and Processing Centre for over two years, leaving in January 2002. He now works in Brisbane as a midwife.
I remember my first day in the detention centres so clearly. I looked up and saw a long line of men, women, and children waiting to have had not taken. I was standing beside a small table in an RAAF tend with a coworker.
It was 40°C in the November humidity. Both ends of our tent will open in a vain attempt to get a breeze through, as we work side-by-side, flies buzzing around us with running down our bodies. It was the first time I had been in a detention centre.
Curtin Immigration Reception and Processing Centre is 45 kilometres from Derby in the Kimberley region in Western Australia's far north. It was originally established to provide temporary accommodation when a number of boat people arriving in Australia exceeded the capacity of the permanent detention centres.
I was taking a break from emergency nursing to be a graduate midwife at Derby hospital when the local pathology laboratory recruited some of us to assist as venepuncturerists in health screening new detailing a set Curtin. That was in late 1999.
When I left Curtin for the last time in January 2002, I was the health services coordinator, answering directly to the centre manager and the health services manager of the Australasian Correctional Management (ACM) Sydney head office. ACM as a private company, which, at this time, was contacted by the Federal government to manage Australia's detention centres.
When I started, we had a handful of nurses and one locum doctor, based in a demountable building, and we used detainees as interpreters. When I left, we had four demountables, a multidisciplinary team of health professionals and access to professional interpreters.
Nurses other front line in the heart of health care in detention centres. The health manager is called the health services coordinator and this is a nursing position. Whoever holds this position is the team leader for the nurses, counsellors, psychologist and doctor. This person ensures that health screening is carried out and ongoing health care is provided. At Curtin, I was lucky to be able to develop and be part of this team of professionals.
The nurses, and others in the health team, work in a security environment, dealing with traumatised clients of a different cultural and mostly non-English-speaking background. All health staff must be adaptable and able to work with chronic and acute caseloads daily. If you lucky, you doctor can perform as a GP as well as an emergency physician. If not, then the nurses will, so you need to have the skills of remote area nurse as well as critical incident skills.
If ever there were need for a nurse practitioner, this is the environment! Detention centres are usually based in isolated locations were local public hospital facilities are limited. All nurses practice at a high clinical level.
At Curtin, we saw over 10% of the population every day. The doctor saw an average of 10 clients. With populations ranging from 300 to 1300, we were a very busy clinic, and triage was essential to ensure the most needy had access to the doctor.
Our roles were many and varied. We covered primary health care programs such as Sunsmart, nutrition, women's health, maternal and child health, antenatal, arbovirus prevention, typhoid and malarial screening, hydration in the tropics and tropical diseases.
There were also acute health problems such as hypertension, diabetes, acute and chronic gastrointestinal diseases, constipation, dehydration and former (sport and assault) and the joy of newborn child health.
We also addressed occupational health and safety issues such as caring for a community on an active building site.
While many of the health issues addressed the routine, only about 1% of the nurses had previous close clinical experience in dealing with clients from Iraq, Iran and Afghanistan (our three major cultural groups). We also had clients from Sri Lanka, Jordan, and Palestine. Cross-cultural training was totally inadequate, con-sisting of a two-hour session presented by an Iraqi national.
Unfortunately, politics is an integral part of detention nursing. You cannot be a detention nurse and not deal with politics, and while mandatory detention remains government policy, they will be a need for nurses to provide quality health care in detention centres.
Anyone who enters a detention centre, is there because they do not have a valid entry visa or have violated to their visa requirements. Most people in detention apply from refugee status. The processing of refugee claims is supposed to be completed within fourteen weeks of arrival, but some taken to six months.
Those still in detention after this time are either awaiting deportation or appealing the outcome of application from refugee status. As a detention nurse, you deal with health issues, not migration issues, however, you need to be aware of the clients' case status as it influences this state of mind and general well-being.
Working as a health professional for a private company such as ACM can give rise to numerous ethical dilemmas. For example, there is the constant dilemma of weighing up the cost effectiveness of providing comprehensive health services to clients who may be released into the community or deported at a day's notice and the issue of follow-up once the person leaves the detention centre.
Ethical dilemmas also arise when government or employer directives conflict with accepted professional standards. On one occasion, I spent two weeks on Christmas Island processing over 500 detainees who had been there for quite a while with no health screening.
As I was leaving, job done, I refused to be the escort nurser to two pregnant women who were being forcibly separated from their husbands and children , so they could be taken to the mainland to have their babies.
I considered the separation and isolation of pregnant women was wrong on professional, medical and ethical grounds and I was appalled that it could happen.
Confidentiality is also an ongoing issue in detention. Any immigration official or detention centre manager can access detainee health records at any time without giving reason. This places a significant pressure on nurses in relation to report writing and recordkeeping and compromises the relationship with their client in relation to confidentiality.
I cannot be totally dispassionate about the joys and difficulties of detention nursing; I simply share with you my experience. I encountered some clients that I wish never to see again, as well as beautiful clients that I miss the looking after.
But like so many other detention nurses, I became burnt out and frustrated at the politicisation of detention and the way in which politicians dictated health care. Many detention nurses have been worn down by the constant stresses in the workplace as well as the hostility of the general community. Most of all, we are tired of being unable to give the care would wish to give - in that sense , we are just like so many other nurses in so many workplaces.
Nursing in detention is particularly our tourists and it is essential to maintain your links with to professional organisations if you are to survive. If it were not for the advice and support of the ANF Western Australian branch, I could not have stayed to become the longest serving health services coordinator. The WA ANF always welcomed me with the assistants are requested quickly and efficiently: not only legal and professional advice, but emotional support to.
Unfortunately, there is no organisation like a Detention Nurses Association for nurses to meet and discuss professional or industrial issues.
The ANF federal secretary, Jill Iliffe, has indicated her interest in organising such a group for detention nurses, so please contact her if you are interested in such a nursing organisation.