Staff attitude

The participants unanimously had no concerns around eligibility or moral dilemmas in providing care for ASRs in the ED (P1–P12). Many were keen to go above their duty to make patients feel comfortable, reassure any eligibility concerns and provide care, as illustrated in the quotes below:

…the way I see it is free at point of entry. No judgments, no nothing. (P4)

I’m here as a nurse. I’m here to make somebody feel safe, secure and valued as a patient. (P8)

I think we’re generally kind of like open to giving them care and kind of looking after them a little bit more. (P6)

We’re quite an open minded, you know, warm department. (P10)

…I would like them to feel valued and welcome when they come to the department after, you know, they’ve had horrific experiences that most of us will thankfully never ever experience… (P8)

He was like worried that he would be charged…I kept trying to explain: “No, no, it’s free”. “Like don't worry we’ll look after you.” (P6)

Although participants agreed that this largely reflected the department as a whole, some did state concern that a minority of staff expressed negative views related to perceived ASR entitlements as described in the quote below:

Some people have got quite entrenched beliefs that, you know, that they’re here and they’re getting more than everybody else and they’re getting free houses and they’re getting free this and they’re not. And that’s a lie. (P8)

…it’s the ‘Oh they get mobile phones, they get taxis everywhere’. Well, no. Have you seen the situation they’re living in? (P4)

Presentation patterns

Discussions on presentation patterns revealed significant heterogeneity among the participants, with one-third of participants believing there was no significant difference in presentations compared with the general population (P5, P9, P10, P11). No patterns were universally agreed upon and contradictions arose on issues such as acuity. Some described patients presenting with ‘minor stuff’ (P12) or early in their illnesses (P8, P10), whereas others described a pattern of delayed, undertreated and often complex presentations not traditionally managed in the ED (P1–P3, P6). In many cases, participants described having to ‘start from scratch’ (P2), ‘wing it’ (P1) and being ‘back to square one’ (P11) as patients’ full medical records were not available.

Mental health presentations featured heavily in many discussions. Participants described challenges managing aspects of patients’ psychological trauma which they have had little experience with as illustrated below:

The idea of true sympathy and empathy for these people is almost impossible, because I have no idea. I can’t put myself in their shoes because I can’t get there. (P4)

Yeah again I would say in triage, quite a lot of mental health. Probably more so after COVID than ever before. (P5)

…don’t think it’s right place for them, if it’s mental health related. (P12)

A further common topic of conversation was around multiple members of a family presenting to the ED together (P1, P2, P7). This was believed to be primarily a consequence of a lack of social support in the community (eg, parents unable to arrange childcare) (P2, P4, P7). This highlights the vulnerability and social isolation of ASR patients which may put them at higher risk of exploitation, substance misuse and mental health problems (P4, P5).

Challenges to optimal care

Despite the positive attitude towards caring for ASR patients, many of the difficulties with managing this group were related to challenges within the ED to deliver optimal care. Language barrier was the most frequently mentioned and emphasised challenge among participants (P1–P12), with many expressing concern that it likely affected patient care as highlighted by the quotes:

Definitely, there’s been a couple of instances recently where I think that the language barriers have made someone’s care not as good… (P3)

Sometimes you’re just using kind of basic communication skills like ‘pain’ and like ‘sore’ which probably isn’t ideal really. (P6)

…you might underestimate his pain. Because of the language barrier. (P12)

It was however highlighted that this issue is no different to any foreign national who does not speak English (P9). ‘Language Line’ —the telephone translation service—was the most used translation tool and although largely easy to use and arguably the only financially feasible option for translation (P5, P6, P9), dialogue could be lost in translation and it could impede the patient–carer relationship (P1–P3, P11). Face-to-face translation was preferred, as illustrated in the quotes below; however, time pressures and limited language diversity in the department meant that this option was rarely possible (P1, P6, P8):

When you go to the telephone system, they can’t see you. You know there’s a different understanding from looking someone in the eyes, watching the body posture. (P2)

You can’t really get the emotions across as much. (P3)

The level of defensiveness drops when there is somebody there that they can look at and speak to, who understands what they’re saying makes a massive difference. (P4)

I found it a bit more like artificial if you communicate using a device, an electronic device… (P11)

The challenge of language barrier and time pressure is perhaps most evident at ED triage—the process by which a nurse has approximately 5 min to assess a patient’s acuity and reason for attendance.25 Telephone and face-to-face translation options are often too time-consuming to be feasible and participants instead resort to using ‘Google translate’ or even simple hand gestures (P8, P10). Difficulties in accurately assessing often complex presentations risk patients being ‘undertriaged’ (P2, P5, P6, P8):

…you need to take the time [at triage] to make sure you’re asking all the questions at the one time on that one telephone call because you’re going, you know, to predict that patient’s journey throughout. (P5)

Time pressure was highlighted as an ongoing challenge by participants in their ability to holistically address many of the complex social, physical and mental issues that ASR patients present with (P5–P8, P10):

…essentially we’re trained to going ‘what’s the reason for presentation?’, ‘why you here?’, ‘do you really need to be here?’ (P2)

They are not aware maybe that the NHS is snowed under and is struggling…and are hopeful that they can have it fixed pretty quickly here, but unfortunately nobody’s getting fixed pretty quickly here. (P8)

P12 describes that because senior doctors must maintain an overview of the department, they are less likely to see ASR patients as they are often more time-consuming to manage (P12):

Maybe that’s why, as a consultant I see less of them, I think now, because I avoid picking them up. They get discussed with me. But I would not go and see them. (P12)

Participants also perceived that the subsequent long waits and overcrowding associated with EDs in the UK currently are likely to be confusing and exacerbating for ASRs (P2, P6, P11). P8 highlights that the overcrowding meant that there was often a lack of spaces in the ED to provide ‘privacy and dignity’ to female ASR patients in cultural dress-wear (P8).

Cultural issues were not emphasised by participants when asked and did not feature heavily in discussions with the main cultural difference described relating to gender norms, for example, female patients requesting a female doctor (P3, P5, P8, P10, P11). Participants did however highlight concerns over health system literacy. Many participants described ASR patients’ lack of system literacy impacting on their care as illustrated below (P2, P8–P12):

They don’t know where they can attend. They don’t know about NHS24, they don’t know about the Out Of Hours. And I think sometimes it’s the first thing, first port of call, is they will come to us here. (P2)

… I do understand that health care systems are really different and what they’ll experience from whatever country they come from to the experience in Scotland would be. (P5)

You got someone, who’s needing follow up with the GP [general practitioner], I find that that’s often very difficult. One to communicate how our health system works, if they’re the first few times experiencing the situation and then two to actually trust that there are the processes in place or services. (P1)

…they come across with the expectation that you do all the investigations required to come up with a diagnosis as similar to their own country. (P11)

According to many participants, this perceived limited system literacy among ASR patients may result in unachievable expectations when attending the ED (P2, P3, P8, P11). Some participants felt that this not only led to ASR and medical staff frustration but may delay ASRs receiving the right healthcare (P4–P5). Participants also admitted their own lack of knowledge, for example, in terms of what community care and services were available for ASR patients (P1, P3–P6, P12). None of the participants had received any training or were aware of any guidance in relation to caring for ASRs (P1–P12):

On our guideline page how much is there about it, hardly anything, plenty about child protection, plenty about asthma, plenty about all your main presentation. There’s no guideline on refugees, in children or adults. (P2)

The perceived barriers cause more problems than the real barriers. (P4)

You only seem to find out how to get something done when you have to get something done. (P4)

I can’t say there’s specific training in the department for this, there isn’t. I think it’s just like your morals as a nurse, lead you to do the right thing. (P5)

Transition in care

Safe discharge is a critical component of caring for patients in the ED: ‘it’s not just a case of, you know, OK. Cheerio. That’s you you’ve been discharged’ (P7). This can be more risky in ASR patients due to a language barrier and the lack of language-specific information leaflets outlining, for example, under what circumstances to return to the ED (P3, P5). Participants also expressed concern that ASR patients may be lost to arranged follow-up from the ED due to limited system literacy and concerns about integration with primary care as well as a lack of financial means, social support and transport knowledge making it difficult for them to attend follow-up appointments (P1, P2, P4–P8, P10–P12). This added complexity and risk leads many to have a lower threshold to admit ASR patients to hospital as outlined in the quotes below:

…where is this [discharge] letter going?; is there anyone on the other end?; does the patient have the skills—language, financial whatever—to be able to link into this entire system, to understand what needs to happen next for their own health. (P1)

I always find myself with language barriers, cultural barriers, issues with risk of loss to follow up. Those things create a lower threshold to admit or lower threshold to scan or lower threshold to intervene on first attendance… (P4)

…we don’t have it translated into a language for them to refer back to. So they’re relying on them memorizing what you’re telling them, which can be a higher risk depending on what the medication is. (P5)

Participants had varying views and experiences when it came to connecting ASR patients with other services. Some participants expressed that the often unique ASR challenges meant that services like social work or mental health did not know how to manage these patients (P1, P5). Others, however, saw no unique challenges connecting ASR patients to other services as highlighted below (P3, P7, P9):

We’re all singing off the same hymn sheet. (P7)

We have challenges with all services for all people these days. (P10)

[Social Work] take this into account that these are asylum seeker…they kind of speed up the process for them. So I think they should take a credit for that. (P11)