Introduction

Nurses in acute psychiatric care encounter young adults and children who have fled their country of origin without the company of their parents or other adult relatives. In 2015, 35 369 unaccompanied refugee minors arrived in Sweden (www.scb.se/en/). Most stated their country of citizenship as Afghanistan, Syria, Somalia, Eritrea, or Iraq. This was a sharp increase compared with the previous years. As in many European countries, Sweden has seen increased support for anti-immigration politics, with right-wing populists receiving 17.5% of the popular vote in the 2018 general election. Public debate has centred on describing immigration as a burden, and young unaccompanied refugees have been accused of manipulating and taking advantage of the system. The Swedish Society of Nurses has been an active voice in advocating the right to care as a fundamental human right.

A recent review of the literature reported a significantly higher prevalence of mental health difficulties (e.g. PTSD, depression, and anxiety) in young unaccompanied refugees compared with the general Western population (von Werthern et al. 2019). The suicide rate among young unaccompanied refugees in Sweden is regarded as ‘very high from both a national and an international perspective’ (Mittendorfer-Rutz et al. 2020, p. 316), and young unaccompanied refugees are overrepresented in psychiatric inpatient care (Ramel et al. 2016).

Research from the perspective of young unaccompanied refugees describes specific challenges in relation to psychiatric care (Majumder et al. 2018) and calls for person-centred, recovery-oriented approaches to care (Jarlby et al. 2018; Majumder et al. 2015). However, the realities of acute mental health settings challenge recovery-oriented practices (Solomon et al. 2021). Nurses experience acute psychiatric care as entailing a conflict between what nurses think they should be doing and what they actually can do (Gabrielsson et al. 2016; Graneheim et al. 2014; Molin et al. 2016; Söderberg et al. 2021; Solomon et al. 2021). Nurses in psychiatric care are at risk for secondary traumatic stress, compassion fatigue, and burnout syndrome (Mangoulia et al. 2015). Secondary traumatic stress and burnout in mental health professionals have been linked with working with persons experiencing traumatic symptoms (Singh et al. 2020). The focus of this study was specific challenges nurses face when caring for young unaccompanied refugees in acute psychiatric care.

Background

Compared with other refugees, young unaccompanied refugees constitute a vulnerable group as they lack the support and the protection of their parents or other adult relatives (Maioli et al. 2021). Young unaccompanied refugees are more exposed to traumatic events and show a higher frequency of psychiatric morbidity compared with accompanied refugee minors (von Werthern et al. 2019)). In a systematic review of risk and protective factors of mental health in young unaccompanied refugees, Höhne et al. (2020) identified number of stressful life events as a prominent risk factor. Stressful life events can involve pre-migration and migration events such as deceased parents, exposure to war traumata, exposure to violence, physical assault, and injury, but also post-migration experiences of cultural daily hassles, discrimination, and having your age disputed. Other risk factors identified by Höhne et al. (2020) involved female gender and low support accommodation. Protective factors for young unaccompanied refugee’s mental health included individual competences such as cultural competences, high levels of everyday resources, and language skills. Other protective factors involved receiving social support and having contact with family members (Höhne et al. 2020). In a review of mental health outcomes of young unaccompanied refugees, Bamford et al. (2021) came to similar conclusions as they identified lack of social support, poor language skills, and experiences of discrimination and daily hassles as important predictors of outcomes.

Mental health support should acknowledge young unaccompanied refugees’ vulnerabilities and resilience by emphasising ‘safe recovery, assessment of complex social needs, and prompt psycho-social care’ (Maioli et al. 2021, p. 6). However, young unaccompanied refugees report predominantly negative views of mental health issues and services (Demazure et al. 2021; Majumder et al. 2015).

To the best of our knowledge, no previous research has focussed on nurses’ experiences of caring for young unaccompanied refugees in acute psychiatric care. Kallakorpi et al. (2018) described nurses’ experiences of caring for immigrant patients in psychiatric units and found that nurses expressed distrust and doubt in asylum seekers’ experiences and reasons for seeking care. Nurses also described cultural conflicts where patients’ relatives were considered both resources and hindrances in recovery. Strategies to deal with stressful situations in the care of immigrant patients included trying to understand the situation from the patient’s perspective, taking a humoristic approach, and distancing themselves from the asylum-seeking process (Kallakorpi et al. 2018). Nurses further believed that care should include flexibility towards cultural habits, be family-oriented, gender-sensitive, engaging and relational, respectful, and involve the use of interpreters. Hultsjö and Hjelm (2005) assessed problems experienced in the care of immigrants in a study involving nurses at a psychiatric intensive care unit. Nurses described problems relating to patients believed to simulate psychiatric symptoms in order to affect the asylum-seeking process, but also difficulties in assessment related to cultural differences. Gender roles could be perceived as problematic, as patients might need to receive care from staff of the same gender. Staff also described problems with unexpected behaviours related to cultural differences, such as refusal to eat and drink, passive behaviour, communication problems due to language barriers and difficulties finding suitable interpreters (Hultsjö & Hjelm, 2005).

Rationale

Further knowledge on acute psychiatric care for young unaccompanied refugees from the perspective of nurses can help inform nursing practice and contribute to developing practice environments that support safe quality care.

Aim

This study aimed to describe registered nurses’ experiences of caring for young unaccompanied refugees in acute psychiatric care.

Methods

The study used a qualitative descriptive design, involving content analysis of semi-structured interviews. While qualitative description serves to provide straight descriptions of phenomena (Sandelowski, 2000), analysis of text always involves some degree of interpretation (Graneheim & Lundman, 2004). Qualitative content analysis allows for the analysis of manifest and descriptive content as well as latent and interpretative content (Graneheim & Lundman, 2004).

Data were collected in Sweden from November 2019 to January 2020. All authors, two women and one man, were nurses experienced in acute psychiatric care. At the time of the study, the first and third authors were working as assistant professors in nursing. The second author was working as a nurse in acute psychiatric care while pursuing a master’s degree in mental health specialist nursing. The study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Tong et al. 2007).

Participants and procedures

This study used purposive sampling, which allows the inclusion of participants with specific characteristics and features (Higginbottom, 2004). Participants were recruited through postings in social media targeting nurse working in psychiatric care. Nurses with experience in caring for young unaccompanied refugees in acute psychiatric care were asked to visit a webpage giving information about the study. For this study, we understood ‘young unaccompanied refugees’ to mean young adults, adolescents, and children who arrived in Sweden as unaccompanied refugees before age 18 but might have been older when having contact with psychiatric care. Thus, nurses with experience from both adult and child and adolescent psychiatric care could participate. Eligible nurses were asked to give their informed consent and provide their contact information through an online form. Eleven nurses agreed to participate in the study and were contacted by the authors. They received oral information about the study and were given the opportunity to ask questions. One of the 11 nurses turned out to lack experience in acute psychiatric care, leaving ten study participants.

Participants’ age varied from 26 to 64 years (mean 46.9). Three were men and seven women. Two were general nurses, while eight were nurses specialized in psychiatric care. Length of experience in psychiatric care varied from one year to 43 years (mean 17.95). Length of experience working as a registered nurse varied between one and 45 years (mean 17.55). The experiences shared in the interviews were mainly drawn from working in adult psychiatric inpatient care (n = 6), adult psychiatric emergency departments (n = 2), child and adolescent inpatient care (n = 2), and child and adolescent emergency departments (n = 1) in different parts of Sweden. Participants’ experiences mainly referred to caring for male adolescents from Middle East and North African countries.

Interviews

Data were generated through individual, semi-structured interviews (Kvale & Brinkmann, 2009). The authors developed an interview guide containing general questions about experiences in caring for young unaccompanied refugees (e.g. What have you done that has been helpful for young unaccompanied refugees?). There were also questions aimed to target participants’ experiences dealing with trauma (e.g. Do you take an interest in how young unaccompanied refugees’ previous experiences affect their current well-being?) and cultural aspects of care (e.g. Do you take an interest in young unaccompanied refugees’ beliefs about mental health and psychiatric care?). The first author conducted six of the interviews via telephone, while the second author conducted four face-to-face at participants’ workplaces. To our knowledge, no one else was present during the interviews. Some participants knew the authors as former colleagues or teachers. The length of interviews varied from 21 to 63 min (m = 35.5). All interviews were audio-recorded.

Analysis

Interviews were transcribed verbatim and analysed using a method for inductive qualitative content analyses described by Graneheim and Lundman (2004) and Lindgren et al. (2020). Interviews were read as a whole and divided into meaning units and coded by the third author. Starting with a manifest descriptive approach, codes were discussed between the first and third author and then categorized in several steps. Continuing with a more interpretive approach, we then formulated three sub-themes and one theme describing nurses’ experiences. Following Lindgren et al. (2020), we understand themes to reflect a higher degree of interpretation and abstraction. Participants were not asked to provide feedback on transcripts or findings.

Ethics approval and informed consent

The Swedish Ethical Review Authority approved the study (dnr 2019-04149). The study adhered to ethical principles of informed consent, voluntariness, and confidentiality.

RESULTS

We identified one theme: learning your limits and three sub-themes describing nurses’ experiences of caring for young unaccompanied refugees in acute psychiatric care: feeling powerless but doing what you can; taking a stance in a politicized environment; and being frustrated and in need of support.

Learning your limits

The main theme, learning your limits, suggests that caring for young unaccompanied refugees meant understanding and managing one’s limitations as both a nurse and a fellow human being. Nurses’ experiences revolved around issues of what they could or could not do for young unaccompanied refugees, and a recurring pattern in nurses’ stories was the need to negotiate and justify the boundaries of one’s own ability to help.

Several nurses shared stories about specific patients that left lasting impressions. Talking about these experiences evoked strong emotions and, although years had passed in some cases, they still questioned whether they had done the right thing and if they had done enough. Other nurses conveyed a more pragmatic approach, as they stated what could and should be done as a matter of fact, suggesting that they had come to accept the limits of what they could reasonably do to help young unaccompanied refugees.

Feeling powerless but doing what you can

A recurring theme in nurses’ description was nurses feeling powerless, as the help they can offer is limited and temporary and cannot change what really matters for young unaccompanied refugees – the absence of family, their traumatic past, and their uncertain future. Still, nurses’ experiences also entailed what they actually can do and stressed the importance of appreciating that. This sub-theme adds to the main theme, learning your limits, as it highlights that nurses need to come to terms with what can and cannot be achieved in caring for young unaccompanied refugees.

Not being able to affect the asylum process, waiting for a decision or waiting for the police to come evoked feelings of being powerless. Nurses described not partaking in such situations when it hurt them too much. Nurses described not being able to control the process, yet being the ones having to deal with the consequences:

I can’t influence the decisions, so it’s like operating in a vacuum or that you are like… one of those puppets that you pull the strings on… #2

Nurses described experiencing feelings of hopelessness relating to not seeing any improvement, having difficulties communicating and the specific needs of young unaccompanied refugees: not having a home, not knowing the language, and not knowing their way around society. Nurses described it as heartbreaking to witness patients’ suffering and not being able to help. Such feelings of hopelessness sometimes became unbearable and persisted after they returned home from work.

When the care you provide lacks a goal, and you know it is pointless, you don’t see any improvement, and you can’t communicate with the patient, something happens with the person providing care… #3

Nurses also stated that young unaccompanied refugees’ admissions were usually quite brief, and they were discharged quicker than other patient groups. They also expressed that young unaccompanied refugees being without a residence permit made the treatment and support options after discharge limited. When talking about the specific needs of young unaccompanied refugees, nurses often addressed the lack of a social network. The absence of family and connections meant they lacked support and basic security in life. Some nurses believed this was a major reason for young unaccompanied refugees seeking acute psychiatric care. Discharging them to their old environment meant that young unaccompanied refugees would be back where they started.

Nurses also described that young unaccompanied refugees often did not need acute psychiatric care at all, but rather the reassurance that what they were experiencing was a perfectly normal response to their life situation and not life-threatening. However, nurses also described the significance of taking the time to listen to young unaccompanied refugees’ concerns, showing an interest in their situation and the value of being able to at least tend to basic physical needs and provide a safe place. One nurse described:

Sometimes it can be helpful to offer a break from life… to get some peace and quiet and find out what really needs to be done, and then they can continue with someone in outpatient care… #8

Nurses experienced a lack of competence and knowledge on trauma, which added to the feeling of not being able to help. This could result in an unwillingness to engage young unaccompanied refugees and their experiences. While nurses typically stressed that acute psychiatric care was not the place for trauma treatment, they emphasized the importance of being aware of the impact of trauma and not avoiding the topic:

It’s different for everyone, but the essence is the same… to engage and listen and be present when… these experiences return to them… … no matter how many traumatic events you have experienced… it is important that somewhere there is an adult who might be able to nurture a seed of hope… #5

Nurses also described caring in a constant state of uncertainty, as neither nurses nor young unaccompanied refugees are able to affect the decisions of government agencies and social services, for example, regarding the asylum process. Typically, young unaccompanied refugees also risked being relocated from one day to the next. Although their housing and company were often perceived as chaotic, it still represented some security and a home. Nurses thus felt a need to act as patients’ advocates in interacting with other authorities. They described difficulties getting information about young unaccompanied refugees’ background and in collaborating with other service providers. This was partly due to separate systems for documentation but also due to a lack of competent staff in supported housing facilities. Nurses also acknowledged that the resources of psychiatric care are limited and not adapted to the needs of young unaccompanied refugees. Nurses described long waiting lists for outpatient treatment, a lack of services specializing in refugees, and a lack of trauma treatment.

One thing nurses did was try to communicate and connect. They described challenges connecting with young refugees, primarily relating to not sharing a common language. Instead, they relied on body language, interpreters, translation apps, or staff who spoke the same language. Finding means of communication was considered essential for connecting and building trust. This was especially important, as many young refugees were believed to have had traumatic experiences in general and negative experiences regarding psychiatric care in specific, making the use of coercive measures harder but more important to avoid. Nurses found it challenging but possible to convey compassion and engagement through body language:

Everybody’s different… but I believe what is most important is to find that connection point so that they feel… respected and safe where they are… #5

Nurses described making adaptions related to young unaccompanied refugees’ cultural beliefs when needed, like letting them talk to male staff if they were uncomfortable talking to women. However, these adjustments were described as the standard approach towards all patients and not specific for refugees and something always accommodated ‘within reasonable limits’. Nurses described being aware that young unaccompanied refugees might have feelings of fear and shame related to traumatizing and stigmatizing experiences of psychiatric care and that flexibility and adjustment might be needed to not add to these.

Doing what you can was also a matter of valuing the small things. Nurses described trying to focus on what works, such as thinking about the one patient for whom they had been able to make a difference, rather than the nine patients they had failed. Nurses reflected on everyday actions of seemingly limited significance as potentially meaningful and important. One nurse described:

I had to accept that for this person, I might be able to do something small like putting on an extra blanket, but nothing more… and that is hard…… I can’t change what’s big, but I can ease what’s small… I believe that way of thinking has helped me not to become bitter towards the system… like my colleagues who quit their jobs… #3

Doing what you can also involved paying attention to and appreciating small signs of progress in the process of developing a trusting relationship or improvement in young unaccompanied refugees’ conditions, like making eye contact or the young person accepting food or drinks. One nurse described how a patient later confirmed that who was present in the room made a difference, even though he was unable to make contact and communicate at the time, and that he had appreciated what he called a ‘warmth’ in the doings of staff.

Taking a stance in a politicized environment

A recurring theme in the nurses’ stories was that of a polarized work environment where staff members’ political opinions affect how they react to, talk about and sometimes, their treatment of young unaccompanied refugees. We chose to interpret this as nurses’ practice environments being politicized. This sub-theme contributes to the main theme, learning your limits, as it highlights how nurses need to be clear about what behaviours they can and cannot accept in caring for young unaccompanied refugees.

Nurses described that it was important for them to stand up for the dignity and rights of young unaccompanied refugees – to take a stance. This involved dealing with overt and covert racism as well as calling out general deficiencies in care. Nurses associated co-workers’ negative attitudes towards young unaccompanied refugees with racist views and prejudice but also lack of knowledge and feelings of frustration. Nurses challenged what they believed was inappropriate remarks during rounds and reports:

I basically feel good about it [calling out racism]… but if I haven’t said anything, I might go home and regret it… and then I think about it more than if I have said something… #6

Nurses described how staff divided into factions taking different approaches and voicing differing opinions regarding young unaccompanied refugees. These approaches and opinions were believed to often be dependent on staff members’ political beliefs. Nurses described how political opinions tended to prevent staff from keeping an open mind and how this would have a negative impact on care. Staff members would be accused of ‘being naive’. Conflicts surrounding the care of young unaccompanied refugees were not always specific for this group but related to, e.g. high staff turnover and communication problems.

Nurses described three major approaches amongst staff. Some would accept and try to make the best of the situation; ‘it is what it is, and there are rules’. Some of these nurses were described as old and weary and content with doing what they must and nothing more. Others were emotionally engaged and believed that ‘something must be done’. Many of these eventually had to go on sick leave, and some had chosen to leave psychiatric care altogether as they could not bear how people were treated. Nurses described how they would lay awake at night thinking about work.

Nurses also described how staff that advocated a restrictive immigration policy assumed that young unaccompanied refugees faked psychiatric symptoms. One way of dealing with this was to not assign staff with negative attitudes to work with young unaccompanied refugees. Negative views on immigration would reflect poorly on nursing practice. Patients were made to wait as a ‘punishment’, be met with disrespect, or avoided. One participant recalled a situation:

I am thinking about a couple of older nursing assistants I used to work with… they could be very… saying very clearly that no I am not going in there because I think it’s wrong that he’s in here… why don’t we throw him out… #3

Nurses also described the use of interpreters as being limited and mainly restricted to communication related to medical treatment, leading to young refugees often being denied the opportunity of meaningful everyday interaction with nursing staff. This was believed to increase the risk for coercive measures and discriminatory practices.

Being frustrated and in need of support

Another persistent pattern in nurses’ experiences was experiencing and dealing with feelings of frustration and the need for clinical supervision and support from colleagues. This sub-theme further adds to the main theme, learning your limits, as it brings forth nurses need for support in establishing and managing morally justified boundaries in relation to young unaccompanied refugees.

Nurses described how dealing with conflicting demands made them feel frustrated. Working with young unaccompanied refugees evoked a lot of strong feelings, and they often felt the urge to take patients home with them. At the same time, they regarded this as unrealistic, as ‘you cannot save the whole world’. They perceived ‘losing your boundaries’ as a risk when working with trusting relationships and something they needed to be able to handle.

Nurses described feeling frustrated when they knew things they could not share with the young unaccompanied refugees, for example, that a deportation was to occur on a specific date. Several nurses used powerful expressions like ‘betrayal’, feeling like a ‘traitor’, or ‘partaking in a hostage situation’ in regard to these situations. Nurses also described experiences related to coercive treatment that left them feeling like they had done something wrong and violated the patient. To deal with such experiences, it was important to ‘remain focussed’ and believe in what you do, and sometimes you had to say no:

It is wrong, what we are doing… it really feels like a violation, and I have intubated before, but I won’t do this… and so it was decided that he would receive intravenous fluids instead… #2

Nurses also expressed a lack of feedback, leaving them not knowing what happened to young unaccompanied refugees after discharge. They were thankful for the rare occasions when they received information about how things turned out.

Nurses described clinical supervision and the ability to reflect with colleagues as important when caring for young unaccompanied refugees. Nurses needed support in dealing with questions of right and wrong. These questions typically related to withholding information about and assisting in sending off young unaccompanied refugees. The use of coercive measures also raised ethical concerns. Staff members suspecting that young unaccompanied refugees were being manipulative would prompt nurses to initiate supervision. However, one nurse stated that staff who held anti-immigration attitudes did not feel a need for supervision, as they failed to appreciate the ethical dimensions of these aspects of care.

Nurses emphasized the crucial significance of support from other staff members. Feedback from colleagues was also important for knowing when they had overstepped professional boundaries.

Discussion

Overall, our findings describe nurses’ experiences of caring for young unaccompanied refugees in acute psychiatric care in one theme: learning your limits and three sub-themes: feeling powerless but doing what you can; taking a stance in a politicized environment; and being frustrated and in need of support. Previous research on nurses’ experiences of caring for immigrants primarily reported on difficulties related to cultural differences and communication and how nurses might distrust immigrants (Hultsjö & Hjelm, 2005; Kallakorpi et al. 2018). Our findings provide new knowledge on how nurses are affected by the moral distress involved in caring for young unaccompanied refugees and how acute psychiatric care is affected by anti-immigration attitudes.

Our findings describe nurses’ experiences of feeling powerless but doing what they can when caring for young unaccompanied refugees. These findings highlight the power of mental health nursing, as well as its limitations. Our findings especially exemplify how nurses do small things that might contribute to patients’ health and well-being. Topor et al. (2018) describe how small things as words, gestures, and actions can improve a person’s sense of self and play an important role in recovery-oriented mental health practice. Our findings suggest that in the absence of a shared language, or if the patient is unwilling or unable to communicate, nurses’ perseverance in trying to establish contact, the use of body language or simple acts of compassion become a crucial part of nursing care.

Our most important findings describe mental health nurses’ experiences of caring in a politicized environment. From a historical perspective, it is evident that psychiatric nursing practice does not operate in a vacuum, unaffected by the wider societal context. Psychiatric nurses have been accomplices in the Nazi mass killings, disguised as ‘care’ of people with mental health conditions (Hoskins, 2005), and psychiatric care has played a prominent role in the ‘treatment’ of political dissidents (van Voren, 2016). These experiences imply that nurses cannot take an apolitical approach to nursing practice – at least not if nursing is to uphold its standing as a profession grounded in professional values and ethics. Our findings suggest that care of young unaccompanied refugees might turn acute psychiatric settings into focal points for intersecting and opposing political ideologies. This includes mental health staff expressing racist views and engaging in discriminatory practices. We believe that in such cases, mental health nurses are morally and professionally obliged to take a stand and, as McKeown and Mercer propose, be ‘actively engaged in the vanguard of resistance to racism, discrimination and fascism’ (2010, p.158). Gabrielsson et al. (2016) suggested that nurses who are unable to take personal responsibility for the patient as a person might respond by creating a physical and emotional distance between themselves and patients and redefining their responsibility as technical and instrumental. We suggest that some of the inpatient staff described in our findings as enacting a discriminatory or racist agenda might have undergone such a distancing process. Thus, nurses who wish to avoid becoming radicalized bigots might need to protect and nurture their moral sensibility, even when this means engaging with persons suffering the consequences of severe and multiple trauma in seemingly hopeless situations. Luckily, our findings also give some directions for how this can be accomplished in a sustainable way; that is, nurses need to focus on what they actually can achieve in their nursing practice, and they need support in doing so.

In our findings, nurses described experiences of being frustrated and needing support when caring for young unaccompanied refugees. We suggest that this frustration might best be understood as nurses experiencing moral stress. Ohnishi et al. (2019) argue that morally sensitive nurses might be good at identifying ethical issues but lack the ability or resources to solve them. To counteract moral stress, nurses need support in managing ethically difficult situations rather than denying or ignoring their moral compass. As echoed in our findings, Jansen et al. (2020) describe nurses who implement coercive measures, knowing it is the wrong thing to do, as exposed to severe moral distress, and how nurses who choose to carry out such orders out of loyalty to the prescribing physician might suffer additional moral stress. This also suggests a lack of professional autonomy, further adding to nurses’ moral stress and feelings of frustration, anger, sorrow, and lack of meaning (Jansen et al. 2020). As nurses caring for young unaccompanied migrants acknowledge that they are unable to magically conjure a family or residence permit out of thin air, it becomes more important for them to recognize and value the therapeutic potential of recovery-oriented, caring mental health nursing (Gabrielsson et al. 2020). These results stress a need to understand nursing as a reflective practice and recognize the value of nurse leadership, clinical supervision, and peer-to-peer support. For nurses to be able to learn their limitations, that is, develop a plausible understanding of what they can and cannot achieve in caring for young unaccompanied refugees, nurses need to be able and willing to reflect critically on nursing practice. These findings also stress the importance of developing trauma-informed approaches to care within recovery-oriented models (Isobel & Edwards, 2017).

The main theme, learning your limits, suggests that nurses struggle to accept the things they cannot change and change the things they can. As suggested by Reinhold Niebuhr (Shapiro, 2014), this may require serenity, wisdom, and courage. Nurses need the wisdom to realize what they actually can achieve in caring for young unaccompanied refugees. They also need the courage to do what they can do – even when this means challenging physicians’ orders or calling out racist colleagues. For this to happen, nurses need serenity in terms of time and a safe space for reflection and collegial support. Good nursing practice in psychiatric care includes being able to take personal, moral responsibility for the patient as a person. We suggest that by focussing on what they actually can do, e.g. ‘the small things’, nurses who care for young unaccompanied refugees are able to take responsibility and thus counteract some of the moral distress without distancing themselves from the patients’ suffering. By relying on the transformative power of mental health nursing (Gabrielsson et al. 2020), nurses might be able to reduce moral stress without reducing their moral sensibility.

Study limitations

The research team included people who have been publicly outspoken about the importance of nursing and nurses embracing basic humanistic values and people with an immigration background. This might have affected who chose to participate in the study and what attitudes and values nurses felt comfortable sharing during interviews.

Conclusions

This is the first study describing nurses’ experiences of caring for young unaccompanied refugees in acute psychiatric care. Findings highlight the potential and limitations of mental health nursing, the importance of nurses’ reflection and peer support, as well as the importance of viewing the roles and responsibilities of mental health nurses and nursing in a societal context. Nurses can make a difference for young unaccompanied refugees in acute psychiatric care. However, in doing so, nurses need support in realizing what they can and cannot achieve.

Relevance for Clinical Practice

It is important to recognize moral sensitivity as an asset in the care for young unaccompanied refugees in acute psychiatric care. Services need to develop strategies for supporting nurses in providing sustainable person-centred care for young unaccompanied refugees. Nurses should enact professional values and call out racist and discriminatory language and practices. Nurses also need to appreciate the value of small things in supporting well-being and recovery.

Acknowledgements

The authors would like to thank the study participants for sharing their time and experiences.

REFERENCES

Bamford, J., Fletcher, M. & Leavey, G. (2021). Mental health outcomes of unaccompanied refugee minors: A rapid review of recent research. Current Psychiatry Reports, 23 (8), 1– 11. https://doi.org/10.1007/s11920-021-01262-8 Corona Maioli, S., Bhabha, J., Wickramage, K. et al. (2021). International migration of unaccompanied minors: Trends, health risks, and legal protection. The Lancet Child & Adolescent Health, 5, 882– 895. https://doi.org/10.1016/S2352-4642(21)00194-2 Demazure, G., Baeyens, C. & Pinsault, N. (2021). Unaccompanied refugee minors’ perception of mental health services and professionals: A systematic review of qualitative studies. Child and Adolescent Mental Health. https://doi.org/10.1111/camh.12486 Gabrielsson, S., Sävenstedt, S. & Olsson, M. (2016). Taking personal responsibility: Nurses’ and assistant nurses’ experiences of good nursing practice in psychiatric inpatient care. International Journal of Mental Health Nursing, 25 (5), 434– 443. https://doi.org/10.1111/inm.12230 Gabrielsson, S., Tuvesson, H., Wiklund Gustin, L. & Jormfeldt, H. (2020). Positioning psychiatric and mental health nursing as a transformative force in health care. Issues in Mental Health Nursing, 41 (11), 976– 984. https://doi.org/10.1080/01612840.2020.1756009 Graneheim, U.H. & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24 (2), 105– 112. https://doi.org/10.1016/j.nedt.2003.10.001 Graneheim, U.H., Slotte, A., Säfsten, H.M. & Lindgren, B.-M. (2014). Contradictions between ideals and reality: Swedish registered nurses’ experiences of dialogues with inpatients in psychiatric care. Issues in Mental Health Nursing, 35 (5), 395– 402. https://doi.org/10.3109/01612840.2013.876133 Higginbottom, G. (2004). Sampling issues in qualitative research. Nurse Researcher, 12, 7– 19. Höhne, E., van der Meer, A.S., Kamp-Becker, I. & Christiansen, H. (2020). A systematic review of risk and protective factors of mental health in unaccompanied minor refugees. European Child & Adolescent Psychiatry, https://doi.org/10.1007/s00787-020-01678-2 Hoskins, S.A. (2005). Nurses and National Socialism - A Moral Dilemma: One historical example of a route to euthanasia. Nursing Ethics, 12 (1), 79– 91. https://doi.org/10.1191/0969733005ne759oa Hultsjö, S. & Hjelm, K. (2005). Immigrants in emergency care: Swedish health care staff’s experiences. International Nursing Review, 52, 276– 285. https://doi.org/10.1111/j.1466-7657.2005.00418.x Isobel, S. & Edwards, C. (2017). Using trauma informed care as a nursing model of care in an acute inpatient mental health unit: A practice development process. International Journal of Mental Health Nursing, 26 (1), 88– 94. https://doi.org/10.1111/inm.12236 Jansen, T.L., Hem, M.H., Dambolt, L.J. & Hanssen, I. (2020). Moral distress in acute psychiatric nursing: Multifaceted dilemmas and demands. Nursing Ethics, 27 (5), 1315– 1326. https://doi.org/10.1177/0969733019877526 Jarlby, F., Goosen, S., Derluyn, I., Vitus, K. & Jervelund, S.S. (2018). What can we learn from unaccompanied refugee adolescents’ perspectives on mental health care in exile? European Journal of Pediatrics, 177 (12), 1767– 1774. https://doi.org/10.1007/s00431-018-3249-0 Kallakorpi, S., Haatainen, K. & Kankkunen, P. (2018). Nurses’ experiences caring for immigrant patients in psychiatric units. International Journal of Caring Sciences, 11 (3), 1802– 1811. Kvale, S. & Brinkmann, S. (2009). InterViews: Learning the craft of qualitative research interviewing, 2nd edn. Los Angeles, CA: Sage Publications. Lindgren, B.M., Lundman, B. & Graneheim, U.H. (2020). Abstraction and interpretation during the qualitative content analysis process. International Journal of Nursing Studies, 108, 103632. https://doi.org/10.1016/j.ijnurstu.2020.103632 Majumder, P., O’Reilly, M., Karim, K. & Vostanis, P. (2015). ‘This doctor, I not trust him, I’m not safe’: The perceptions of mental health and services by unaccompanied refugee adolescents. International Journal of Social Psychiatry, 61 (2), 129– 136. https://doi.org/10.1177/0020764014537236 Majumder, P., Vostanis, P., Karim, K. & O’Reilly, M. (2018). Potential barriers in the therapeutic relationship in unaccompanied refugee minors in mental health. Journal of Mental Health, https://doi.org/10.1080/09638237.2018.1466045 Mangoulia, P., Koukia, E., Alevizopoulos, G., Fildissis, G. & Katostaras, T. (2015). Prevalence of secondary traumatic stress among psychiatric nurses in Greece. Archives of Psychiatric Nursing, 29 (5), 333– 338. https://doi.org/10.1016/j.apnu.2015.06.001 McKeown, M. & Mercer, D. (2010). Mental health care and resistance to fascism. Journal of Psychiatric and Mental Health Nursing, 17 (2), 152– 161. https://doi.org/10.1111/j.1365-2850.2009.01489.x Mittendorfer-Rutz, E., Hagström, A. & Hollander, A.-C. (2020). High suicide rates among unaccompanied minors/youth seeking asylum in Sweden. Crisis, 41 (4), 314– 317. https://doi.org/10.1027/0227-5910/a000636 Molin, J., Graneheim, U.H., Ringnér, A. & Lindgren, B.M. (2016). From ideals to resignation–interprofessional teams perspectives on everyday life processes in psychiatric inpatient care. Journal of Psychiatric and Mental Health Nursing, 23 (9–10), 595– 604. https://doi.org/10.1111/jpm.12349 Ohnishi, K., Kitaoka, K., Nakahara, J., Välimäki, M., Kontio, R. & Anttila, M. (2019). Impact of moral sens