The Change Created by Syrian Asylum Seekers in Health and Nursing Services Provided in Hospitals: A Qualitative Study

ABSTRACT


INTRODUCTION
Contemporary warfare often pivots on power dynamics, and the bitter conflict in Syria, which commenced in March 2011, serves as a stark reminder of this shift (Nacar, 2015).The resultant internal strife forced millions to abandon their homeland and seek refuge in various nations, such as Turkey, Lebanon, Egypt, Iraq, and Jordan (AFAD, 2013).This mass displacement, and the subsequent influx of Syrian asylum seekers in these countries, brought about new challenges in several sectors, most notably in healthcare services.
Turkey, which began providing health services for Syrian asylum seekers in the province of Hatay on April 29, 2011, quickly became a key sanctuary (Nacar, 2015).Over time, these services expanded to other provinces housing asylum seekers, offering healthcare free of charge, not only within border provinces but also in hospitals across the country (Ministry of Health [SB], 2013).These services were rendered in three primary ways.Initially, injured civilians crossing the border were transported to the nearest hospital via 112 emergency health services and, if necessary, referred to secondary and tertiary health centers or private hospitals (Akkoca, 2015).Secondly, primary, and preventive health services were offered within and outside temporary accommodation centers.Lastly, Syrians received free treatment in secondary and tertiary public and private hospitals, facilitated by referrals from accommodation centers located in border provinces.
Despite these comprehensive measures, the sudden and vast influx of refugees stretched the healthcare system to its limits, particularly in border regions.While the number of hospitals seemed adequate, they struggled to cope with the escalated demand due to physical infrastructure constraints and resource scarcity (Çiçek Korkmaz, 2014;Orhan & Gündoğar, 2015;Savaş et al., 2015).Furthermore, hospitals were unprepared to tackle such a crisis, leading to an overall drop in service quality.
Health and nursing services have been disproportionately affected by the refugee crisis.Yet, the literature primarily focuses on the health issues of the asylum seekers post-war, often overlooking how the hospitals and their services have adapted to this new demographic reality.Thus, this study aims to fill this research gap by exploring the changes in health and nursing services in hospitals in the border region triggered by the arrival of Syrian asylum seekers.The key research question is: 'How did Syrian asylum seekers affect health and nursing services?'"

Study Design
The study was designed and applied according to the qualitative research model of semi-structured interviews.

Study Participants
The study population comprised all hospitals in the border region where asylum seekers were situated.To ensure maximum diversity, care was taken to include nurses working in different positions across various units from seven hospitals that constituted the study population.Specifically, these nurses were employed at a university hospital, five private hospitals in the province of Gaziantep, and a state hospital in the province of Kilis.These locations were chosen due to the high density of Syrian asylum seekers and ease of access.The inclusion criteria were: (1) being a nurse providing care to Syrian asylum seekers, (2) having a work experience of at least one year in the hospitals, and (3) willingness and enthusiasm to participate in the individual interviews.The exclusion criteria, on the other hand, were: (1) not providing care to Syrian asylum seekers, (2) having less than one year of work experience in the hospitals, and (3) unwillingness or inability to participate or complete the interviews.A total of 68 nurses, who volunteered to participate in the research and provided care to Syrian asylum seekers, were selected.The data collection phase of the study was concluded after 68 interviews when it was decided that the data had become repetitive and data saturation had been reached.

Data Collection
Data was collected with the Semi-Structured Interview Form, developed by the researchers with the help of the opinions of three experts (Çiçek Korkmaz, 2014;Kenny & Hull 2008;Scannell-Desch & Doherty, 2010).Interviews were conducted by the primary investigator (AÇK) and the study investigators were female.The first author is a research assistant with a Ph.D. student and with previous experience of trained conducting interviews.Second author is a PhD and professor.The study data was collected between July and December 2015, the peak period of the Syrian civil war and of the arrivals of Syrian asylum seekers in Turkey.The interviews were held in the manager's room, meeting room, or nurses' room, depending on the participants' preference.At the beginning of the interview the participants were verbally informed about the purpose of the study, how long the interview would take, the reason for the recording and that all data obtained from the interview would be confidential.Points that were deemed to be very important were noted separately in writing.Each participant was interviewed once and no one left the study.The interviews took 30 to 85 minutes.

Data Analysis
Content analysis was used in the analysis of the data.The data obtained was evaluated by two researchers independently from each other and each researcher determined the meaning that arose from each word and sentence and these meaningful expressions were grouped as codes, main themes, and themes.The obtained main themes, themes and subthemes were later gathered together and re-evaluated by the researchers and the process was finalized with their mutual agreement.The participants' statements were written down, as well as their interview number and the institution they worked in.The Consolidated criteria for Reporting Qualitative research (COREQ) was used to report findings (Tong, Sainsbury & Craig, 2007).The coding was as follows: the first interviewed person of the state hospital was coded as 'SBH1', the first of the university hospital as 'UH1' and the first of the private hospital as 'OH1'.

Ethical Consideration
Study data was collected after the ethics committee approval from ethics committee and the institutional permissions from the seven institutions where the research was conducted was received.Written consent was obtained from all participants who accepted to participate in the study after reading them the informed voluntary participation form.The volunteer participant information form was presented in writing and their written consent was obtained.The participants were reminded that they could turn off the recording devices used during the interviews at any time.

RESULT
Examination of the personal and professional characteristics of the participants showed that 61.7% had a bachelor's degree, the mean age was 30.59 ±7.34 (19-52) years, the total time working in the profession was 9.21±7.72(1-33) years and the time working in the institution was 5.23±6.07(1-32) years.The data was analyzed under two main themes; change in health services and nursing services, and seven themes.

Theme 1: Change in Health Services
The first main theme contains the change in health services after the asylum seekers arrived.These changes describe changes in the physical structure and hospital equipment as well as the general health services provided by the hospital (Table 1)."…before there were two beds each in the rooms and only one bed each in the rooms at the end of the corridor.Patients in the single rooms at the end of the corridor even received special services.Now we have rooms with three beds with other things and seats standing in between so they are squeezed in.The single rooms at the end of the corridor now have two beds and there are no such things as private rooms anymore.Therefore, patients are lying very close to each other, the distance between them is at most 20 cm-30 cm (SBH, 22)"."Syrian patients caused an increase in the number of beds and this number increases even more in intense periods of the war (UH, 9)" "The additional building is very good.Our old building was insufficient (SBH, 7)".

Shortage pf medical consumables
"…There is a great difference between the number of materials used in a Turkish patient or other patients and the number of materials used in Syrian patients.The number of materials used such as sponges, antiseptics and wound care units are two to three times higher for Syrian patients… (OH, 17)".

Decline of hygiene conditions
"My unit is the biggest in the hospital, it has 50 beds and a very long corridor.As it is mixed and because the number of Syrians is too high it makes it difficult to oversee the unit and clean it (SBH, 10)".

Turn into a louder environment
"They turn the volume of the television, which is in another language, all the way up….they also talk too loudly (UH, 17)"."As far as I could observe in the hospital, they sleep during the day and are awake at night; they also listen to music until 3-4 in the morning… (UH, 9)".

Change in Healthcare Delivery
İncrease in the number of patients admitted "Three times, 90 wounded patients came at once and one time, 100 wounded patients came at the same time.After that, groups of 20-30-40 patients came but these were very bad days for us… (SBH, 14)".".... there was a lot of change, especially in the emergency clinics, the birthing clinics and surgery units (UH,1)" Increase in bed occupancy rate "… Syrian patients are hospitalized for a long time, for example 3 to 6 months and even a year.Therefore, the bed capacity for the locals inevitably decreased.Turkish patients, who have an infection and will be released in three days, must wait in the emergency room because there is no space because the treatment of the Syrian patients takes too long (UH, 5)".
Very serious cases come to our clinic.Patients require severe and long-term treatments from such injuries as gunshot wounds.No beds are left empty when Syrians are operated on and if no beds are left, the surgeries of Turkish patients are postponed (UH, 19)".
Change in patient's care needs (health needs priority and an intensive-long treatment process) "We accept seriously injured patients from Syria and their hospitalization times are very long.They often occupy a bed for 15 days to one month and we cannot send them away before they have recovered.This way their hospitalization times can be very long… (UH, 18)"."70% of Syrian patients have severe chronic diseases.They are usually hospitalized due to kidney failure or heart disease and almost all of them have nutritional deficiency.Patients with nutritional problems do not recover for at least 12 days.These are the patients that stay in the hospital for a long time… (UH, 5)".

Change in the patient admission process
"…Some of our patients came with different IDs.While the patient came with the name 'A' during the first visit, he came with the name 'B' during the second.That one person who identified himself with different names created a problem for us.The same tests were repeated for this patient and we did what already been had done (UH, 9)"."Since there is a significant decrease in both outpatient clinics and the number of doctors, Turks have started to turn to private hospitals.If we have four doctors available, one is sent to the containers, one is looking after Syrians, and only one or two are left in the polyclinics trying to care for the Turkish patients.This causes longer waiting times or Turkish patients are unable to get an appointment… (SBH, 15)".

Theme 2: Change in Nursing Services
The second main theme includes how nursing services have changed during this process and the conditions in which nursing care is provided.Upon examination of the interviews, the themes of inability to implement the nursing process, insufficient resources, inability to ensure patient safety, inability to ensure employee safety and problems regarding working conditions were created (Table 2)."…The variety of patient profiles we see has increased.Before the war, we had patients who were hospitalized with the diagnosis of LVH (cerebrovascular diseases), maybe with hyperglycemia, maybe with hypoglycemia, or because of a traffic accident, or with other diagnoses.These were the diagnoses we knew mainly, but when the war happened, of course, this was the first time we encountered both nursing diagnoses and doctor diagnoses.(SBH, 24)"."We inserted a catheter because one patient required fluid follow-up.We would insert the catheter but the patient would remove it.This situation greatly affected the patient's treatment.We could not decide on the appropriate applications because we could not track the patient's status (UH, 16)", Failure to implement nursing care "…As we often disagree, it remains in the dimension of follow-up and treatment.They have difficulty in understanding us, and we cannot explain.Sometimes the translator is not enough.Therefore, we cannot effectively implement nursing care.(UH, 14)".Failure to evaluate nursing care "What happened to the applications we made to Syrian patients, how did it happen, did it pass or not?We don't know.We are having a communication problem.They can't transfer it to us and we can't follow it."(SBH, 6)

Insufficient resources
The lack of human resources "Since the number of Syrian patients is high and the number of nurses is low, I do not think that we are providing adequate care for our patients.…(UH, 4)" "…They divided the pediatric unit into Syrian and Turkish units but the number of nurses was divided into two, so there were initially 10 nurses and now only 5 in each, no additional personnel was hired (SBH,12)".

The lack of material and equipment
"…As a patient, he does not know if he has allergies, if he knows, he cannot tell us and if he is able to tell us through a translator, the translator may not be able to translate correctly.Because we have little information about the patient, we do not know if there will be complications or if the patient has allergies.Some patients even develop an allergy due to analgesics (SBH, 1)"."After the Syrians arrived, our biggest problem was infections.They have serious infections and VRE (Vancomycin Resistant Enterococci) grows in each patient.This stems from failure to communicate (UH, 5)" "Keeping the patient alive is a priority for us, as patients arrive in severe conditions.Issues such as developing bed wounds or if the patient is going to fall out of bed, are secondary concerns.(SBH,22) "Keeping the patient alive is a priority for us, as patients arrive in severe conditions.Issues such as developing bed wounds or if the patient is going to fall out of bed, are secondary concerns (SBH, 22)"."Especially the patients who are not able to turn and position even if they are amputated, also suffer from pressure sores.The patient has a fracture, for example, we have a Syrian patient, and he has fractures all over his body.There is no pressure sore at the moment as we cannot position it continuously, but it is expected to happen.(OH, 16)" İncrease in drug administrati on errors rate "…As a patient, he does not know if he has allergies, if he knows, he cannot tell us and if he is able to tell us through a translator, the translator may not be able to translate correctly.Because we have little information about the patient, we do not know if there will be complications or if the patient has allergies.Some patients even develop an allergy due to analgesics (SBH, 1)"."We had a problem in terms of time in drug applications.Too many patients, too many treatments.We delay medication hours (UH,15)"."… there were misunderstandings about giving oral medications to the patient (ÜH,7).

Inability to ensure employee safety
The lack of physical conditions "The physical ventilation of the hospital is not working.It negatively affects our work.There is both smell and temperature (SBH, 6)"."…This is a special service for the war-wounded and sick.…we do not have a treatment room, a treatment room was not considered.Made with very simple materials, the ceiling leaks every time it rains.SBH, 13)" İncrease in chemical risk factors "…we were working in the emergency room and we got the information that the wounded would come in.The wounded came in and after that we got a bomb warning.A patient was mistakenly transferred with a bomb.Of course, those bringing in the patient were also Syrians...If a bomb were to explode, a lot of people would die (SBH, 7)"."..When mass injuries come, all sides are cleaned with bleach, up to the walls, and the cables of those monitors are cleaned well.Our environment is definitely cleaned with bleach every day and we start the day.(SBH,19)."

İncrease in biological risk factors
"A friend of ours got measles last year.Because of this situation, we have all been vaccinated.The patient has hepatitis but we don't know (SBH, 4)"."Our cut and piercing injuries increased, our pregnant nurses were exposed to increased risk of infection…(UH, 1)"."The patient is not breathing properly, …the patient arrives bloody and it is difficult for us to get it together.The patient is coming in bloody and I have to clean him… (SBH, 6)"."…we get patients with severed arms, full of blood, patients that were buried under debris, whose head has split open, whose scalp has separated from their skull so that the brain is visible, patients with intestines, liver or the stomach coming out, patients with bones sticking out from the body, and also patients with severed fingers due to hand grenades…(SBH, 22)", İncrease in ergonomic risk factors "…We have problems with our musculoskeletal system because we are constantly standing.We have neck and back pain and sometimes I cannot feel my legs after a shift.Recently, my friend was unable to pay attention due to fatigue, got dizzy and fell… (SBH, 6)"."…Diseases both psychologically and physically arose from the situation; varicose veins, herniated disc, and headaches as well as an increase in migraines, and sinusitis because we were under psychological pressure (UH, 1)", İncrease in psychosocia l risk factors "Your workload is increasing, you can't explain yourself, he doesn't understand you, your job stress increases, you can't get satisfaction, the number of your staff is missing and problems arise constantly.We are under stress from work (UH, 4)."If your communication with the relatives of the patients is not very good, this will disrupt our working environment and affect our working psychology.We have to work in a more stressful environment …" (SBH, 24)

Adverse working conditions
Increase in working hours and shifts "We work double our normal shift times.We are unable to rest.Because we work in shifts, it is important for us to properly rest.If we cannot rest, we cannot concentrate and we are unable to recover when we get sick (SBH, 6)".

İnability to use vacation leaves
"For example, an injured person comes into the emergency room and we call our colleagues from home…I cannot take a leave in this intense work environment".…So, you put your vacation off... (SBH, 16)" Cont..... "…We look after more patients but do not get a salary increase (SBH, 11)" "We do not demand anything as a fee, but there is nothing psychologically.I don't know, we haven't seen anything psychologically, whether it's activities or rewards.There was no psychological training or anything to encourage people in the hospital.(SBH, 2)."…Now, we don't see a different application, a different reward, a different honor, or something too much.People only do what they see fit according to their own conscience.(SBH, 18)" Manager and business pressure "Some of our managers tell us things like 'we do not own the luxury to get sick'.We work in inhuman conditions.Some of my colleagues have serious health problems that would prevent them from working but they are also put on extra shifts from time to time…(SBH,6) Negative impact on family and social life "…The condition of the injured people affected us a lot, psychologically.Then you don't have a lot of energy because I'm so tired and go home exhausted, you can't spare much time for your wife and children.If I have finished half an hour, an hour of food and dishes, I want to lie down and rest immediately.Our social life is almost gone, I don't want to go out.It feels like tiredness to me, going out, traveling.When you feel tired, you want to lie down and rest.We forgot about traveling, wandering.Of course, it was reflected in our family life in this way (SBH, 10)" The lack of safety "We see a lot of injured and dead people, which has an effect on us.We think about things like; will the war affect us, will it come to us, what happens if a bomb explodes here?Because sometimes a bomb comes in with the patient.We removed many bombs from patients… (SBH, 14)".

DISCUSSION
The arrival of asylum seekers has considerably affected health services in the region.It has led to an increase in service requests and bed capacity, shortages in equipment and materials, deteriorating hygiene conditions due to overcrowded hospitals, and increased noise levels within the hospitals.Efforts have been made to mitigate these challenges.The surge of Syrians arriving in Turkey and the rise in the number of patients seeking medical attention in border hospitals, including victims of mass injuries from the war zone, have led to high bed occupancy rates.These factors are considered the primary reasons for the change in general health services.Çiçek Korkmaz (2014) reported that the hospitalization rate of Syrian asylum seekers at Kilis State Hospital was 29% between 2012 and 2014.Similarly, Orhan & Gündoğar (2015) found that in 2015, between 30% and 40% of the total health services provided in state hospitals along the border were for Syrian asylum seekers.
These changes in healthcare services have directly affected nursing services.Notably, nurses had no prior experience dealing with war injuries due to firearms, leading to difficulties in determining the correct nursing diagnosis due to the complexity of the cases.It was seen that there was lack of knowledge about the care specific to these patients.This finding suggests that the ability to determine the correct nursing diagnosis for patients with severe conditions depends largely on the nurse's experience.In addition, the language barrier while communicating with the patient to determine their needs for a correct nursing diagnosis has another important effect.Paans, Nieweg, Van der Schans, and Sermeus (2011) reported in their systematic review that several factors influence the correct and common use of nursing diagnoses, including the nurses' education and experience, work environment, hospital policies, institutional resources, caregiver motivation, patient condition, and severe medical diagnosis.
The study participants identified A severe nursing shortage as a primary issue.It was revealed that hospitals that previously operated with an insufficient number of nurses continued to do so even after the arrival of asylum seekers.This shortage is attributed to multiple factors, including the increased patient load and a failure to take into account the increased workload when planning nursing work.Key factors affecting nurses' workload include the number of patients, the care needs of the patients, and tasks performed by the nurses outside of patient care (Yıldırım, 2002).A study by Dumit & Honein-AbouHaidar (2019) found similar impacts of the Syrian refugee crisis in Lebanon on nursing, nursing practice, and the healthcare system.
Between 2011 and 2013, when the war's effects were most intense, temporary assignments of nurses from other regions were made by the Ministry of Health to alleviate the workload and address the manpower deficit.This, however, was a short-term solution.It was revealed that the opening of new hospital units was planned without taking into account the existing resources or competence of the nurses, which affected the planning.Planning new hospital units without considering existing resources and nursing competencies further complicated the situation.During the war years, between 2011 and 2014, there was an increased rate of transfers, further reducing the number of nurses in hospitals.A total of 60 healthcare workers, including nurses, midwives, and health officers, requested reassignments (Çiçek Korkmaz, 2014).
Failure to ensure patient safety under the main theme of 'change in nursing services' is one of the issues that participants emphasized most.It was determined that the infection rate increased, and medication errors and pressure sores occurred more frequently after the asylum seekers arrived.Balkan (2016) reported that no routine infection screening was carried out for Syrian asylum seekers, that examinations were only performed with symptom-based diagnostic approaches, and that the necessary precautions were not taken when injured Syrians were brought to the hospital.It was determined that as a result of adverse effects on working conditions, the working hours and emergency shifts increased, the salary did not change despite the increased number of patients and workload, the hospitals did not have a reward system, the management and work pressure was intense, that family and social life were negatively affected by these conditions, and that safety could not be guaranteed.The lack of safety was especially emphasized under this theme.In interviews carried out in 2015, it was seen that their worries and fears that one day a howitzer or rocket would explode in Kilis province were real.Information that 25 people lost their lives and 367 houses were damaged by the Katjusha rockets from Syria to Kilis province between January 18 and October 2, 2016 were reported in the press.
The qualitative data obtained need to be more generalizable since they reflect the interviewees' perspectives.As the subject has not been examined in this before and because it is a problem specific to Turkey, it was difficult to establish a scientific publication basis for the debate.Since the number of asylum seekers worldwide is increasing daily, determining how asylum seekers have changed health and nursing services may be beneficial for future planning and improvements in migration situations.

CONCLUSION
This study represents a pioneering effort at the national level to explore the impact of Syrian asylum seekers, displaced by the civil war, on the health and nursing services in hospitals located in Turkey's border provinces.The findings of this study shed light on the transformation in health and nursing service delivery within hospitals that first received Syrian asylum seekers.
We found under the overarching theme of 'change in health services,' that the influx of patients into hospitals has increased, primarily due to Syrian asylum seekers and war-wounded individuals.Hospitals are striving to provide health services amidst high bed occupancy rates, which have led to changes in patient admission systems and care needs.This transition is significantly reflected in the nursing services offered.In regard to 'change in nursing services,' our research identified key issues.There has been a struggle to provide adequate nursing care due to resource deficiencies, resulting in a lack of patient and employee safety.Further, nurses' working conditions have been negatively affected by these developments.
This study highlights significant conclusions: the resource scarcity experienced by hospitals has resulted in serious challenges in healthcare service provision.It shows that the arrival of the wounded from the war zone has led to changes in working conditions and has impaired the assurance of employee safety.
Based on these findings, we suggest a strategic approach to address the challenges faced by the healthcare system amidst mass migrations.There should be improved planning, including resource allocation, for health and nursing services to accommodate the increased patient load without compromising on the quality of care.Further, measures need to be implemented to ensure the safety of patients and healthcare workers, and to improve working conditions for nurses.As global asylum seekers continue to rise, these considerations will become increasingly essential.
In conclusion, the study contributes valuable data that underlines the significant impact of asylum seekers on health and nursing services in border hospitals.As such, it provides a foundation for further research and policy development in this critical area.

Table 1 .
Themes and Sub-themes Obtained in Change in Health Services Main Themes

Table 2 .
Themes and Sub-themes Obtained Change in Nursing Services Main Themes to see the patient's epicrisis, I want to know what was done to the patient.At least I want to see the patient's history, the patient's history is not taken.It just says the bomb has exploded.Syrian patients have no history (SBH, 6)"."…They cannot give correct answers to the questions you ask about the patient's history and history.You cannot give adequate care to the patient when you cannot learn about situations such as the patient has a medication, he/she uses, he/she has any ailment, he/she has a problem with the previous surgery.The Syrian patient is in distress when he says he cannot express himself, and you cannot.For example, the patient has epilepsy and faints, and you can confuse him with preeclampsia, you do not understand why he fainted.When the patient comes to him and you talk a little, you learn that he has epilepsy because it is not something that comes out in the tests.…(SBH,8)This is one of the places where Syrian patients are dense.You allocate five minutes to other patients (Turkish patients) and 15 minutes to Syrian patients.In this case, it affects our nursing care, diagnosis, and nursing process.(UH, 5)".