The Rules: Nursing in a Detention Centre

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4 May 2004: The Ethics of Nursing in a Detention Centre - "The whole reason we have detention centres is political, it would be naïve to think otherwise. 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...."

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Nursing in a Detention Centre

An edited version of this article was recently published in Australian Nursing Journal (Feb 2004, vol 11, no 7, pp 32-33) under the title "Frontline nursing in detention". The text of that version is posted here.

by Michael Hall
former Nurse at Curtin IRPC
August 2002

This was my first impression of a detention centre. It was the first time I had been in a detention centre. I was at Curtin IRPC which stands for Curtin Immigration, Reception and Processing Centre and is 45kms from Derby on the mothballed Curtin air force base in the Kimberley in Western Australia's far north.

Curtin was originally established to temporarily accommodate about 300 people due to the sudden rise of boat people arrivals exceeding the capacities of the permanent detention centres. Soon Curtin's population doubled and then doubled again with the original detainee accommodation being supplemented with tents. Camp development began in a frenzy and was continuing when I left over two years later.

It was only a few years ago that I was taking a break from my usual emergency nursing focus to be a graduate midwife at Derby hospital. The local Path lab recruited some of us nurses to assist them as venepuncturists at the detention centre for health screening of new detainees. That was in late 1999.

When I left Curtin for the last time earlier this year I was the Health Services Coordinator, answering directly to the Centre Manager and then the Health Services Manager in the Australasian Correctional Management (ACM) Sydney Head Office.

When I started we had a handful of nurses, one locum doctor and one demountable building for us all to work from while using detainees as interpreters. When I left we had 4 demountables, a multidisciplinary team of health professionals and access to professional interpreters. Nurses are the front line and the heart of health care in detention centres.

The health manager is called the Health Services Coordinator and this is a nursing position. Whomever fills this position is the team leader for not only the nurses but also the counselors, psychologist and doctor. This person ensures that not only is health screening done but that ongoing health care is provided.

At Curtin I was lucky to be able to develop and be a part of a team of professionals. The nurses and others in the health team must 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 case loads daily. If you're lucky your doctor can perform as a GP as well as an emergency physician. If not then the nurses will, so you will need to have the skills of a remote area nurse along with your Critical Incident skills.

* * * * * *

Before I continue I must comment on how politics has become an integral part of detention nursing. Not withstanding this fact, and whatever the politics of detention are, the simple fact remains that while mandatory detention remains government policy there will be a need for nurses to provide quality health care in these detention centres.

Unfortunately the Australian community is polarised in regards to the issue of refugee versus illegal immigrant. Some people, including friends of mine, think detention centre clients are all Al Queda members while other people, including some other friends of mine, believe they are all helpless refugees.

Nurses don't like being the piggy in the middle. The more we talk about nursing in detention centres the more ammunition we seem to provide to extremists. How? Because people will tend to to chose what they remember we say.

If I talk about manipulative clients or e.g. the detainee at Curtin who I was told allegedly talked to a guard about coming terrorist attacks in America only a week before September 11, then the One Nation supporters lap it up.

If I talk about the photographs I've seen of Taliban torture, executions of women and children or the brutal behavior of ACM guards and immigration (DIMIA) officials, then the refugee activists say they are all poor refugees.

You cannot be a detention centre nurse and not deal with politics. That is the first rule of being a detention nurse. Today I wanted to talk about being a nurse.

Unfortunately no one can separate the nursing role from Party politics. Everything you do at your work, you must expect to be examined by some human rights committee or be talked about in parliament. Leading up to the last federal election I was constantly reminded by my superiors that the detention issue had the potential to bring down the Federal government.

What we learnt is that it could also save the government. The second rule of being a detention nurse is that anyone who enters a detention centre is there because they have entered the country illegally or violated their visa requirements.

According to the Federal government you are not a refugee until they say you are. Processing of refugee claims are supposed to be completed within fourteen weeks of arrival. Some take up to six months. These determinations are made by the Department of Immigration, Migration and Indigenous Affairs - DIMIA.

Those still in detention after this time are either awaiting deportation or are appealing their visa refusal. This issue is very relevant to the detention nurse. You are an impartial health practitioner and are forbidden by DIMIA to comment on visa matters. Meanwhile you need to be aware of your clients case status because it will influence how you deal with them and may indicate what their state of mind may be. This information is handy for example when dealing with suicidal clients.

You are an employed by Australasian Correctional Management (ACM). The immigration department, known as DIMIA, contracts ACM to run the centres while still having their own officers on site to oversee operations. As a nurse you deal with health issues not immigration issues.

Therefore the third rule of being a detention centre nurse is to know your brief. The duties of a detention nurse are quite clear. You are to provide for all the health care needs of your client group while they are in detention. Your employer is a private company so the focus begins with minimising expenditure.

This strategy has developed some limitations recently because the human rights groups and refuge advocacy groups have learnt what specific questions to ask about a particular client's care.

DIMIA and ACM are now acutely paranoid about these 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.

Why should we pay for anything when the State will when he is released, I was told. By February I am told to start organising services. For a child who allegedly has never had any specialised care we logically started with arranging specialist health assessments eg an Occupational Therapist assessment.

These have to be booked with the local health services with the obligatory waiting time. In March, after the mother had complained to DIMIA about herself and her disabled child being kept in detention, a senior ACM manager comes to a Health Clinic staff meeting where I am abused in front of my staff for not having done anything "since December".

The lesson here is that there is no need to provide the health care required unless there is a chance that that DIMIA &/or ACM can come under criticism. This also raises the interesting point that it is actually in the interests of the ill and disabled to enter Australia illegally because you then have a chance of a visa. Not a better chance - A chance.

If the same person applied from overseas they would have no chance of a visa because DIMIA would simply not accept anyone that may cost them money to provide services to e.g. health care. You may remember the gentleman who last year set fire to himself on the steps of parliament house. He did so to protest the fact that the government would not accept his daughter into Australia because she has cerebral palsy. The government does not dispute this - it admits it as it is now a vote winner.

The fourth rule of detention nursing is that whatever DIMIA wants they get. For example ACM has a policy that I was instructed to enforce, by my health line manager in head office, that states that if a DIMIA official wishes to view a detainees medical health record then they need to obtain the detainee's written permission. I informed the local DIMIA official who told me in no uncertain terms that I was to instead do what he says.

Soon the inevitable request for a medical health record came to which I requested DIMIA provide evidence of the detainee giving permission. In full view of ACM and DIMIA staff, as well as detainees, this career immigration official yelled abuse at me, threatened to have me permanently removed from the premises and then, while physically threatening me, he proceeded to remove medical health records from the clinic.

At this time I was told by the on site senior ACM manager to give any immigration officer whatever they wanted whenever they wanted it despite our company's policies and despite my direct instructions from ACM Head Office. Despite the obvious bullying and intimidation I never got support from ACM.

My health line manager did attempted to address this issue for me but but to no avail as senior ACM management do not want to offend DIMIA. The detention contract comes first - staff are expendable. My written request to the Nurses Board of Western Australia, hand delivered to a Board member, about my legal responsibilities relating to health record storage and access, went unanswered.

DIMIA will always do what they want to do. ACM can be fined by DIMIA if there are breaches of contract. My on site manager told me once how DIMIA was fining ACM for using detainees as interpreters. The incident reported was allegedly when some new detainees arrived at Curtin that the ACM manager used one of them, who could speak English, to translate for him as he spoke to the new arrivals.

What my ACM manager told that had really happened was that it had been the DIMIA manager who had asked the new arrivals if any could speak English. When some came forward the DIMIA manager used them to translate for him and then gave them over to the ACM manager to use.

This was the same DIMIA manager who then fined ACM for using detainees as interpreters. The point was pretty irrelevant for me because ACM head office had authorised a payment schedule for detainee workers which included using detainees as interpreters in the Health Clinic.

This was despite me complaining that it was unprofessional/unethical etcetera and that we should at least have phone lines installed for telephone interpreters as there were (and still is) insufficient on site official interpreters. I was ignored. DIMIA can behave in any manner and get away with it.

My days with ACM were finally numbered when I was posted to Christmas Island. While there I refused to be the escort nurse for two pregnant women who were being forcibly separated from their husbands and children so that they could be taken to the mainland to have their babies.

Their families were not allowed to accompany them because once on the Australian mainland they would be able to apply for a visa. Breaking up families meant that the wife would voluntarily leave the mainland to reunite with her family. These ladies would. Especially because while on the mainland they are kept in isolation from other detainees. They were also not told their legal rights. This separation and isolation of pregnant women is wrong on so many levels: ethically, professionally, medically - it is appalling that it could happen.

But I was told later by an ACM health manager that yes - my refusal to do the escort was a difficult ethical decision that I had made but I'm a manager now and I have to rise above such things. So here I have an ACM health manager I have to rise above my ethics. I have to follow the instructions of a politician despite all the scientific research that states such a separation at such a time for such a duration is grossly negligent and could even be construed as abuse.

I think I'll stick to my ethics. To top this incident off, when these ladies did arrive at Curtin, I was asked by a DIMIA official if I was going to provide any care for them. Ignoring the insult, I stated that just because I objected to DIMIA transferring these women without their families, that does not mean that I would contribute to their distress by refusing them health care. These ladies were not the problem - DIMIA's unethical treatment of them was.

This is where we get to rule number five. You must maintain your links with your professional organisations. If it was not for the advice and support of the Western Australian branch of the Australian Nursing Federation I could not have stayed so long in detention nursing to become the longest serving Health Services Coordinator.

The WA ANF has always since provided me with any assistance I requested quickly and efficiently. Not only legal or professional advice but emotional support too. I've come home at 2 am after a riot, checked my email and send off a query to the State Secretary. Before I've logged off I've got a reply. That is pretty bloody good service. Since leaving detention nursing and becoming a house dad I am still supported by my professional body - the WA ANF.

Final rule. Everything that goes wrong is the fault of the individual, everything that succeeds is a result of company policy. There is a culture of blame in detention nursing that is entrenched and unavoidable. As a detention nurse you are the classic weak link. You are a care bear and therefore you are not to be trusted.

If there was a leak then it must have been the nurses. The detention officers will always accuse a nurse to protect themselves even if it means being creative with the truth. We had a depressed detainee who had requested to be put into a quiet room separate from others.

We complied thinking that a little time apart, with free access to his friends may be beneficial. Unfortunately this man's depression increased, and his appetite decreased dramatically. He was monitored closely by the health staff and detention officers. He was not on a hunger strike. One evening he was unwell and the detention officers called for a nurse to visit him. Because of the man's depression the nurse also called the counselor to attend. The detainee's mouth was very dry and although willing to drink he said he was too uncomfortable. He could not even manage to take crushed ice.

The nurse said if he was unable to drink or eat that he may need intravenous (IV) rehydration. She was then called away to attend someone else. After talking to the counselor for a while the detainee presented to the health clinic requesting intravenous rehydration. The nurse contacted the doctor and the detainee was rehydrated.

Now if this man had been on a hunger strike, DIMIA would have been notified. If he had refused to eat and drink for so long that his health had been compromised the nurses would have informed DIMIA and the doctor could have obtained permission from the Federal Immigration Minister for permission to forcibly rehydrate him. This was not such a case.

Never the less as this man was rehydrated a detention officer rang DIMIA and informed them that a hunger striker had been rehydrated. The result of this ACM officer not bothering to ask the nurse what she was doing was that the DIMIA official stormed into the health clinic, verbally abused the nurse (in front of detainees and other ACM staff) for not informing them about this "hunger striker" and how dare she rehydrate him "without Ministerial permission"!

The DIMIA official then took the detainees medical health record without permission (and while the nurse was still using it) and stormed out. The health record was later found in the Shift Managers office where the DIMIA official had left it lying about unattended. When ACM called an official investigation, as a result of the DIMIA complaint about breach of process, I was told by the acting senior ACM manager, at a managers meeting, that I was at fault but that the investigation would be impartial.

The investigating officer eventually found that Policy had not been breached and that blame could not be put onto one person. When the senior ACM manager returned he discussed the issue with me. He told me not to take it personally and that some things I just have to accept and then move on. He then went on to inform me that the investigating officer was incorrect in his findings and that he had informed the investigating officer what his findings should have been and will be.

These were that my nurses and I were at fault for, apart from other things, not notifying him and DIMIA that this man was on a hunger strike. Therefore the nurses including myself would be receiving disciplinary letters and that DIMIA will then be satisfied that ACM had corrected the fault.

This gross manipulation of an official investigation was appalling. To crucify someone just to satisfy DIMIA's complaint was unacceptable. I submitted an official complaint about this as well as the DIMIA officials bullying and harassment of my nurse. The new investigation (undertake by my health line manager from Head Office) exonerated my nurses and I but again nothing was done about the bullying and harassment conducted by DIMIA officials.

I mentioned that I'm a house dad now. Not a domestic engineer or such rubbish euphemism - I'm a house dad. No I don't find it boring. You'd think so after my doing four years of acute A&E nursing, studying and then practicing midwifery and then being at the coal face of detention nursing for over two years.

I've actually become a resource person for detention nurses who ring me for legal direction and yes, emotional support. Needless to say my legal advice consists of referring people to the ANF but I can also help with interpreting the ACM policies to help nurses defend themselves.

Unfortunately there is no organisation like a Detention Nurses Association for nurses to meet with and discuss professional or industrial issues. If there are local organisations for prison nurses then I suggest that detention nurses join these, as well as the ANF, of course. After all detention nurses work for a company whose main focus is gaols, as their name states: Australasian Correctional Management.

I'm finding my support role decreasing as more and more nurses who know me leave ACM. That is not to say that the debriefing has finished. Mine is ongoing six months later. I'm sorry I couldn't give a totally dispassionate speech about the joys of detention nursing. I am here to give you my experience.

There were some detainees that I wish to never see again while there were some beautiful clients that I have met and yes, that I miss looking after. But I have friends like myself who were discarded by ACM when we became burnt out or perceived as a liability just as I also have friends who have resigned in disgust at the management practices of ACM, DIMIA and the politicians dictating healthcare.

Many nurses have been worn down by the constant harassment and bullying in the work place from detention officers, DIMIA officials, ACM management and also from detainees. Most of all we are tired of the fact that we cannot give the care we wish to.

In that we are just like so many other nurses.

Thank you.