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natural law; positivist law; hard cases; ronald dworkin; lon fuller; martin luther king jr.

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Introduction

In the context of the development of posttraumatic stress disorder (PTSD), depression, anxiety and several somatic (co)morbidities, unaccompanied minor refugees (UMRs) belong to a so-called "vulnerable" [ 1] high-risk group for these psychologically and psychiatrically relevant disorders [ 2, 3, 4]. Their experiences before and during migration and the fact that they enter receiving countries without family members can cumulate with other determinants of health, such as age (≥ ≤ 16 years), gender [ 5] and residential permit status. Protective factors and UMR supporting actions gain importance here and can be summarized as psychosocial care (PSC). European states, such as Belgium, the United Kingdom, Sweden and France, have reported a high increase in applications for asylum by UMRs [ 6]. In the years 2015 and 2016, Germany received the highest number of UMR asylum seekers (90% of them male) and according to the youth welfare offices the number of UMRs increased from 3000 in 2010 to approximately 45.000 in 2016 [ 7]. In 2018, the number of UMRs entering Germany declined to 12,201 [ 8].The current humanitarian crisis on the Greek islands and the statements of some European countries, such as Germany and France, suggest that the number of UMRs in 2020 and 2021 will increase again [ 9]. This review examines the PSC of UMRs.

Within the European context, PSC structures and the related policies differ greatly, making it difficult currently to standardise them. The supranational and national legal levels are, thus, legally binding, guiding and enforceable and can therefore be compared with each other, as for the German example (Table 1).

Table 1 Policies regarding PSC for UMR on European and German Level

The example shows the difference between EU-wide regulations and possible exclusions of PSC-relevant conditions within actual praxis. Given the 1989 UN Convention ofthe Rights of the Child, children are granted the right to adequate protection and humanitarian aid. The Charter of Fundamental Rights of the EU states that children are entitled to the protection and care necessary for their well-being, and all actions related to children must follow the best interests of the child. The German regulations of the youth welfare act include that every young person has the right to be supported in his or her development and be educated to become a self-reliant and community-oriented personality (§1 Abs. 1 SGB VIII). The Act was clarified in 2005 with the Child and Youth Services Further Development Act, which entitles UMRs for guardianship. The ambivalence of EU-wide and national regulations is evident in Germany, where residence status determines the possibility of a family reunion. The Europe-wide regulation specifies, in assessing the best interests of the child, Member States shall cooperate closely, taking due account in particular of the following factors: possibilities for family reunification and legal guarantee of family reunification[ 10]. In juxtaposition to this guarantee, the Residence Act of 2016, as part of asylum law in Germany, excludes persons eligible for subsidiary protection (to which UMRs can belong) from a family reunion [ 11].

PSC can be defined as services that give support within the psychological and social field and contribute to preventing the hardening of mental disorders and psychological distress. Thus, psychosocial care services include psychological counselling, therapy and psychiatric short- and long-term interventions. In this context, mental health is understood as "a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to contribute to his or her community" and implies psychological well-being and the absence of psychiatric disorders [ 12]. Alongside psychological and psychiatric support, PSC promotes integration and social participation because it aims to improve and stabilise the physical and mental state of health. The provision of support in bureaucratic procedures can serve as an example here [ 13].

The studies conducted in the German context show that PSC of UMRs is provisionally administered by emergency and refugee assistance [ 14] in so-called "clearing houses" [ 2] and legally administered by youth and social services. Furthermore, health service research has identified several cultural, legal, and structural barriers in healthcare access and utilisation for (adult) refugees [ 15, 16, 17]. UMRs have been scarcely studied in this context [ 5]. Most of the existing evidence comes from the psychological and epidemiological fields of health service research and underlines an increased need for PSC among UMRs [ 18, 19]. The legal, social and cultural mechanisms that form care structures have not yet been presented in a comprehensive way. The literature showed that psychosocial processes and mental health care are of great importance for UMRs and cannot be investigated separately.

Regarding the UMRs' access to PSC, questions on how this access is contextualised (e.g., legally) and how it functions in practice as well as which barriers exist, has not yet been asked in this scope. We know that due to local contexts, the UMRs' different personalities and diverging structural conditions, the UMRs' PSC access and utilisation is not extensively comparable. Therefore, the existing literature offers diverging selective analyses (e.g., concentrating on female UMRs and their specific health care needs), theoretical discussions and region-specific empirical findings. An overview on how PSC is generally structured and which barriers and beneficial aspects exist is so far missing. The following realist review (RR) examines contexts, mechanisms, and outcomes of PSC for UMRs and will enrich the existing body of literature by trying to analyse realistic processes. It thus synthesises the existing findings on UMRs PSC.

Methods

The RR methodology was applied to reveal the inner workings of PSC and its strategy to improve the mental, social and physical well-being for UMRs. Following the basic pillars of critical realism, by working with methodologically ideal-typical context-mechanism-outcome configurations (CMOs), a RR aims to unravel causal mechanisms [ 20, 21].

In this study, the realist approach investigates the mechanisms (M) of how and why PSC programs and contexts (C) may produce multiple outcomes (O) for UMRs. The term context in this regard denotes conditions, structures and cultures that may cause adverse or beneficial mechanisms. For instance, under asylum and youth care policies, the access of UMRs to a PSC may be hindered or fostered depending on the age and citizenship of the UMR [ 23]. Accomplished transformations that move from context to outcome or that are circular can then affect agency, relations and practices [ 22] because different factors are associated or cease to work. As an example, limited access to care services, such as regular psychiatric care, can lead to UMRs having to go to other care facilities. As ideal-typical constructs, realist CMO configurations are presented in a mechanism (M) that might result in different outcomes, including undersupply or the need for specific care strategies (O). For instance, in a given contextual environment, a certain UMR psychosocial context comprising asylum and youth care law alters care conditions and constraints, "which then triggers mechanism(s) that produce both intended and unintended outcomes. Intervention X may work well in one context but poorly or not at all in another context" [ 24]. An example is the undersupply that can occur when the treatment is not youth- or migration-sensitive.

Stage 1: identifying the review question

The question is how PSC works (C) and why specific mechanisms (M) determine (un-)intended PSC outcomes (O), conditioned by asylum and youth care policies.

Stage 2: formulating an initial theory

The underlying initial theory model serves as the first orientation tool of the method. As a starting point in our attempt to outline the contexts and conditions of PSC, it functions to subsequently compare the findings of the literature review. The theory aims to produce a hypothesis with an innovative character. The theory model contains a three-dimensional conceptualisation based on micro-, macro- and discursive levels. Thus, these three levels include subjective characteristics of UMRs and social phenomena in everyday life at the micro-level and political regulations that determine their PSC system at the macro-level. Discourses and stereotypes-depending on how something is talked about or defined-which form social life, comprise an intermediate level in the model (shown in the pyramid as a peak). (Fig. 1).

Initial theory on PSC for UMRs

The general division between micro- and macrostructural levels of PSC allows the inclusion of the UMRs' protective and risk factors, social conditions, societal surrounding (such as living conditions) and psychological health. All these phenomena arise and have effects on the micro-level as well as on the macro-level.

These macro and micro factors can be mediated by daily and specialised UMR-related discourses and concepts. Such a theory must reflect the PSC needs of UMRs and the context factors, including assimilation and acculturation theories [ 29]. The theory building offers a comprehensive sociological,process-related model that seeks to refine the key premises, general conditions and modes of operation of PSC.

First, the micro-level of the initial theory consists of predisposing factors, PSC needs and utilisation. Taking into account the variety of different spatial and gender-specific contexts, utilisation as a microsocial factor must be included in the preliminary considerations of an initial theory [ 30].

Second, within the theoretical framework, the individual level is fundamentally linked with macrostructural factors, such as health and migrations policies, on different regulatory levels.

Third, another element of the theory construct covers the discourses and concepts of PSC for UMRs and links micro- and macrosocial outcomes. Here, the theory aims at capturing intersections of individual, structural, and discursive contexts that influence PSC. This part is strongly inspired by approaches and recent debates of intersectionality and othering discourses that focus on public and migrant health [ 34, 35, 36]. The inclusion of intersectional perspectives enables the model to consider overlapping inclusions and exclusions, i.e., discrimination and privileges. The approach can also be helpful with regard to public and global health research that focuses on care situations for migrants and refugees [ 37].

Within the focussed discourses, othering denotes a sociopsychological differentiation process from people (or the self) in relation to the host community. In this process, migrants are perceived as "others" and as alienated from the in-group (e.g.,german host society).

For example, the sequential trauma concept (as part of special scientific discourses) that understands trauma as processual and contextual [ 38] everyday discursive events, such as othering and narratives about UMRs, are conceptually included. The barriers of PSC might then become effective on a general language-based, cultural or juridical level.

The first overview of the possible conditions and mechanisms of the PSC of UMRs now offers the starting point for the literature search. The theoretical considerations are first kept in mind and are presented again in the evaluation of the search results, which makes it possible to compare the preliminary considerations with the results. Therefore, the aim of the RR is to explain different findings from the literature on different theoretical bases and not to only use one initial theory as a basis for interpretation.

Stage 3: Searching and selecting primary studies

To refine the initial theoretical framework, based on a search query for empirical evidence dating from 2005 until 2019, the studies' search was performed between January and March 2019. The publication period was chosen because of the particular interest in the European migration context since 2005, the year when the council of the European Union published a directive on the minimum standards for the procedures for granting and withdrawing refugee statuses [ 39]. Since then, the directive has become effective as a set of common rules for dealing with asylum seekers across the EU.

Using the electronic databases Social Sciences Citation Index (Web of Science), PubMed/MEDLINE and GBV (German library network), the primary research articles and review studies were chosen and considered to be of the highest relevance to the scope and focus of the study. The RR focuses on the PSC situation of UMRs in Germany, not least due to Germany's special position as a receiving immigration country in 2015 and 2016. Still, the body of literature, which includes important theoretical approaches from the pan-European context, and empirical data are included.

Search terms pertaining to UMRs in all topics and fields in articles in the above-mentioned electronic databases were chosen and included. First, common acronyms for UMRs and Unaccompanied Refugee Minors as well as Unbegleitete Minderjährige Ausländer were searched in the following style: "UMR" OR "URM" OR "UMA". A second step included broadening the search by using fully written forms in a single search procedure: "asylum seeker OR asylum-seeking OR refugee OR migrant OR displaced OR Flüchtling OR Geflüchtet AND Minor OR young OR adolescent OR minderjährig OR junge OR youth AND Unaccompanied OR separated OR unbegleitet".

In total, 974 potentially relevant titles were imported into the electronic literature database (Fig. 2). The articles' exclusion due to their allegiance to the research period and the deletion of duplicates led to 517 left publications. Non-English or non-German articles were excluded ( n  = 5) because of the focus explained above, and the large majority of the screened evidence was published in peer-reviewed English and German language journals.

Flowchart Stage 5: appraising study quality

With regard to their relevance for the study scope and their matching against the exclusion criteria displayed in Table 2, these 517 titles and abstracts were screened and independently checked by HSU and EK. Based on the previously mentioned criteria, 448 studies were excluded, as the main focus of these studies was not UMRs, their mental health (as for psychological problems and psychiatric symptoms), their legal situation or the European context. The non-European evidence was excluded. The excluded literature mainly focused on refugees in general, accompanied minor refugees or on refugees in the South American and Oceanic contexts. Moreover, editorials, letters and commentaries were excluded.

Table 2 Inclusion and exclusion criteria used for the screening of the study's scope: inclusion/exclusion criteria

Stage 4: extracting evidence

Finally, 34 articles that contained empirical evidence of sufficient rigor and relevance were retained, and these articles were included in the extracting and synthesising process (Fig. 2). Studies on the psychological and mental well-being of UMRs were dominant ( n = 21). A MAXQDA document served as a variables' manager, by which for each article, eight categories were applied to document characteristics, such as study design, data or methods, journal or publisher, year, country, scientific discipline, relevance and rigor [ 21]. This document is provided in Supplementary file 2. To ensure collaborative and gender-sensitive insights, one male and two female sociologists, namely, HSU, EK and MM, interpreted the data. Furthermore, by collaboratively comparing the topics and theoretical approaches, the empirical evidence was checked against the theoretical frameworks, to potentially integrate it into a refined theory and final framework.

Stage 5: appraising study quality

The final screening of full-texts functioned as a quality appraisal process for the evaluation of relevance, rigor and outcomes. Using MAXQDA software [ 40], HSU openly and axially coded the extracted evidence, and after the content was allocated to codes within categories, EK and MM carried out a subsequent and collaborative review of the generated code and category system. Followed by qualitative ( n = 6), quantitative approaches ( n = 4), mixed-methods designs ( n = 3), and monographs ( n = 3), reviews and systematic syntheses ( n = 15) were used in the majority of the selected articles. The relevance of the selected papers was classified by the "thick/thin continuum" [ 21], which refers to a paper's density of evidence regarding CMOs that are relevant to the study's scope. Thick titles included rich and detailed accounts of relevant CMOs pertaining to PSC among UMRs, whereas thin contributions offered sparse data [ 21, 28]. Thin articles predominantly measured just one relevant aspect, such as psychological interventions for UMRs, without revealing much about mechanisms that could have mediated any observed effect and could have provided a wider context. By taking into account the rigor and richness of the evidence, the relevance of the selected papers was categorised as a thick, moderate or thin contribution [ 21, 28]. The multiple occurrences of the term "UMR" as well as the potential of the texts to provide extensive or specific knowledge about the sought-after topic's rigor and richness were measured constantly. Qualitative and mixed-methods studies tended to provide thicker evidence than did quantitative works, whose content was predominantly moderate or thin with respect to relevant CMO compositions (Supplementary file 2).

Stage 6: synthesising relevant and contradictory data with propositions

Four steps were taken to synthesise the final empirical evidence. First, based on the extraction of the interrelated CMOs-concepts explaining mechanisms-, the superordinated CMO propositions were formulated. As a kind of summary heading, these propositions did not entirely reflect all mechanisms, but they were "close enough to observed data to be incorporated in propositions that permit empirical testing" [ 41].

Third, the formulated sub-processes and mechanisms summarizing CMO propositions were again checked by re-reading the papers and considering the initial theory. Throughout the synthesis process, they were tested with primary evidence and against contradictory findings [ 21, 28]. Finally, HSU, EK and MM checked whether the evidence was used properly in the interpretative synthesis, and after discussions, all authors agreed upon potential misreadings and ambiguities [ 28, 42].

Results

Characterised by their interrelatedness, the dominant, multiple contexts, mechanisms, and outcomes (CMO propositions) turned out to be the following:

the intersections of transitions (e.g., of adolescence and migration);

the need for context-, culture-, and gender-sensitive mental and PSC; and

the undersupply within PSC (see Fig. 3).

For UMRs, the final PSC framework including contexts, mechanisms and outcomes

These contexts and outcomes are mediated by pre-, peri- and post-migratory stressors as well as care structures and are, moreover, influenced by overarching discourses and concepts (CMO proposition 4 in Fig. 3). They comprise adverse and beneficial mechanisms in the PSC of UMRs.

Proposition 1

If (C1) the processes of migration and adolescence define an intersection of transitions for UMRs, post-migratory stressors could be triggered (M1) and may lead to a need for psychosocial care (O1).

This intersection of transitions functions as a risk factor for PTSD [ 49] and at the same time demands multiple adjustment and coping strategies [ 46, 50]. Post-migratory stressors are multifaceted [ 51] and shape the UMRs' daily lives, psychosocial well-being and mental health; they include material, social and daily stressors as well as acculturational stress. Especially, constant negotiations with authorities and a general lack of residence stability can lead to the UMRs' lack of trust in the arriving societies and especially in its care systems [ 46, 52].

Proposition 2

If UMRs have a psychosocial care need (C2) and are confronted with deficient care structures (M2), an undersupply of the UMRs psychosocial health care (O2) could occur.

Social and political conditions of arrival are part of living conditions and post-migratory stressors that contribute to the already vulnerable and partially traumatised state of some UMRs [ 53, 58]. The arrival phase marks an important period in the processing of the experiences of settling in the new environment [ 51]. On the one hand, social and cultural adjustment is highly linked to the personal as well as the social background and motivation of the UMRs themselves and their attitude towards their new living conditions [ 46]; on the other hand, it is also linked to the existence of either welcoming or othering cultures within the arrival country [ 6]. The political contexts concerning the right to family reunification and the classifications of UMR countries of origin as safe or unsafe define further mechanisms [ 49, 52] that shape care contexts, as described above. Possibly undersupply and failures to recognise the UMRs' needs [ 46] and barriers to PSC can be reinforced by the general ambiguity between human and children´s rights and asylum law [ 49]. For example, within the German context, the conflict between the youth welfare legislation (SGBIII) and the German Asylum Laws (AsylG) put caregivers in disempowering situations, which consequently promote risks for PTSD chronification and the undersupply of PSC for UMRs [ 49, 52, 59]. Due to inappropriate legal conditions, there is a certain risk of administrative detention throughout Europe and especially Germany [ 60]. These conflicts relate to unclear responsibilities within youth welfare, questions concerning family reunions [ 61] and protection needs of UMRs [ 62, 63, 63]. Especially regarding the importance of the arrival phase as a time in which UMRs need to find stability and in the meaningful phase of processing traumatic events, their adjustment can be hindered or impeded by law-related ambiguities [ 51]. During this period, the need for psychotherapeutic or psychiatric interventions can be intensified. Low-threshold offers in these fields cannot alleviate the underlying structural conditions but can provide partial relief. Another outcome is gender and relates to gender-specific reasons to flee [ 44] (e.g., FGM female genital mutilation [ 49, 52]). One of the multiple reasons the female proportion of UMRs is relatively low in the arriving countries is the fact that girls face multiple dangers of sexual exploitation during their migration process and beyond (in Germany, of the total UMRs, girls comprised 8,6% in 2015 [ 52] and 10% in 2016 [ 44]). Because of gender-specific flight experiences and care needs in the arrival countries, girls have a vulnerability that forms a context. Due to male-specific or gender non-sensitive PSC strategies, female UMRs´needs are barely addressed and with that gender forms an outcome at the same time. Gender specificity also applies to acculturation processes and social roles, as women experience shifting gender norms and roles during and after their migration [ 64]: numerous different facets of transition can thereby be demonstrated in the case of female UMRs. The question of gender-specific care programs and their use by female UMRs could not be explained by the literature reviewed.

Proposition 3

The existing undersupply of psychosocial health care for UMRs (C3) and further adverse structural obstacles (M3) might lead to an urgent need for sensitive care strategies and concepts (O3).

Concerning the PSC structures and policies, again, the German context offers an example of the European experience of UMR care-specific realities. In 2015, the institutional and social structures in the field of youth welfare services, administration, schools and psychosocial centres faced the requirement for immediate establishment that was appropriate for new structures and for the consolidation of existing ones. Amongst others, these excessive demands were mediated and handled by individuals, such as counsellors of psychosocial centres and became part of interdisciplinary and provisional care networks [ 65].

Due to inconsistencies of structural conditions [ 58] (across regions and cities, administrative units with different population densities), there was a need for a mapping of the existing care structure across places and regions. Deprived regions and rural areas, in particular, had to overcome excessive demands resulting from shifting UMRs to institutions of established care structures within metropolitan areas (such as Berlin). This transfer resulted in excessive demands for well-established existing structures and an with that an undersupply of PSC for UMRs on the ground. Psychiatric institutions for children and young people, in particular, had to compensate for this undersupply situation [ 66]. In addition, high thresholds to care form barriers that might lead to missing diagnoses or possible chronifications [ 67, 68]. Those structural barriers include residency permits, persisting asylum procedures, unclear or inconsistent care practices, missing cost coverages, language barriers and the absence of language mediation and stigmatisation of mental health issues [ 69, 70, 71]. New care facilities are, therefore, needed and should comprise sustainable care, legal frameworks, the language and cultural skills of caregivers, clear and sufficient financing, time resources for personnel, and less administrative efforts for care processes and interventions [ 58].

Proposition 4

Everyday, lay and specialised expert discourses and concepts (C4) might have a (non-)protective effect on UMRs (O4) and should be approached in a context-sensitive manner (M4).

Discursive labelling and the contextual classification of UMRs are sociologically, empirically, legally and morally rooted [ 49] and render a connection of migration, migration policies, national legislation, international conventions and human rights standards with ideas about UMRs´ needs, legitimacy and hopes. Declaring the possible family reunion as a danger [ 61] and therefore strengthening othering processes [ 49], socially rooted narratives such as the concept of so-called anchor children (as children that are sent by their parents to improve the family´s economic status) contribute to the degradation of the social recognition of UMRs. Everyday discourses and narratives, such as the idea of so-called anchor children, may function as othering mediators [ 46] and frame UMRs with negative stereotypes [ 49, 51]. This may cause the UMRs psychosocial adjustment to be impeded, their own expectations for adjustment to be challenged and may even lead to self-othering [ 46]. Negative stereotypes and stigmatisation of mental disorders and psychiatric care can also reduce the mental health of UMRs and their use of services. Low-threshold PSC services can be the first step into mental health care and pave the way to recovery.

The overarching everyday and scientific discourses thereby in manifold ways shape the UMRs' PSC and their social positions. A frequently phrased and used framework, namely, the dichotomy of vulnerability and resilience, is common within psychological- and mental health-related publications on UMRs [ 6, 72] as well as the expert jargon. The ambivalence of these approaches and interpretations of UMRs becomes relevant when the consequences of their application are considered. A generalisation of the UMRs' resilience might lead to an overestimation of their capacities to process traumatic experiences. Short-term interventions, thereby possibly further on provoke chronification and unmet care needs. On the other hand, a generalisation of vulnerability might lead to an underestimation of the UMRs resources, strengths or capacities [ 73] and may function as a barrier in the context of successful resource-oriented interventions [ 61]. UMRs might identify with their own vulnerability and have difficulties adjusting in the arriving countries.

Discussion

This is the first realist-informed synthesis of the UMRs most recent PSC situations in high-income countries in the European Union, specifically Germany. The findings reveal that the UMRs' life stage is deeply characterised by intersecting transitions of migration and adolescence and confronted with personal and societal obstacles that might be enforced by binary and generalising discourses around them.

PSC is shaped by policy regulations located between international human rights and domestic asylum laws and the direct microsocial outcomes of that interaction (e.g., an undersupply that can deepen chronification). In addition, the general discursive level is particularly significant, as the everyday concepts and expert jargon shape PSC and its processes. This review has shown that deficient PSC contexts, underlying structures and mechanisms can lead to fundamental gender-specific and socio-spatial care barriers ( e.g., in metropolitan areas such as Berlin): If those barriers are not balanced out by care strategies and networks at the local level, further PSC needs might be consolidated. The following paragraph first summarises the RR's findings and provides an interpretation of the results of the CMO constellations in their propositions. Furthermore, the strengths and weaknesses of the RR approach in relation to the chosen topic are discussed. To be able to establish a link to PSC in practice, recommendations for action and implications conclude the discussion.

Key findings and interpretation

This study investigated the mechanisms (M) of PSC programs within different contexts (C) and the programs' multiple outcomes (O).

Proposition 1 explained the connection between the intersecting processes of migration and adolescence and post-migratory stressors as well as the resulting PSC needs of UMRs. Their health care needs are examined by various disciplines, such as health service research. Therefore this review argues to link theoretical approaches such as the flight phase model with approaches from developmental psychology [ 33]. The special need for psychosocial care as previously described in proposition 1 has already been suggested by Huemer, who compared UMRs and accompanied minor refugees. Her study showed the importance of social support (e.g., family) for young migrating people and provided indications on how social contact and family support act as protective factors [ 47].

Proposition 4 discussed discourses and concepts, their effect on UMRs and their care. The synthesis of several studies [ 2, 49, 51] showed that the concept of sequential trauma may serve as a comprehensive and suitable tool for capturing the UMRs' mental health and their PSC contexts. Furthermore, generalising concepts such as "vulnerability" or "resilience" [ 1] should be critically reflected within everyday practices and academic research. Amidst increasing numbers of arriving UMRs to Germany and other European countries, a critical reflection of concepts and discourses is crucial [ 6]. In summary, UMRs are said to be in age- and migration-specific transition processes; thus, special PSC needs arise. A possible shortage of PSC has various consequences for the well-being of UMRs. Within the care system, it is not only a question of the structural existence of care facilities but also of sensitive care concepts.

Strengths and limitations

The limitations of this work are related to the high level of abstraction [ 20], which is applied in the preparation of the initial theory and in the refined framework. Consequently, second- and third-order interpretations (such as the development of CMOs and its propositions) can merely have a reduced claim for translation into PSC practice. Due to the broad variety of reviewed literature across disciplines and research topics as well as different prevalence data the empirical evidence of the CMOs is inconclusive. For instance, the available data on PTSD indicate a prevalence range between 19 and 54% [ 51]. Another limitation includes the focus on literature written in English and German; this restriction is due to our own language barriers (e.g., lack of Arab, French, Turkish, or Russian literacy). The fact that the evidence is regionally and nationally specific and that there is a high variability and diversity of the PSC programs can also be listed as a limitation within the given RR. Nevertheless, the RRs methodological approach and the given results allow the development of PSC practical recommendations that can be applied across European countries and especially in the German context.

Recommendations and implications

Research strategies on UMRs should be shaped and informed by intersectional approaches [ 79] that provide ways of interpreting the multiple discriminations, privileges and complexities of social integration. Approached as being embedded in diverse social categories (as minor, (un-)accompanied, (non-)religiously or culturally diverse) UMRs might receive a more differentiated contextualisation by health service research and social sciences.

Finally, the political circumstances shaping UMR policies and PSC regulations are based on asylum status´ and legitimacies of access to PSC. When these policies and legal structures contribute to the existing traumatisation and PTSD among UMRs, they promote othering and victimisation [ 35]. Humane, health equity-oriented and inclusive policies can meet the special needs of UMRs by perceiving their particular situation of dependency and at the same time by promoting their resources through shaping integrative and empowering psychosocial and social settings. Moreover, the intersections of inclusion and exclusion call for non-discriminatory treatment, universal access opportunities beyond citizenship, and individualised provision of support.

Author information

Affiliations

1. Institute of Medical Sociology, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle, Saale, Germany

Hanna-Sophie Ulrich, Emma Kohler, Matthias Richter & Martin Mlinarić

2. Department of Public Health, Institute for Health, Brandenburg University for Technology Cottbus-Senftenberg, Senftenberg, Germany

Jacob Spallek

3. Department of Surgical and Conservative Pediatrics and Youth Medicine, University Hospital and Polyclinic for Pediatrics, University Hospital Halle, Saale, Germany

Daniel Clauß

Contributions

HSU managed the whole process of the realist review and drafted the manuscript. HSU, EK and MM, interpreted the data and collaboratively checked it against the used theoretical framework. Titles and abstracts were screened and independently checked by HSU and EK. HSU openly and axially coded the extracted evidence, identified mechanism patterns, and allocated findings to codes within categories. EK and MM carried out a subsequent and collaborative review of the generated code and category system. HSU, EK and MM checked whether the evidence was used properly in the interpretative synthesis, and after discussions, all authors agreed upon potential misreadings and ambiguities. JS, DC and MR were involved in the design of the paper, and refinement of the synthesis of evidence. All authors contributed to the writing of the final version manuscript and approved the final manuscript.

Corresponding author

Correspondence to Hanna-Sophie Ulrich.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical approval was granted through the ethical committee of the Medical Faculty of the Martin Luther University Halle-Wittenberg, Germany (2019 -042) for the study FKZ 31/41.

Ethical approval

Ethical approval was granted through the ethical committee of the Medical Faculty of the Martin Luther University Halle-Wittenberg, Germany (2019 -042) for the study FKZ 31/41.

Supplementary Information

Below is the link to the electronic supplementary material.

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Ulrich, HS., Kohler, E., Spallek, J. et al. Explaining psychosocial care among unaccompanied minor refugees: a realist review. Eur Child Adolesc Psychiatry (2021). https://doi.org/10.1007/s00787-021-01762-1
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Keywords

Psychosocial care

Migration

Unaccompanied minor refugees

Realist review

mental health

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Explaining psychosocial care among unaccompanied minor refugees: a realist review - European Child & Adolescent Psychiatry

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Research on the psychosocial care (PSC) of unaccompanied minor refugees (UMRs) has mainly taken a socioepidemiological approach and has focused on the perspectives of experts in the field. In contrast, the knowledge concerning the differing context factors and the underlying mechanisms of current PSC which could inform policy recommendations is scant.

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Frearson, S. (2019). Perceived educational impact, challenges and opportunities of hospice placements for foundation year doctors: a qualitative study. Future healthcare journal, 6(1), 56. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520090/

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Abstract

Foundation year one doctors (F1s) are expected to recognise and care for dying patients, but previous studies have found they can feel unprepared, stressed and unsupported when faced with such situations. Although hospice placements can provide good experiential learning for junior doctors, no studies to date have included F1s. This study used an interpretivist approach to explore educational opportunities and challenges in hospice placements from an F1's perspective. Six F1s who had recently completed hospice placements were interviewed individually. Data analysed qualitatively showed that F1s valued informal experiential learning and felt well supported by senior doctors. The most important learning outcome was the acquisition of enhanced communication skills and challenges included the risk of becoming medically deskilled. F1s felt their medical practice had changed as a result of hospice placement, most commonly in communication skills and recognition of the dying phase. The author recommends increased utilisation of hospice placements in foundation training programmes.

KEYWORDS: Foundation year, junior doctor, hospice, end of life, palliative care

Introduction

General Medical Council guidance in Outcomes for graduates stipulates that they should be able to 'contribute to the care of patients and their families at the end of life, including management of symptoms.' 1 The UK Foundation Programme covers the first two years following graduation from medical school. It has a spiral curriculum comprising a core of twenty outcomes, one of which is 'manages palliative and end-of-life care under supervision.' 2 In theory a hospice placement could be an ideal opportunity for foundation year one doctors (F1s) to prepare to meet this outcome. However, such placements remain a rarity in foundation programmes, with the Association for Palliative Medicine including only one F1 post in their 2016 workforce survey. 3

Palliative care teaching in medical schools can be fragmented, and is rarely formally assessed. 4 Emphasis is placed on how to improve health, with little teaching on what to do when this fails. 5 Newly qualified doctors can feel unprepared, unsupported and even distressed when caring for dying patients. 6,7,8 They have described 'being left' to cope, fearful that their lack of experience could make things worse for patients. 9 Palliative care is often learnt on the job, with little formal teaching. 10 F1s can find communication about end-of-life decisions and recognition of the dying phase challenging and can also lack knowledge of cancer care and symptoms. 11,12,13 There is a perceived lack of senior medical support when caring for dying patients in hospital placements. 12,14 However, support from other team members, in particular nursing teams and senior doctors, can significantly enhance learning environments. 15

Few studies have looked at junior doctor placements in hospices. One study found that senior house officers (SHOs) considered there to be excellent experiential learning opportunities in UK hospice placements, but this was tempered by feelings of being isolated from their peers, and emotional toll. 16 Another study involved six F1s mostly in split oncology and palliative medicine hospital posts, where it was reported that although such placements helped develop skills in diagnosing dying and breaking bad news, split posts and on-call rotas could detract from the positive educational experience. 17 The current study took an interpretivist approach aiming to explore individual F1 opinion of hospice placements, in order to provide some insight into this under-researched area.

Methods

The study setting was a 16-bedded UK hospice. Six F1s each year have an 8 week long placement, with no on call commitments and limited contact with other F1s. Using a purposive sampling technique all F1s who had a hospice placement between August 2016 and March 2018 were invited to take part in the study. The researcher, a hospice consultant, had an established professional relationship with participants as their former clinical supervisor. Professional relationships can compromise voluntary informed consent. 18 To limit this, an opt-in recruitment strategy was chosen whereby participants were contacted via email by a third party (an educational administrator) and asked to email the researcher if interested in participation. Of the eight F1s contacted, six gave written consent to be part of the study, and two decided not to participate because of time constraints.

Individual participants chose the location for their interview; four decided to use the education department facilities in their base hospital, one chose the hospice secretarial block, and one opted to be interviewed at home. Face-to-face individual interviews were performed by one researcher who had previously been participants' educational supervisor. In order to mitigate any restriction in response due to the power balance between interviewer and interviewee, power balance was acknowledged at the beginning of each interview and participants reminded that the researcher's role in this instance was to gather opinion not to act as an educational supervisor. 19,20

Individual interviews were chosen as the data collection method because in-depth interviews allow detailed exploration of opinion, impact and outcomes from an individual perspective. 21 Secondly, hospice placements are likely to be complex experiences, and these types of experience are generally better explored using individual interviews. 22 Semi-structured interviews, using an interview guide were chosen for their ability to provide consistency and to ensure relevant topics are covered, whilst allowing flexibility to pursue topics important to individual participants. 22 The interview guide was piloted on a junior hospice doctor not otherwise involved in the study. Participants were asked about learning needs, educational opportunities, challenges and changes in practice (supplementary material S1). An array of prompts, probes and checks tailored to each individual were used to explore topics in detail or clarify meaning. 21 Field notes were made of non-verbal communication and reflective notes of initial impressions and themes were written following interview. 19

Interviews were audio-recorded and then transcribed verbatim. Using an inductive approach transcripts were analysed by a single researcher using a qualitative thematic approach. 22 Transcripts were read iteratively until themes emerged from the data. Themes were structured via codes into an index which was adjusted until all relevant concepts from all interviews were assigned a code (supplementary material S2). This index was then applied across the data set and themes sorted into a framework to allow easy comparison across and between themes and participants. Any outlier responses were examined and their relevance carefully considered. Data saturation was reached with no new themes emerging after five interviews. To add rigour, a second qualitative analysis was performed using a constant comparator approach. 23 Two transcripts were randomly chosen and similarities and differences between them considered. This process was then repeated with the introduction of a third and then subsequent transcripts. As the results from both methods of analysis were concordant, with the thematic analysis providing most detail and the constant comparator illustrating contentious issues, they were merged for analysis purposes. Respondents were emailed a copy of the results and asked for their validation of the findings.

This project was screened by UCL Research Ethics Committee and considered exempt from full ethical review. NHS trusts and training programme directors were informed of the study and gave their permission for it to proceed. The study complies with the Consolidated Criteria for Reporting Qualitative Research. 24

Results

Six F1s participated who had completed a hospice placement between one day and fifteen months prior to interview (Table ).

Table 1.

Six main themes emerged from the data.

1: Learning environment

The learning environment at the hospice was considered supportive with an emphasis on teaching. Most participants discussed having time to be thorough and to hone key skills. Participants felt staff were supportive and available, which gave them confidence; Dr D:

I did feel confident enough to take a history from a patient because I knew I had my seniors and everybody else available.

2: Learning needs

Communication skills were mentioned by all participants as their predominant learning need; Dr F:

Talking to patients... I was terrified about, I remember thinking 'These people are dying; I have to talk to them.'

Only one participant (who had a career break between medical school and F1) viewed some of his learning needs as unmet; Dr C commenting, 'at least 90% were met '.

Most of the participants brought up gaps in knowledge and experience. Several discussed a lack of palliative care teaching at undergraduate level, describing being actively kept away from dying patients; Dr F:

If you say, 'Can I go clerk a patient?' They would say, 'Don't go to that room, they are palliative care, it's not very appropriate for you to talk to them.' So, you don't really see it at all.

Participants spoke at length about the difficulties of delivering good palliative care in hospitals. Most had experienced a lack of important end-of-life decision making and some even spoke of instances where dying patients were missed out on ward rounds. Others raised a lack of teaching and opportunity to practise communication skills; Dr A:

It didn't even come to avoiding it, we just didn't have that opportunity... we weren't really allowed to discuss it.

3: Learning opportunities

All participants spoke positively about learning opportunities at the hospice (Box ).

Dr E sums up the group feeling by commenting:

By far and away the greatest emphasis was placed on communication skills.

All participants considered management of complex patients, prescribing at the end of life and gaining a general understanding of hospices and palliative care as important additional areas of learning.

Participants viewed informal learning opportunities to be of greater value than formal, and spoke extensively about informal opportunities to learn communication skills, through observation of senior doctors and practising these skills themselves; Dr A:

The first few weeks it was mainly observing the other doctors and seeing how they do it and then after that I got the opportunity to do it myself as well. You learn from both.

The role of senior doctors in education was discussed at length, including teaching on ward rounds, role modelling, feedback and educational sign-posting. F1s valued being given responsibility to clerk new patients and discuss possible management plans with senior doctors.

4: Potential challenges

Most participants identified emotional toll as a potential challenge, yet none of the participants felt this had affected them personally during their placement. The reasons for this varied from being older, feeling supported and the short placement duration. One participant felt the hospice was a positive place, another felt as long as he was doing the best for patients, he didn't feel emotionally drained; Dr F:

I didn't feel that the hospice was a sad place, I felt the exact opposite, I felt it was a very positive place... I genuinely never came home feeling that was an emotionally draining day.

Some participants felt they had ample opportunities to use their clinical skills; others (with career aspirations in anaesthetics and surgery) missed performing complex procedures. The potential for becoming medically deskilled was a contentious issue; three participants felt strongly they were not deskilled; others felt slightly deskilled in acute medical competencies, but agreed this was outweighed by gaining alternative additional skills; Dr F:

I think I got competent in other ways... there was a whole skill set that we got that they don't have.

None felt personally affected by a lack of peer support; most found either medical or nursing staff provided this, or that contact with other F1s in weekly teaching sessions or social media groups was sufficient.

5: Change in practice

Everyone agreed that their hospice placement had changed or would change their practice, most commonly through the acquisition of communication skills. However, better recognition of the dying phase, end-of-life pharmacology and management of complex patients were also mentioned, as was knowledge of when and how to refer to hospital palliative care teams. F1s came to recognise that palliative care was an active process rather than simply withdrawing medical treatment; Dr A:

Actually, there is quite a lot you can still do in terms of management and investigations for the [palliative] patients which beforehand I probably didn't recognise fully.

One participant felt that his knowledge in end-of-life care could not be utilised as this was the job of the hospital palliative care team. However, the others disagreed with this, feeling that they had developed important transferable skills; Dr F:

Whatever job you are in you can transfer it, at some point in your life you are going to encounter dying patients.

Two F1s who had their placement many months prior to interview described extensive changes in practice after their placement, and they also reported becoming increasingly aware of this as time went on. Both felt confident to challenge others in their management of patients at the end-of-life and to prompt end-of-life discussions.

6: Recommendation of hospice placement and suggestions for improvement

All participants would recommend a hospice placement. They believed that the skills they had gained were important and could not be learnt elsewhere; Dr A:

I think you learn stuff in this job that you wouldn't learn on a general medical rotation or surgical rotation or whatever.

When asked for suggestions to improve hospice placements, participants most often suggested being given more responsibility.

Discussion

This study is the first of hospice-based F1s and demonstrates that such placements can enable F1s to gain confidence in end-of-life care and communication - areas that newly qualified doctors may find challenging. 6,7,8 As other studies in similar settings have found, participants valued experiential, informal learning opportunities, particularly when interacting with patients and other staff. 9,10,16,17 Here, this experiential learning was achieved with suitable support from staff, but in other studies learning on the job has been described by junior doctors as being through making mistakes and being 'thrown in at the deep end'. 5,10 F1s placed emphasis on the role of senior doctors in informal learning. Although already extant, this finding underlines the important educative role senior doctors have in supporting and teaching newly qualified doctors. 10,14,17 Some of the most valued learning opportunities were patient-related, for example, when given responsibility to do challenging tasks such as clerking new patients. Other research has also identified the importance of patient (or client)-centred tasks, being given responsibility and completing challenging tasks when learning in a workplace. 15,25,26 F1s were able to identify informal learning opportunities and describe how they had learnt from them. This is in contrast to other research on workplace-based learning which has described informal learning as invisible, tacit and complex. 25

Many of the other findings here replicate those from other studies. For example, communication skills have been acknowledged as a predominant learning need for junior doctors along with recognition and symptom control of dying patients. 13 Gaps in education and experience in both communication skills and palliative care have also been recognised previously, and other study participants have described being afraid of talking to dying patients and not knowing how to care for them. 5,6,7,9 The limitations of providing palliative care in hospital settings, with dying patients being missed on ward rounds and given aggressive treatments have also been previously reported. 5,13 All participants felt that their hospice placement had or would change their practice, mainly through acquisition of transferable skills such as communication skills, improved recognition of dying and management of symptoms, findings in keeping with previous research. 17 Only one participant believed that palliative care skills were not required in his current specialty (general surgery - in which other studies have shown palliative care can be sub-optimal). 9,10

In contrast to other studies, although participants acknowledged emotional toll and lack of peer support as potentially challenging, none had been personally affected by these for varying reasons. 16,17 Challenges faced by junior doctors in other studies such as feeling under or over-supported, limited time with patients, poor inclusion in teams, split job plans, on-call rotas disrupting learning, and limited time with seniors were also not identified here. 15,17 Again in contrast to previous research with hospice SHOs, the hospice F1s studied here did not perceive conflict between medical and nursing teams, possibly because their placement was too short to detect this. 16

Unique to this study was the fact that F1s found the hospice learning environment comfortable and less pressurised than hospital environments. They were also conscious of the emphasis on teaching within their placement. These perceptions have not been previously reported in literature and it is impossible to know if these are specific to this hospice, or if this is something inherent to palliative care, related to its slower pace and holistic nature. Participants were divided in opinion as to the potential of hospice placements to medically deskill. This is a new concern, which in other studies was negated by participation in a medical on-call rota during palliative care placements. 17 As time increased from hospice placement, the effect of the placement on participants' practice seemed to heighten. No studies have found this strengthening of the impact of hospice or palliative placement over time.

Study limitations include the risk of bias; the researcher's previous role as educational supervisor could have compromised consent, influenced responses and skewed results, despite efforts to limit this via third party recruitment and open acknowledgement of roles and bias. This is a small scale study with a small and heterogeneous sample. For example, two participants were older than the others, and when they were discussing emotional toll they felt they had enough life experience to cope. Participants also had a wide range of career aspirations, and this influenced opinion; the aspiring anaesthetist considered lack of complex procedures particularly disadvantageous. This means that results may not be directly transferable when considering other groups of F1s in similar settings. This is especially so because UK hospices vary widely, in terms of size, charitable status and resources. Notwithstanding these provisos, these results provide a real insight into the opportunities and challenges of hospice placements during training and evidence that even a short hospice placement has the potential to change future practice.

Recommendations

Consideration should be given to increasing the number of foundation year palliative care posts to enable more trainees to achieve important generic skills in end-of-life care, symptom control and communication. This would not be without challenge: introducing palliative care placements could limit other placement options in already crowded rotations and may not necessarily appeal to trainees. In addition, many hospices are independent of NHS trusts which may be an added complication. However, with the increasing emphasis on community placements in foundation training programmes, hospices (considered a community placement) could present an ideal solution. 27

Individual foundation school directors could work together with local palliative care providers to identify potential palliative care placements.

Studies using serial interviews could be a useful way of enabling a deeper understanding of how hospice placements influence practice over time.

Research which includes the educational supervisors' views of what competencies are gained during a hospice placement would enable further exploration into the educational value of hospice placements.

Hospitals should consider how to increase adequately supported exposure of both medical students and foundation year doctors to patients at the end of their life, so providing them with opportunities to observe and develop communication skills in this difficult area.

Conclusion

A hospice placement can equip trainee doctors with the necessary skills and confidence to recognise, care for and communicate with patients at the end of life and their families. The educational opportunities in hospice placements are valuable, in particular for informal experiential learning. The hospice environment is supportive and conducive to learning, and placement value can be maximised by encouraging trainees to do patient-centred tasks and to take on clinical responsibilities. Although most challenges of hospice placements were considered either not relevant or outweighed by advantages, the potential to medically deskill was highlighted. This could be overcome by greater integration of palliative placements with oncology services or participation in an on-call rota. This study has added to the body of literature describing junior doctors' lack of confidence in caring for, and communicating with, dying patients. It has also suggested one possible solution to these problems, through the provision of a short hospice placement for trainees. Training leads should consider the integration of more palliative care or hospice placements into junior doctors' training programmes.

Supplementary material

Additional supplementary material may be found in the online version of this article at http://futurehospital.rcpjournal.org :

S1 - Interview guide.

S2 - Final index.

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Perceived educational impact, ­challenges and opportunities of hospice placements for foundation year doctors: a qualitative study

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Foundation year one doctors (F1s) are expected to recognise and care for dying patients, but previous studies have found they can feel unprepared, stressed and unsupported when faced with such situations. Although hospice placements can provide good experiential learning for junior doctors, no studies to date have included F1s.

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What counts as evidence of inclusive education?

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Well done! You have a wide mixture of different approaches in your subject area. I wonder if there is a dominant approach? You will learn more about how to analyse articles in more detail next term - especially the difference between positivist and post-positivist approaches - but this is a  good start.

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Well done! You have a wide mixture of different approaches in your subject area. I wonder if there is a dominant approach? You will learn more about how to analyse articles in more detail next term - especially the difference between positivist and post-positivist approaches - but this is a  good start.