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Aims and objectives:To gather insight in conditions important to an understanding of undocumented migrants’ life situations and more specifically to explore undocumented migrants’ quality of life and how we can understand the various domains of quality of life related to demographics, living conditions, migration history and inflicted burden. Background:Undocumented migrants suffer from economic hardship and acculturative stress, limited psychological and social support and at the same time restricted access to health care and social welfare. Design: An exploratory mixed methods design using primarily quantitative data with a qualitative component was implemented. Methods: Sociodemographic data on 90 undocumented migrants were collected, and self‐report questionnaires on quality of life and psychological distress were completed, supplemented by qualitative data obtained through interviews and additional qualitative questions. The STROBE checklist for cross‐sectional studies was used for reporting this study. Results: Quality of life in our group of undocumented migrants was poor. Leaving their home country because of war or persecution, hunger, having experienced abuse, homelessness and higher age were statistically significantly associated with poorer quality of life. Having membership in a local association and having a partner were statistically significantly associated with better quality of life. Qualitative data indicate that marginal living conditions, fear of death and suffering and conditions associated with dependency were the main components comprising the burden to our respondents, reflecting their precarious juridical status as undocumented migrants. Conclusion: Our respondents’ poor quality of life was related to the complex interplay between possible exposures to traumatic experiences before and during flight and post‐migration traumatisation in relation to our respondents’ experiences of economic, social and acculturative hardship in Norway. Relevance to Clinical Practice: Responses called for to improve undocumented migrants’ quality of life and eliminate barriers to their health care appeal more to nurses as a professional group and to those in positions of authority than each individual nurse on duty. Eckbo’s Legacy (Major og advokat Eivind Eckbos Legat). Grant Numbers: 15350 (2011), 59362 (2013)

To explore undocumented migrants' mental healthcare needs and more specifically to explore how undocumented adults living in Norway perceive psychological distress, to gather insight on their living conditions and to explore associated living condition risk factors.Undocumented migrants are defined both nationally and internationally as an especially vulnerable group with regard to their health status, living conditions and barriers to access to health care and social welfare.An exploratory mixed-methods design using primarily quantitative data with a qualitative component was implemented.Socio-demographic data on 90 undocumented migrants were obtained, and self-report questionnaire on psychological distress was completed, supplemented by qualitative data obtained through interviews.The level of psychological distress was extremely high in our group of undocumented migrants. Leaving their home country because of war or persecution, economic strain, homelessness, hunger and having experienced abuse was significantly positively associated with psychological distress. Contrary to what was predicted, having family and work was not significantly associated with the reduction of psychological distress. Additional qualitative data indicate that having family entails great responsibilities and work implies exploitation to such an extent that any potential positive influence this has on mental health, such as a sense of belonging and a reasonable standard of living, is outweighed.The high level of psychological distress indicates a need of additional diagnostic evaluation and mental health care. The living conditions were so marginal that their day-to-day existence was threatened.We recognised a need for an interdisciplinary and dynamic approach to mental health care. Undocumented migrants are in need of a minimum of psychological and material support assuring basic needs such as shelter and appropriate food and access to health care and social welfare.

There is an ongoing discussion concerning personal vs. impersonal considerations in professional care. In this article, three different positions within the ethics of closeness will be discussed. These are: (a) reserving the ethics of closeness for close experienced others, 'including the experienced Other', which is Nortvedt's position; (b) trying to bring the distant, non-experienced others closer, 'including the Third'; and (c) finally, an examination of whether a perspective of closeness may lead to the exclusion of various groups in need of help, 'including the Other at the expense of the Third'. These positions are discussed with a view to clarifying some of the challenges that the ethics of closeness faces when it maintains that greater ethical obligation is associated with personal than with impersonal relations, without discussing the terms on which the obligation is based. Key questions that arise for a nurse or other health professional are: If our primary moral responsibility is for those that are close to us, the experienced others, who is to be responsible for those that are outside the established health services, the non-experienced others? Is it evident that favouring the experienced others is based on legitimate needs? Can a discussion on the legitimate basis of nursing be avoided in questions relating to closeness and priorities? This discussion touches the heart of our discipline. Is a one-sided perspective of closeness, rejecting moral responsibility for those with whom we have no relationship, a defensible ethical position?

Legal protection is marginal for a large number of people globally due to war, persecution, torture, terrorism, statelessness and the very state of illegality from which undocumented migrants suffer great hardship. Right now, human rights violations are reflected in the largest number of refugees since the Second World War, according to the United Nations High Commissioner for Refugees. The ongoing humanitarian disaster unfolding along the borders of Europe makes refugees even more vulnerable to traumatic experiences and death during the flight and at the borders. This crisis affects various authorities such as police, immigration authorities and health professionals ‘who are all facing dilemmas which occur in the middle of the ongoing, unresolved conflict of interest between human rights, healthcare, social welfare and the security and sovereignty of the modern state’. There is a risk of (further) polarization between the need for safety and well-being for the majority/host population and the need for safety and well-being for individuals and groups with a precarious juridical status in society. An example would be undocumented migrants and asylum seekers who seem to be particularly vulnerable with respect to their state of health, living conditions and lack of access to medical assistance, nursing care and social welfare. Barriers such as the discrepancy between human rights and national laws, limited awareness of human rights among health professionals, limited knowledge of healthcare needs among those with a precarious juridical status, no common understanding of what is defined as sufficient healthcare and payment terms in the established healthcare system are all factors significant to this. The discrepancy between human rights and national laws is particularly visible in countries where different laws make access to healthcare for, for example, undocumented migrants a risk because health professionals are obliged to report ‘undocumentedness’ to police and/or immigration authorities. In Germany, these obligations are due to The Residence Act which claims undocumented migrants must be reported to authorities if they seek public services and even criminalizes assistance of undocumented migrants, including healthcare, with a fine or imprisonment. In Denmark, the Danish Immigration Service is responsible for healthcare to those without legal stay if their address is known, but they are also obliged to inform the police of the address. However, nearly all countries in the world have ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR), which includes the ‘Right to Health’ in Article 12. Norway did include this covenant in the law on Human Rights, which took precedence over other Norwegian laws in 1999. Also the Immigration Act in Norway (effective as of 1 January 2010) states that humanitarian assistance and medical aid shall not be criminalized, even if there are limitations for undocumented migrants’ access to healthcare also in Norway due to, for example, payment terms, that such access is limited to emergency help, and that rejection of application for mental healthcare in the ordinary system of help in Norway is often explained with reference to the unstable life situation of asylum seekers and undocumented migrants. Thus, a two-tiered health service system may be said to be in place in which the

Background: Undocumented migrants may find themselves to be extraordinary vulnerable to health problems because of political, economic and social marginalization, language barriers and cultural constraints, fear of police and migration authorities, lack of psychological and social support, losses and discrimination. However our knowledge both nationally and internationally is limited. Aim: The purpose is to gather insight in undocumented migrants’ state of health, their need of health care and significant gaps in existing knowledge. Method: A systematic literature review in the databases Cinahl, Medline, PubMed and SveMed. Results: There is a huge protection gap between undocumented migrants’ need of health care and access to health care. Restricted access may also be one major factor to the existing gaps in knowledge. Public health, reproductive health and their living difficulties as undocumented migrants have to some extent been studied so far. Less is known of mental health, chronic illness and state of health to the children as well as to elderly people. Conclusion: There is a need to strengthen the efforts to make the ordinary system of health care work to including undocumented migrants, to protect charity – based health – centres, and to increase research and development to contribute to undocumented migrants’ access to adequate health care.

The aim of this article is to continue the discussion about factors of importance for an including ethics of care. A further polarization between partiality and impartiality does not seem a relevant approach. What is important is to direct attention both to the other and to the third person, which requires an acknowledgement of responsibility that extends beyond established relationships. Thus, we need to draw attention not only to the vulnerability existing within every seriously ill or injured person, but to factors of importance for marginalization of groups like refugees, people suffering from serious mental illness, and substance misusers, to mention some in the Western world. Marginalized groups are groups experiencing a discrepancy between need of health care and care given. They are not given proper priority in the distribution of resources, and they may experience ignorance when they first meet the healthcare system as patients. Efforts to understand what circumstances can lead to inadequate inclusion indicate that the elements of differentness and extensive losses of life contexts which may be causing feelings of hopelessness and helplessness in the health professionals, are key factors posing challenges to empathy both within and beyond established relationships, besides geographical distance. Groups of people who have suffered extensive loss in their life contexts may be threatening for us, as they reflect our own fears, and remind us of our own vulnerability. I raise the question: How can we contribute to meeting the need for an ethics of care that extends beyond the familiar to the unfamiliar both in established and non-established relationships?