Effective Communication for Displaced Persons

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Original Editor - Donald John Auson & Jordan Awale as part of the PREP Content Development Project

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Introduction

Communication is the process of exchanging information, ideas and thoughts between two or more individuals which can include verbal and non-verbal forms. Effective communication is important for it can be the ground for building good interpersonal relationship. In the healthcare setting, effective communication can create a more effective therapeutic setting leading to improved outcomes and attainment of goals.

Communicating with Refugees

A refugee is someone who has been forced to flee their country and crossed an international border to find safety in another country as a result of persecution, war or violence. However, establishing communication is often a challenge. They may be speaking a different language or a different dialect. Cultural differences are another factor to consider when communicating with refugees.

A study published by the BBC Media Action in July 2016 presented the needs of refugees when it comes to communication and access to information as well as the challenges humanitarian agencies face when it comes to providing the needs of refugees. The study also showed that communication needs are not only for the information, refugees need: to be listened to, to be able to tell their stories, to participate in dialogue that provides them with physical, social and psychosocial support and, trauma counselling.

Strategies have been implemented to address communication barriers. A review identified four strategies used in the healthcare setting to address communication barriers. These are: cultural mediation, interpretation, translation of health information, and guidance and training for health care providers.

Building Trust

Trust is a key factor when it comes to communicating with refugees. It can be a catalyst or a barrier in establishing communication with refugees. Trust is defined by the Merriam-Webster Dictionary as “assured reliance on the character, ability, strength, or truth of someone or something”. Having trust on healthcare workers involves reliance on the capabilities and competence of the staff, even with the existence of uncertainties and without assurance.

Factors Affecting Trust

• Communication Skills
• Knowledge

Ways to Build Trust

• Improve Communication Skills; Verbal and Non-Verbal
• Increase Knowledge

Creating Therapeutic Space and Alliance

Creating therapeutic space involving refugees involves some challenges due to communication barriers, cultural differences and other factors. However, these challenges can be overcome. This involves clear communication between the healthcare service provider and the patient through the aid of interpreters or translators. Participation of the patient in creating goals has been known to lead to better outcomes.

There are different strategies that can be implemented in order to decrease the challenges when communicating with refugees. Some of these strategies include:

• Cultural Mediation
• Interpretation and Translation
• Cultural Adaptation of Health Information and Materials
• Guidance and Training for Health Staff.

Other strategies that can be implemented are: a migrant-friendly hospital initiative, employment of bilingual staff, and establishment of a database of language needs.

Interpreters and Translators

An Interpreter is a skilled and trained person that converts oral information into another language, while a translator is a skilled and trained person that converts written information into another language. Their role is to make clear communication between the health care provider and the refugee who are both speaking different languages. Their goal is to convert oral or written information as “meaning for meaning” and not as “word for word”. This implies that interpretation and translation must be done with some context of the message being conveyed as well as the emotions and expressions it was delivered with. You can read further details about the Use of an Interpreter and Translator for People with Refugee Experience.

Key Points for Communicating with Interpreters

• Shorten the sequence of your sentences. Do not give long sentences with many words
• Adjust the kind of language that you normally use e.g. less medical or formal words, instead use Lehman’s terms
• Make sure that information is not lost in translation. It is easier if you stick to saying short, concise sentences
• Interpreters should not have to feel the need to filter what they are translating. No matter how crude, harsh, or offensive, the interpreters should still translate exactly what was said from the patient. The purpose of this is to enable medical professionals to gain a full understanding of how the patient is feeling.
• It is the medical professional’s job to work out what is going on if the conversation is going off topic, they should make sure they are in control. So following on from the point above, the professional should encourage the interpreter to translate EXACTLY what the patient has said at all times, but ensure only the important necessary details are told
• As you try to be in control, it is CRUCIAL to make sure that the interpreters you work with have breaks and adequate rests. Breaks are VERY important for interpreters and mental fatigue can massively affect the quality of translation. Also please consider the potential psychological effects of either past experiences or interpreting the trauma of patients, it is so important to make sure that they do not burn out!

Facilitating Optimal Communication

Physiotherapists working with refugees/migrants must administer a client centred approach in rehabilitation service. This implies offering culturally sensitive care which includes the ability to communicate appropriately with the person(s) seeking help. Communication is central and important in all types of clinical work, but the need for communicative skills is especially important in the treatment of vulnerable groups. Here, vulnerable groups are refugees and migrants, i.e.  people who have been displaced or have fled from their native country. Their cultural background is therefore different from that of the country where they seek physiotherapy and rehabilitation. As always, it is important to see the individual - not a stereotype group member - and offer service which assist the person to reach his/her goals. Communicating is something we do every day. We are used to it; it is simple but still complicated as many barriers and factors come into play and disrupt communication.

The encounter between the physiotherapist and refugee or migrant typically starts in a therapy room. Although the therapeutic room varies based on circumstances, the situation and setting becomes a sociocultural space and per se, it is the physiotherapist’s home ground. The environment could create an asymmetric situation since the professional is “at home” while the care seeker is “visiting”. Further, the physiotherapist represents authority, and challenging authority might be uncommon and scary for the patient. It is important to be aware that tacit and unwritten rules such as these (and others) represent barriers for culturally sensitive communication and could influence the rehabilitation process. The barriers need to be overcome to balance the relationship between the therapist and patient. It is the physiotherapist’s obligation to initiate this process and communication is important for the process.

The ability to communicate is a key to providing physiotherapy services. A treatment session is a joint project between the therapist and the client, and it is essential to have something in common to do something together. Establishing common ground is therefore essential. Rehabilitation services in physiotherapy is typically stretched over time, which gives a unique opportunity to do this. Although communication can be one-directional, like listening to the radio - or the physiotherapist telling the patient what “to do”, we understand communication as an active process where messages are exchanged between two or more individuals  (link to Physiopedia).

The concept “effective communication” used by some, covers the ability to listen as well as interacting with clients based on a mutual understanding (link to King), which is the essence in culturally sensitive care. Communication in rehabilitation is an ongoing process between the physiotherapist and clients who have refugee experiences. Sometimes an interpreter is required in the therapy room. The presence of a third person, could influence communication in many ways.

Culture, education, and experience influence the physiotherapist’s communication style and skills and the same can be said for the patients. Communication can take on different forms, it can be verbal or non-verbal, it can be expressed by facial expressions and body language, and even silence. The dialogue is central: using language in some form to exchange ideas and thoughts. A dialogue implies that the involved parties listen aiming at creating something together that is meaningful in the situation. It also implies an ability to take on the other person’s perspective. By asking questions, listen to the answers and acknowledge the stories told, it is possible to establish a therapeutic alliance built on trust. This is particularly important in the treatment of vulnerable groups, such as refugees and migrants. It could also create new knowledge and insights for all involved parties.

In the clinic, it is the patient’s needs that guides the communication. Still, most likely it is the physiotherapist who controls the communication by initiating the dialogue and by selecting the follow-up questions and topics. However, the therapist must facilitate the dialogue so that the client has an opportunity to present his/her story. It is also the therapist’s obligation to make clear that they have heard what has been said, and to use the story as a starting point for further communication.

Some topics like rape, abuse, harassment, and torture are e sensitive and difficult to bring forward. Because it is difficult and touchy, there is always a risk that the dialogue turns into a monolog or maybe “interrogation”, even if it is not intended. Communication around these topics requires a sound therapeutic alliance based on trust and mutual recognition.

Language gives “I” an opportunity to participate in a dialogue, but this must also apply to “the other”. Language represents an opportunity to sorting experiences and guide ideas and thoughts and prepare for reflections on each other’s perspective. A pre-requirement is that there is a common language. Language barriers influence communication, the rehabilitation services offered, and also the end result of treatment (link to articles).  Interpreters should be available but their presence could have an impact on the process as well as the end result.

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