Primary Health Care Gender-Based Violence Training

Communication Skills for Providing GBV-Related Care and Services

In this module, you will learn about effective communication strategies for working with survivors of GBV.

Learning Objectives

By the end of this module, you will be able to:

  • Define and explain the importance of “survivor-centered approach”.
  • Demonstrate non-judgmental and non-stigmatising attitudes when talking with patients about GBV.
  • Use communication skills such as open-ended questions and active listening techniques.
  • Use appropriate language and body language to communicate with patients about GBV.

Learning Activities

  • Reading: Sipho’s Story (5 min)

    A 36 year-old man arrives at the health clinic. He is shaking and disheveled. He walks carefully as if he is in pain.

    The nurse in-charge comes to the waiting room. In front of the other patients, the nurse asks the man about the purpose of his visit.

    Nurse: Where have you come from? Why are you here?

    Man: My name is Sipho. I was… My boyfriend has attacked me.

    Nurse: How did your boyfriend attack you? Did you anger him in some way? Had the two of you been drinking? Did he rape you? Are you in pain right now?

    Sipho: No, he drinks sometimes but I had done nothing wrong. He became angry when I said I was too tired to have sex. He hit me, and then he forced me to have sex.

    Nurse: We can do a rape kit so that you can press charges with the police. Let’s go. I’m sorry but I have many other patients and we don’t have much time.

    How do you think the nurse handled this interaction with Sipho? In the box below, type in 2-3 ways the nurse could have handled the interaction better. Then tap the compare answer button to compare your answer to an expert’s.

    This module will address more effective communication strategies for handling these issues.

  • Reading: Human Rights and the Survivor-Centred Approach (5 min)

    Before we learn about the best practices for interacting with GBV survivors, let us focus on an important concept that forms the basis for survivor-centred care: human rights.

    International agreements identify human rights as the right to:

    • A life free from fear and violence.
    • The ability to make decisions including sexual and reproductive decisions for oneself.
    • The ability to refuse medical procedures.
    • The ability to take legal action.
    • Access to high quality health services that are available and acceptable to women.
    • Access to health care services offered without discrimination (treatment is not refused based on race, ethnicity, caste, sexual orientation, religion, disability, marital status, occupation, or political beliefs).
    • Access to care, treatment, and counselling that is private and confidential and that information is disclosed only with the consent of the patient.
    • Access to information that has been collected about one’s health (including medical records).

    What does this mean in the health care setting? It means that you should treat all suspected and confirmed survivors of violence fairly and respectfully without discrimination.

    A survivor-centred approach to caring for survivors of gender-based violence seeks to empower the survivor by emphasizing their rights, needs, and wishes. It means treating the survivor with dignity and respect and providing a supportive environment during their care. The health care provider or legal team should seek to empower the survivor to make their own choices. The role of the provider is to give the survivor the information they need to make informed decisions about their medical and psychological care and legal options. A survivor-centred approach also means ensuring that the survivor can access the highest quality care and services.1 This might involve providing them with information about legal options, safe housing options, counseling options, and information on STI and other testing as well as helping them understand pros and cons of pursuing different options. In this module we will discuss how good communication skills, including asking questions in a helpful way and doing active listening, can help empower a survivor to make their own choices.

    Experiencing gender-based violence can make survivors feel powerless. The survivor-centred approach works to restore that power and helps survivors begin to recover through while empowering them.

    Respectful, caring communication is a key element in providing survivor-centred care and services. Appropriate communication will help you get the information you need to provide the right care to the survivor, and will give the survivor the support they need to help cope with their experience of violence.

    When treating survivors of GBV, be sure to:2

    • Reinforce their value
    • Respect their dignity
    • Listen to their stories, taking what they say seriously
    • Respond in a way that does not blame or judge them
    • Provide information and counselling so they can make their own decisions

    When talking to a patient about violence, be sure to show that you are listening and that you care.

    The next section of this module focuses on communication skills.

  • Reading: Being Nonjudgmental (5 min)

    When providing care for survivors, it is crucial that you are not judgmental. You may not always approve of the survivor’s decisions or feel comfortable with what she chooses, but you must remain neutral and nonjudgmental. The wishes of the survivor should determine what kind of care you provide.

    Informing versus advising

    Your role as the healthcare provider is to provide services and information. It is not your role to advise the survivor on the best course of action. Advising is a form of judging what is best for someone else. A survivor-centred approach leaves it to the survivor to weigh her options and decide what to do. Your obligation is to provide complete and accurate information about the options that are available, as well as clear information on the limitations of the services you can provide and what she can access via referral.


    Survivor-Blaming

    Placing blame on the survivor for her assault or judging her does not show respect, nor does it help focus on the needs of the survivor as required by the survivor-centred approach. Blaming the person can lead to the survivor feeling victimized all over again and create more trauma (secondary trauma).

    Language can carry hints of blame or can stigmatize a person. For example, many people refer to women who have experienced sexual assault as “victims”. This training refers to them as “survivors” to highlight that the person is not merely someone to which a terrible thing has been done. They have actively survived, and this demonstrates power. However, individuals themselves may choose to call themselves survivors or victims, according to their preference.

    Tips to avoid blaming:

    • Avoid “Why” questions (“Why were you…”).
    • Do not emphasize the survivors’ behavior, such as if they were drinking or in a dangerous location when the violence occurred. These are not causal factors for violence.
    • Treat all survivors with respect and dignity regardless of the circumstances of the violence.

    Which of the following statements indicate judgement or blame?

  • Case Study: Eliminating Survivor Blame (5 min)

    Recall the case of Sipho from the beginning of this module. Sipho presented to the clinic after being assaulted by his boyfriend. The nurse says to Sipho “I want to be sure that you’ve had a chance to tell me anything you want me to know. Is there anything else you would like to talk about?”

    Sipho replies “I feel like if I hadn’t made him mad, this wouldn’t have happened. I’m scared I’ll make him even angrier if he finds out I came here.”

    What is the best way for the nurse to respond? (Select all that apply.)

    This case study adapted from the IRC Clinical Care for Sexual Assault Survivors Psychosocial Toolkit.

  • Reading: Using Active Listening (10 min)

    Active listening is a set of behaviors showing a person that you are paying attention. It includes body language and a nonjudgmental stance.

    Listening is the most important part of good communication. It may be the most important thing you can do to support and care for a survivor of GBV. It involves more than just hearing the survivor’s words. It means:

    • Being aware of the feelings behind their words
    • Being sensitive to both what they say and what they do not say
    • Paying attention to body language

    Click or tap on each component of active listening to learn more.

    How you act:
    • Be patient, calm, and gentle.
    • Do not pressure the survivor to tell you their story or to keep talking.
    • Let them know you are listening by nodding your head or responding verbally.
    • Do not look at your watch or the clock.
    • Do not speak too rapidly.
    • Do not answer the telephone, look at the computer, or write.
    • Allow for silence.
    • Allow patient/ survivor to speak in their own language.
    • Avoid using medical jargon.
    Your attitude:
    • Acknowledge the survivor’s feelings.
    • Let the survivor go at their own pace. Do not rush them.
    • Do not judge what they have or have not done (e.g., destroying evidence by taking a shower) or how they are feeling.
    • Let go of your own fears and prejudices, as they may be sensed even if you do not intend to show them.
    • Do not express negative opinions about the patient or others.
    • Do not think and act as if you must solve their problems for them.
    • Do not make promises you cannot keep (for example, never promise the patient that the perpetrator will be arrested).
    • Do not contact the perpetrator or others to hear their side of the story.
    Body language:3
    • Face your patient squarely with your shoulders facing them.
    • Keep an open posture; do not cross your arms across your body (a closed posture).
    • Sit or stand at the same level and close enough to the survivor to show concern and attention but not so close as to intrude. Sitting at the same level is especially important when addressing children.
    • Maintain regular, gentle eye contact that is culturally appropriate (i.e., do not stare, understand that patients may avert their eyes to show respect to authority, etc.).
    • Maintain a relaxed posture; do not fidget, tap your foot, click your pen, etc.
    What you say:
    • Give them the opportunity to say what they want.
    • Encourage them to keep talking if they wish.
    • Do not interrupt.
    • Wait until the survivor has finished before asking questions.
    • Stay focused on the survivor; do not share stories about yourself or other people.4
    • Avoid using leading questions.
  • Activity: Open-Ended Questions (5 min)

    Recall Sipho, the man who presented at the Primary Health Centre at the beginning of this module after being assaulted by his boyfriend. What are some open-ended questions you can use to explore Sipho’s story?

    For each question, move the slider to indicate whether the question is open-ended or closed-ended (meaning that the question can be answered "yes" or "no" or with a specific piece of information).

    What happened between you and your boyfriend that led you to come here?
    Have you been assaulted?
    Why don’t you start your story from the beginning?
    How did you come to be here at the PHC?
    Going to your boyfriend’s house late at night wasn’t a very good idea, was it?
    What can I do to help you today?
    You’ve been raped, haven’t you?
    What would you like to talk about with me today?
  • Reading: Using the OARS Model (10 min)

    When talking to a survivor about their story, it is important to pay attention to what they express as their needs and concerns. Also pay attention to what they do not say: you can learn a lot from their body language and moments of silence. The OARS Model5 is an approach to communication using verbal and no-verbal techniques that is helpful when trying to understand a survivor’s needs. Click or tap on each skill to learn more about it.

    Open-ended questions

    Open-ended questions are questions that cannot be answered with a simple yes or no, or a one-word reply. Open-ended questions encourage the person to talk instead of answering with one word or short phrases. Using open-ended questions will help you more efficiently learn what has happened to your patient. The patient should be doing most of the talking. When you ask open-ended questions, you are asking the person to think, reflect, and give you her opinions and feelings. The respondent has control of the conversation.

    The purpose is to:

    • Establish a safe environment and build a trusting and respectful relationship.
    • Explore, clarify, and gain an understanding of your patient’s world.
    • Learn about the patient’s past experience, feelings, thoughts, beliefs, and behaviours.
    • Gather information.
    • Help the patient make informed decisions.

    How to ask open-ended questions:

    • Phrase your questions as invitations to speak.
      • What would you like to talk about?
      • Could you tell me more about that?
    • Ask ‘how’ or ‘what’ questions.
      • How do you feel about that?
      • What happened next?
    • Avoid ‘why’ questions because people may feel defensive (for example, ‘Why did you do that?’). The person may feel like you are asking her to justify a decision or behavior.
    • Do not ask leading questions, such as ‘I would imagine that made you feel upset, didn’t it?’

    Be sure to ask for clarification if you do not understand a survivor’s response to your question.

    Affirmations

    Affirmation statements acknowledge positive aspects of the patient’s life and can be about what a patient has done or a personal strength or ability of hers. You should listen carefully to what your patient is telling you before making affirmation statements.

    The purpose is to:

    • Build rapport, demonstrate empathy, affirm exploration into the patient’s world.
    • Affirm the patient’s past decisions, abilities, and healthy behaviours.
    • Build a patient’s confidence.

    Examples of affirmation statements:

    • I’m so glad you came to the clinic today—it’s not always easy.
    • You don’t deserve this.
    • I’m sorry this happened to you.
    • It shows a lot of strength that you went to your sister for help.
    Reflective listening

    Reflective listening shows the patient that you are listening intently and understanding what she is saying. With this skill, you should listen carefully, observe the patient’s body language and behaviour. Let the patient know you have heard and understood her by repeating back what she said in your own words. By using reflective listening you can help a patient make more thoughtful decisions.

    The purpose is to:

    • Demonstrate that you are listening and trying to understand the situation.
    • Offer the patient an opportunity to ‘hear’ her own words, feelings, and behaviours reflected back to her.
    • Reflect the patient’s general experiences and ‘in the moment’ experience of the clinic visit.
    Summarising

    Summarizing can be used to briefly restate the main points covered in the patient provider interaction, link two pieces of a conversation, or transition to a new topic. Some examples of summarizing might include:

    • Let’s go over what we have talked about so far.
    • A minute ago you wanted to… Maybe now we can talk about how you might try…
  • Quiz: Communication Dos and Don’ts (10 min)

    For each statement, move the slider to whether you should communicate that way (“do”) or whether you should not communicate that way (“don’t”).

    Nod your head or say, “Ah, I see,” from time to time to show that you are listening.
    Wait until the survivor has stopped speaking before you ask a question.
    Cross your arms while talking or listening to a survivor.
    Push a survivor to keep talking if she has not provided enough details.
    Give her the chance to tell you what help she wants from you.
    Use leading questions.
    Try to finish her thoughts for her.
    Assure her that you will protect her confidentiality.
    Tell a survivor what she should do next.
    Repeat back what she has said in your own words to check for understanding.
    Maintain gentle eye contact and a relaxed posture.
    Tell a survivor, “You should be grateful that you are alive”.
    Use open-ended questions.
    Share stories of similar things that have happened to people you know or to other patients of yours.
    Take notes on your computer or take a phone call while consulting with the survivor.
    Phrase your questions as invitations to talk.
  • Reading: Key Points (5 min)

    To sum up, here’s what you learned in this module:

    • The survivor-centred approach emphasizes the importance of respecting the survivor’s needs and wishes.
    • Reassure the Survivor that it is not her fault and that you believe her.
    • It is important to be non-judgmental when working with survivors. Showing judgment can re-traumatize a survivor of GBV and add to their difficulties.
    • Do not tell a survivor what to do or try to solve her problems for her.
    • Listening means more than hearing a person’s words. It means attending to what they say, what they do not say, what they express with their bodies, respecting silences, and showing empathy.
    • Open-ended questions are better at bringing forth useful information than closed-ended questions.
    • Reflective listening techniques help clarify meaning and highlight the survivor’s perspective.
    • Active listening techniques demonstrate respect and support for the survivor and create a safer environment for her to share her story.
    • Gently encourage a survivor to talk if they wish but never force them to do so.
  • References
    • 1United Nations. End Violence Against Women Now
    • 2WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 pp 3-5.
    • 3International Rescue Committee. Clinical Care for Sexual Assault Survivors Psychosocial Toolkit. 2014.
    • 4WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 pp 17-19.
    • 5 Miller, W.R. et al. The OARS Model: Essential Communication Skills. In Motivational Interviewing: Preparing People for Change. 2nd Edition. NY Guilford Press. 2002.