evidence and practice
Open Access Empowering migrants during the resettlement process: applying Peplau’s theory of interpersonal relations
Irene Nakasote Ikafa Lecturer in Nursing, Faculty of Medicine and Health, University of New England, New South Wales, Australia
Colin Adrian Holmes Adjunct Professor, College of Medicine and Dentistry, James Cook University, Queensland, Australia
• To enhance your awareness of the issues that involuntary migrants commonly experience during the resettlement process
• To recognise the potential benefits of applying Peplau’s theory of interpersonal relations to support and empower involuntary migrants
• To understand the improvements to migrant support services that could be made
Background For many people, known as involuntary migrants, emigration is a last resort to escape armed conflict and persecution. Emigration may have positive outcomes for these people, but they may also experience several associated stressors that can have a negative effect on the resettlement process, particularly where there are significant lifestyle and cultural differences.
Aim To explore the issues affecting involuntary African migrants during their resettlement process in Western Australia and how Peplau’s theory of interpersonal relations could be used to inform how migrant support services could be improved to empower and support migrants.
Method An exploratory, qualitative research design was used. In-depth interviews were conducted with 30 involuntary migrants and five migrant support service providers. Thematic content analysis was used to identify themes from the data.
Findings Eight themes emerged from the data: reasons for migration; multiple losses; isolation and loneliness; employment issues; financial constraints; racial discrimination; migrants’ needs; and migrant support services.
Conclusion Migrant support services were often not easily accessible, culturally appropriate or sufficient for involuntary migrants. Peplau’s theory could be used to guide and empower migrants as they use support services and navigate the resettlement process.
Mental Health Practice. doi: 10.7748/mhp.2020.e1469Peer review
This article has been subject to external double-blind peer review and has been checked for plagiarism using automated softwareCorrespondence
Ikafa IN, Holmes CA (2020) Empowering migrants during the resettlement process: applying Peplau’s theory of interpersonal relations. Mental Health Practice. doi: 10.7748/mhp.2020.e1469Open access
This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0) (see https://creativecommons.org/licenses/by/4.0/), which permits others to copy and redistribute in any medium or format, remix, transform and build on this work, even commercially, provided appropriate credit is given and any changes made indicated.
Published online: 21 July 2020
black and minority ethnic - culture - discrimination - diversity - ethnicity - mental health - multiculturalism - nurse-patient relations - patients - patient empowerment - professional - racism - transcultural care
Migrants include voluntary and involuntary migrants who have no intention of going back to their homeland (Muggah 2003, International Organization for Migration 2015). Voluntary migrants choose to move to another country, for example to seek employment and better life opportunities. In contrast, involuntary migrants – also known as refugees or forced migrants – are forced to leave their countries to escape civil wars, armed conflict, persecution or other disasters, and cannot return because of a well-founded fear of persecution (Toole and Waldman 1993). They may have experienced sudden unrest in their country and been forced to leave immediately amid chaos and uncertainty about the future (Crowley 2009).
Involuntary migrants may consider themselves fortunate when they arrive in their host country and are often relieved to be in a comparatively safe environment (Ward 2000, Irfaeya 2006). However, their resettlement can quickly become stressful as they experience issues finding their way around their new city or town and are unsure of how to accomplish daily activities such as using public transport, purchasing goods and using household utilities, as well as other unfamiliar community services for example public swimming pools. According to Pittaway et al (2009), involuntary African migrants have lived in refugee camps for long periods, with many of their children born and raised in these camps; they can experience issues in adjusting to their new circumstances (Abkhezr et al 2018).
This article reports on a study to explore the issues affecting involuntary African migrants during their resettlement process in Western Australia, undertaken in response to the increasing numbers migrating to Australia (Australian Bureau of Statistics 2011). Peplau’s (1952a, 1952b) theory of interpersonal relations was used as the theoretical framework for the study, in view of involuntary migrants’ need for interpersonal support. Although this theory is specific to mental health practice, it can be applied to all areas of care, and could empower and assist migrants with the resettlement process in their host country.
Involuntary African migrants may experience language barriers, social isolation, racial discrimination and unemployment, all of which can have a detrimental effect on their resettlement (Pittaway et al 2009, Abur 2018). Language issues are a crucial factor for migrants to Australia from non-English speaking countries, and Pittaway et al (2009) found that lack of proficiency in the English language negatively affects the ability of involuntary African migrants to obtain employment.
The experience of social isolation and loneliness is also common among all migrants to new countries because of separation from their extended family members, friends and the loss of social networks (Ward 2000, Murray 2010). Ogunsiji et al (2012) found that West African women in Australia experienced issues in developing social networks and obtaining employment; this led to feelings of loneliness and isolation, which negatively affected their mental health.
Subsequently, involuntary migrants are often profoundly affected by homesickness. Although this is not well understood, many studies have found it to be a common consequence of transcontinental migration (Eisenbruch 1991, Redwood-Campbell et al 2008, Rosbrook and Schweitzer 2010). For involuntary migrants, even those escaping conflict and persecution, homesickness can become so distressing that the only acceptable resolution is to return to their country of origin, regardless of the cost or dangers involved.
To compound these issues, experiences of racial discrimination are common among non-white migrants in countries such as Australia where the established population is predominantly white. African migrants can be subjected to clear discrimination (Guilfoyle and Harryba 2009, Guilfoyle and Taylor 2010, Salleh-Hoddin and Pedersen 2012). Fozdar and Torezani (2008) found that involuntary migrants in Australia experienced high levels of discrimination, while Shakespeare-Finch and Wickham (2010) found that six out of 12 Sudanese refugees in their study experienced racial discrimination and verbal abuse. These experiences resulted in feelings of exclusion, fear and regression. Participants also stated that racial discrimination made it highly challenging for them to find employment in Australia.
Involuntary migrants need to be empowered when they arrive in a host country such as Australia because they can experience challenging situations. Solomon (1976) described an American programme in which empowerment is offered as part of a problem-solving strategy for stigmatised people such as refugees. Cochran and Dean (1991) asserted that local communities can have a significant role in the empowerment of migrants, for example providing interpreting services and assisting in the validation and recognition of overseas qualifications (Spinks 2009).
There is no specific research on the importance of empowerment in the resettlement of involuntary migrants; therefore, this study aimed to address this gap by evaluating support services and using Peplau’s theory as a framework to support and empower involuntary migrants during their resettlement process.
Peplau’s theory of interpersonal relations
In Hildegard Peplau’s (1952a, 1952b) theory of interpersonal relations, the therapeutic relationship between the nurse and the client is central to mental health practice. Peplau’s theory aims to facilitate problem-solving and coping skills in the context of this relationship, to provide effective care and work towards resolving the client’s mental health issues. The relationship comprises three phases: orientation, working and termination (Box 1).
Phases of Peplau’s theory of interpersonal relations
• The client identifies a need and seeks professional assistance and support
• The mental health nurse meets the client as a stranger, they exchange views and the nurse clarifies their role in the process
• The nurse develops rapport and trust with the client, establishing a therapeutic relationship with them
• In this phase, it is crucial that the nurse demonstrates interest in the welfare of the client, while encouraging them to ask questions and voice their needs
• The nurse recognises that the client has the power to address their issues, which will emerge from the therapeutic relationship
• The client identifies the nurse as someone who can assist them with their issues
• The mental health nurse undertakes the roles of counsellor, advocate and teacher, and identifies the client’s needs or issues to be addressed, such as anxiety, social isolation, low self-esteem and confusion
• The nurse introduces the client to available healthcare services and resources
The mental health nurse undertakes the resource and leader roles, working with the client to plan, implement and evaluate their care. The client uses the therapeutic relationship and the resources being offeredThe mental health nurse educates the client about their condition, assists them to develop their problem-solving and coping skills, and facilitates the client’s goal settingAs the client becomes increasingly independent, the power shifts from the nurse towards the client
• The client begins to feel that their situation has improved, and starts planning and pursuing their goals
• Effective communication and interaction with other clients, nurses and non-clinical staff are maintained, while the client establishes alternative sources of support
• The nurse can undertake the leader and resource roles, encouraging social and physical activities to enable the client to achieve a normal, productive and fulfilling life. Progress can be satisfying for the client and the nurse
• There is a mutually agreed termination of the therapeutic relationship between the nurse and the client
Peplau’s theory also includes six therapeutic relationship roles that mental health nurses can undertake: stranger, advocate, counsellor, teacher, leader and resource roles. Mental health nurses are required to use various therapeutic skills, including being present, authentic, respectful, using active listening skills and demonstrating empathy to clients (Dziopa and Ahern 2009, Delaney and Ferguson 2011, Moreno-Poyato et al 2016). This theory provides a framework that mental health nurses working with involuntary migrants can use for interpersonal support.
To explore the issues affecting involuntary African migrants during their resettlement process in Western Australia and how Peplau’s theory of interpersonal relations could be used to inform how migrant support services could be improved to empower and support migrants.
The study used an exploratory, interpretive, qualitative research design, which forms part of the PhD of the lead author (INI) about the resettlement experiences of African migrants in Australia and the support services available to them.
The participants included ethnic African migrants from sub-Saharan African countries living in Western Australia. Convenience and purposive sampling methods were used to recruit participants.
People were invited to participate in the study if they met the following inclusion criteria:
The exclusion criteria were:
The five migrant support service providers who participated in the study were managers or senior officers working in organisations funded by the government (Box 2).
Migrant support service providers who participated in this study
• Provider 1 – the president of the African Community Association of Western Australia, which provides assistance and information about support services to African community leaders, who then disseminate it to their communities
• Provider 2 – worked for the Ethnic Communities Council of Western Australia, which provides information and support to various ethnic groups in Western Australia
• Provider 3 – worked for a migrant resource centre that provides long-term settlement services to support the integration of involuntary migrants into communities
• Provider 4 – worked for the Association for Services to Torture and Trauma Survivors, which provides a free confidential counselling service for survivors of trauma and torture
• Provider 5 – worked for Centrecare Migrant Services, which provides long-term settlement services to involuntary migrants
Participants were recruited using several approaches. Flyers describing the study were distributed and displayed in public places around the Perth metropolitan area. Participants were also recruited from the social networks of the lead author. A total sample of 30 involuntary African migrants and five migrant support service providers was obtained. Of the involuntary migrant participants, 19 were female and 11 were male. Eight participants were aged 21-30 years, four participants were aged 31-40 years, 13 participants were aged 41-50 years, and five participants were aged 51-60 years. All the participants came from war-affected countries, including Burundi, Democratic Republic of the Congo, Liberia, Somalia, Sudan, Sierra Leone and Zimbabwe.
Data collection and analysis
The qualitative data were collected using in-depth, face-to-face interviews with African migrants about their experiences of the resettlement process and their perspectives on migrant support services. Migrant support service providers were also interviewed about their perspectives of migrants’ needs and support services. The interviews took approximately 45-60 minutes to complete. Interviews were audiotaped with the participants’ permission, then transcribed for analysis.
The data were analysed using thematic content analysis with open coding, with each transcript being read and reread to ascertain the meaning of its content. Similarities and differences in the data were identified and colour-coded, and words capturing similar ideas were captured to create broad categories, which were then reduced to develop the final themes for analysis.
Approval to conduct the study was granted by the Human Research Ethics Committee of Murdoch University, Perth Campus, Western Australia. Informed consent was obtained from all participants. The participants were assured of complete confidentiality and anonymity, and that any response would be identified only by a number or pseudonym that could not be traced to any specific person.
Eight themes emerged from the data analysis:
• Reasons for migration.
• Multiple losses.
• Isolation and loneliness.
• Employment issues.
• Financial constraints.
• Racial discrimination.
• Migrants’ needs.
• Migrant support services.
Reasons for migration
Eleven participants stated that they escaped from civil war and persecution from their homeland and had lived in refugee camps in neighbouring countries before they were finally resettled in Australia with a refugee status:
‘It’s actually civil war which made me come to Australia. There was no peace in my country; we were running away from rebels that were fighting with the government soldiers, so we had to run for our lives, got to a neighbouring country and stayed in the refugee camp until we had the opportunity to come here’ (participant 13).
Participants experienced multiple losses, including the loss of their culture, food, family, friends and social networks:
‘Oh, heaps [of losses] – your family and the support network. It’s not there – it takes a lot to build that up’ (participant 11).
Isolation and loneliness
Some participants felt isolated and lonely, missing the social and extended family support to which they were accustomed:
‘I started to distinguish things and I found that [Australians] are very secluded; they don’t like to mingle if they don’t know you. Like, we have neighbours who we have lived next to our house for several years, but we hardly say “hi” – we just pass each other… We give them their space and they give us our space’ (participant 12).
A significant cause of stress and frustration identified by ten participants was related to finding employment:
‘I would say, not finding work in my field that I studied, like I did my university degree [in Australia] but I haven’t got a job in line with my career, which is so distressing and frustrating’ (participant 7).
‘Though we may have education back in our homeland, we come [to Australia and] we struggle to have our qualifications recognised and, if they are recognised, the next battle is to find a job in your profession’ (participant 8).
‘I am a little confused because I thought by now I would be well settled [with a job] and be comfortable’ (participant 23).
‘It’s not easy to get job opportunities. When you come and you are new – they always look at your experience in Australia, so it’s very hard to find a job’ (participant 24).
Many male participants identified their main concern as being associated with financial constraints. They reported that it was easier to find minor jobs than professional jobs (those that require specialised knowledge and advanced education or training):
‘Of course there are financial difficulties because, when we Africans come to Western countries like Australia, we have a financial handicap because of unemployment. There are barriers of stereotyping whereby, people look at you and assume certain things about you that can even affect you in a harmful way mentally when you are looking for jobs’ (participant 6).
Many participants reported that racial discrimination was present in the employment market, workplaces and community. More than half of the involuntary migrants (n=18/30) who were interviewed reported that they or their family members had experienced racial discrimination:
‘I think racism [is] unfortunately grounded in the history of this country, so it is something that people will find very difficult to escape from and it is going to be around for a long time. I’m not talking about the racism where people call you names or where you walk on the street and someone says “go [back to your] home”, but silent racism… Especially when you go to institutions, you get that silent treatment – turning heads and treating you like you don’t exist. You’re standing right there, but you don’t exist’ (participant 18).
‘I would say one thing that still sticks to my mind for me is racism here – it is there, but it is subtle and many times people do not want to talk about it. About a year ago somebody came to my property and grafted it, and it had racial slur’ (participant 29).
The five migrant support service providers identified some common needs among African migrants. They reported that it is important for people coming from refugee camps to be shown how to use basic household utilities, taught how to use common community infrastructure and orientated to the Australian cultural and legal system:
‘I suppose needs that we see amongst people – refugees – is getting used to a new culture, using ATMs [automated teller machines] and public transport. I suppose another need is linking people with their community, so that they can visit on a regular basis, like in the Mirrabooka area, there are so many Sudanese people and they feel comfortable living there’ (provider 3).
‘Coming from refugee camps to come to a big city like Perth can be overwhelming due to cultural shock. They need to learn a new system [in Australia]’ (provider 4).
‘We pick them from the airport, show them how to use household utilities, and straight away they start asking, “When are we going to school? When are we learning English?”’ (provider 5).
The migrant support service providers reported that they mainly supported refugees:
‘The refugees need high level of support. A lot more of our energy goes into just putting a lot more structured education in place such as educating them how to use household utilities. Effectively, for the first six weeks we answer any questions. “I want to enrol my children in school”, [so] we work out what schools are available, how they get there – it’s the real practical support’ (provider 3).
Migrant support services
Perspectives of migrants
All involuntary migrants reported that they received migrant support from the Integrated Humanitarian Settlement Strategy when they arrived in Australia and were provided with initial intensive settlement support. Participants also reported that they were able to access other migrant support services provided by the government such as Centrelink, Medicare and public housing:
‘I did [receive support], like Centrelink and at the moment, I’m living in a Homeswest house – government [public] housing’ (participant 13).
‘Yes, just like everyone who comes here on a refugee visa, we get support. We come as permanent residents and get support from Centrelink’ (participant 22).
‘I was able to get migrant support services because we were brought here by the United Nations High Commission for Refugees, so there was that support’ (participant 26).
Most participants suggested that support services should be broader and culturally appropriate for migrants.
Perspectives of migrant support service providers
The five migrant support service providers reported that migrant support services were not easily accessible by African migrants and they were insufficient to meet their needs:
‘We only give emergency relief assistance to new migrants. For example, we give phone vouchers. We also give them Coles vouchers to assist them with their initial settlement’ (provider 1).
‘To be honest, I look at it in the grand scheme of things. My main reason for saying this is that I don’t think there’s enough [support for migrants]. There’s enough people providing services, but they don’t provide broad enough services for everyone [such as] individualised English language tuition’ (provider 3).
‘We assist them with many basic skills such as showing them how to use public transport and how to use ATMs to access banks and we introduce them to the legal system in Australia. Refugees are given three weeks to learn about the system, this is not enough’ (provider 4).
‘I don’t think there’s enough support and there’s not enough coordination of what goes on to people. It may be there, but people don’t know because of communication barriers’ (provider 5).
The migrant support service providers recommended several improvements to support services that could be made, such as consulting with migrants, adapting services to meet their needs and coordinating long-term services.
In this study, all the participants had escaped armed conflict and persecution from their countries. They reported that they had experienced multiple losses, isolation and loneliness, and were missing the social and extended family support to which they were accustomed. Perlman and Peplau (1981) stated that loneliness is a negative feeling that follows when people feel that their interpersonal relationships with others are not sustaining their emotional needs. Therefore, migrant support services need to explore and address involuntary migrants’ relational and emotional needs.
Several male participants identified financial constraints were an issue because they had difficulty finding employment in Australia. In addition, many of the participants in this study had experienced employment issues, particularly finding professional jobs, which was a significant cause of frustration. Similarly, Pittaway et al (2009) established that unemployment among African migrants in Australia has been heightened by racial discrimination and lack of work experience. The Refugee Council of Australia (2011) also reported that employment services were not effective in supporting this group of migrants to find work.
Most of the participants reported that they or their family members experienced racial discrimination, and that this was present in the employment market, workplaces and community. These findings are consistent with those of other studies. For example, in the UK, Hack-Polay and Mendy (2018) established that, irrespective of their qualifications, migrants were often rejected from employment opportunities. In the US, Heger Boyle and Ali (2010) also concluded that racial discrimination affected involuntary migrants’ ability to obtain formal employment, while Murray’s (2010) study of Sudanese migrants in Australia found that one third of participants experienced discrimination. Another Australian study by Fozdar and Torezani (2008) also found that refugees experienced high levels of perceived discrimination.
Applying Peplau’s theory to the resettlement process
During the orientation phase of Peplau’s (1992) theory of interpersonal relations, the nurse meets the client as a stranger, establishes a therapeutic relationship with them, and identifies their immediate needs. The Integrated Humanitarian Settlement Strategy is the first settlement and healthcare service agency with whom all involuntary migrants in Australia have contact. The mental health nurses, doctors and other professionals who work for this agency provide initial assessment of involuntary migrants’ needs and intense settlement support on their arrival.
The migrant support service providers in this study reported that they collected refugees from the airport, undertook orientation, showed them how to use household utilities, assisted them with shopping and answered any questions. They also ensured that migrants had access to support services that met their immediate needs such as Centrelink, Medicare and healthcare services. Mental health nurses working for the Integrated Humanitarian Settlement Strategy can also recognise issues such as homesickness, isolation, loneliness, anxiety and stress and refer them for counselling. It is essential that all those working with this group of migrants exercise interpersonal skills and communicate clearly to identify and address migrants’ immediate needs, which may differ from one person to another.
The working phase of Peplau’s theory comprises identification and exploitation subphases. During the identification subphase, healthcare professionals such as mental health nurses working for the Integrated Humanitarian Settlement Strategy can identify and assess involuntary migrants’ signs of trauma, anxiety and refer them to services such as the Association for Services to Torture and Trauma Survivors for free confidential counselling. Mental health nurses can also ensure that new arrivals have access to healthcare resources, teach them coping strategies and problem-solving skills and support them to set goals for their future. During the exploitation phase, involuntary migrants can be encouraged to use community services, such as public libraries and public swimming pools. Appropriate uptake of community services and facilities can result in greater community integration of migrants and promote their mental health.
The migrant support service providers in this study reported that people coming from refugee camps needed to be shown how to use common community infrastructures. They acted as resource experts, teachers and advocates for migrants, and educated them how to use ATMs, public transport, public libraries and swimming pools. They also enrolled their children into schools and encouraged migrants to undertake apprenticeships or further their education at technical and further education institutions or universities to increase their chances of finding employment.
The migrant support service providers reported that they provided a high level of support to involuntary migrants. During the termination phase of Peplau’s (1952b, 1997) theory, involuntary migrants begin to feel settled and work towards achieving their goals. They become self-reliant, independent and able to obtain employment. Shakespeare-Finch and Wickham (2010) identified support strategies such as the establishment of wider migrant support networks that can assist and empower involuntary African migrants and facilitate their integration into their new country and community. Once they are well integrated, involuntary migrants can successfully compete for employment and cease to depend on support services provided by their community and government. Migrant support service providers and mental health nurses can reassess involuntary migrants and ensure they remain settled, then mutually agree to terminate the relationship.
Participants may have self-selected by being able to read recruitment flyers because no participant required assistance with reading or an interpreter. In addition, the participants were recruited from one state in different areas of the Perth metropolitan region in Western Australia, which limits the generalisability of the study findings.
This study explored the issues that may affect involuntary African migrants during their resettlement process in Australia. The participants reported that they used support services, but that these were often not sufficiently broad or culturally appropriate. Migrant support service providers identified that involuntary migrants required a high level of support and that the available support services were inadequate and not easily accessible. They recommended several improvements that could be made to these migrant support services, such as consulting with migrants, adapting services to meet their needs and coordinating long-term services.
This study appears to be the first to use Peplau’s theory of interpersonal relations to identify how migrant support services might be improved to ensure they offer effective support for involuntary migrants. Peplau’s theory can be used by mental health nurses and migrant support service providers to guide and empower involuntary migrants as they use these services to navigate the resettlement process.
Implications for practice
• Mental health nurses could use Peplau’s theory of interpersonal relations as the basis for working with migrants to empower and support them during the resettlement process
• Mental health nurses need to continuously update their knowledge and be aware of the services and resources available for migrants and ensure all migrants can access these services if necessary
• Migrant support services can be improved by consulting with migrants, adapting services to meet their needs and coordinating long-term services
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Assessing the benefits of social prescribing
Social prescribing provides GPs and other healthcare...
Patient empowerment through information
There is widespread agreement that patients should be...