Older persons’ worries expressed during home care and supportive communication: Analysing audio-recorded visits

Background: Person-centred care is advocated as the gold standard for delivering quality healthcare services for older persons in general, and for home care in particular. Personcentred care means being respectful of and viewing the person’s own preferences and understanding of his/her health and emotional well-being, values and spiritual beliefs, while planning, executing and evaluating healthcare. The moments when the older person shares and discusses his/her emotional well-being with the visiting nursing staff is termed emotional communication and this term may be used as a lens to explore features of communication relevant for person-centred care. There is currently a lack of insight into how emotional communication during home care visits is carried out, and how the discussion of emotions - in particular older persons’ worries - are discussed. Given that these aspects are essential to the well-being of older persons, the focus of this thesis is on exploring expressions of worries and the nursing staff’s responses to these worries. Aims: The overarching aims of this thesis are: a) to explore how older persons express their worries to nursing staff during home care visits, b) to investigate how the nurses and nurse assistants respond to the worries expressed, and c) to discuss the findings within a supportive communication framework and discuss whether current communication behaviour is likely to facilitate person-centred care delivery in home care services. These aims are achieved in three studies which are described in this thesis comprising three papers as well as a general discussion. Design, materials and methods: This study was part of an international research project with the acronym COMHOME, designed as a cross-sectional study. The material analysed included 195 audio-recorded home care visits in Norway collected from four units of home care during December 2013 and May 2014. The visits captured communication between 48 older patients (≥65 years) and nursing staff (n=33), including nurse assistants (n=17) and registered nurses (n=16). The visits collected varied in length, number of tasks and complexity to be managed during the visit, time of day and day of the week. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) was used to identify expressions of distress and the subsequent responses by providers. Two coders applied the system to the complete material. The inter-rater reliability, Cohen’s kappa, was >0.6. Data were subsequently analysed using both a qualitative and a quantitative approach. Drawing on the qualitative analysis, a coding scheme for thematic content in patients’ expressions of worries was developed. Paper I and paper III: Statistical testing explored associations between variables. Sum-categories were computed for the specific VR-CoDES categories covering patient expressions of worries and the nursing staff’s responses. VR-CoDES categories were clustered together based on the definitions provided by the system. Sum categories of patient expressions of worries included: a) verbal and non-verbal expressions referring to emotion, b) references to unpleasant states/circumstances, and c) contextual hints of emotion. The nursing staff’s responses were grouped based on communicative function and divided into emotion-focused responses, content-focused responses and responses ignoring/blocking the cue/concern. Group differences were analysed using Pearson’s chisquared test or Fisher’s exact test. In paper I, a logistic regression model was included to test which variables promoted responses that allowed further disclosure of emotion (emotion-focused responses). In paper III, adjusted residuals (cut-off set at ≥2/≤–2) were used to guide analysis of associations between what types of nursing staff responses were associated with specific themes and sub-themes of worries. Paper II: The qualitative analysis included a novel two-step approach, starting by deductively identifying expressions of worry using the VR-CoDES in 38 of the visits. Then these emotional moments in the communication, through studying the transcripts of the expressed emotions combined with listening to the whole of the conversations, were inductively approached using qualitative content analysis. Findings: Paper I showed that 74% of visits were identified with one or more expressions of distress as described by the VR-CoDES. Worries were usually expressed as hints to distress rather than as explicit statements in which a negative emotion was named. Nursing staff most often elicited expressions of distress (56%). Responses to distress included 48% emotion-focused responses, 32% aimed at the content of the emotional expression (content-focused responses), 20% ignored the emotional expression, and 0.2% blocked the patient (Ignoring or blocking responses). When controlling for the individual patient and nursing staff, the multivariate logistic regression model showed that nursing staff’s elicitation of the emotional expression (vs spontaneously expressed by the patient) and patients’ expression with a reference to an emotion (vs reference to unpleasant states or contextual hints) were both explanatory variables for emotion-focused responses. This is the pattern observed irrespective of whether the member of staff was a nurse or nurse assistant. Paper II showed that the emotional expressions were grouped under four main categories and a series of sub-categories: 1) worries about relationships with others, 2) worries about health care-related issues, 3) worries about ageing and bodily impairment and 4) life narratives and value issues. Several unpleasant emotions were revealed through the analysis of the expressions, visualised as a layer or layers influencing how expressions of worries were expressed and shared by individual older persons. Paper III showed that “ageing and bodily impairment” was the most frequent theme amongst worries expressed, covering 66% of all emotional expressions. “Health care-related issues” comprised 15% of the expressions, followed by “relationships with others” and “life narratives and value issues” which accounted for 9% of the expressions, respectively. Elicitation (facilitated by the nursing staff vs spontaneous expression by the patient) was associated with theme of worries. Nursing staff significantly more often elicited themes of worries which were especially prominent for “life narratives and value issues”. However, worries about “ageing and bodily impairment” was elicited equally often by the older persons as by the nursing staff. Themes of worries were significantly associated with how nursing staff responded. Adjusted residuals indicated that this association was based on features of the sub-themes found under two of the main themes: “ageing and bodily impairment” (coping with existential challenges vs expression of pain felt in the moment); and “relationships with others” (being a burden vs losing social ties). Conclusions: Emotional expressions by older persons come across mostly as hints and address several topics. Nursing staff are more likely to focus on the affective component of the worry in the instantaneous response when they elicit the emotional expression themselves and when the expressions include a reference to an emotion, a pattern unrelated to the status of being a nurse or a nurse assistant. The responses of nursing staff are associated with thematic content in general and expressions of pain in the moment are more often ignored as compared to other thematic content. The patterns characterising how nursing staff respond to worries are likely to influence level of support experienced by the older person and the type of information the nursing staff gather about an individual patient’s emotional state. This may have implications for how effective nursing staff manage to implement precepts of person-centred care in a given care situation. Implications for training: Recognition of the moments when the older person shares worries and ways nursing staff can provide support may be used as an approach to train nursing staff, students and other care providers in communication that may underpin person-centred care-delivery in home care services. Suggestions for further research: This thesis suggests a framework describing different ways nursing staff can engage in emotional communication by using supportive response behaviours when addressing the expressions of worry by older persons to reach personcentred communication outcomes. It should be noted that this framework requires further testing to establish its validity and practical use. Moreover, there is a need for establishing older person’s preferences when it comes to nursing staff’s response behaviours, and a need for investigating nursing staff’s perspectives on how to best engage in supportive communication when working in home care. This will help theory constructions as to which features are actually perceived as person-centred and supportive for older persons and nursing staff during emotional communication in this setting. Based on the findings presented in this thesis, further research investigating how best to address and support worries about “ageing and bodily impairment” seems especially important. Another important subject is whether nursing staff actually follow up on older person’s experiences of pain in the moment in a way that facilitates person-centred care during home care visits

Older persons’ worries expressed during home care and supportive communication: Analysing audio-recorded visits

Background: Person-centred care is advocated as the gold standard for delivering quality healthcare services for older persons in general, and for home care in particular. Personcentred care means being respectful of and viewing the person’s own preferences and understanding of his/her health and emotional well-being, values and spiritual beliefs, while planning, executing and evaluating healthcare. The moments when the older person shares and discusses his/her emotional well-being with the visiting nursing staff is termed emotional communication and this term may be used as a lens to explore features of communication relevant for person-centred care. There is currently a lack of insight into how emotional communication during home care visits is carried out, and how the discussion of emotions - in particular older persons’ worries - are discussed. Given that these aspects are essential to the well-being of older persons, the focus of this thesis is on exploring expressions of worries and the nursing staff’s responses to these worries. Aims: The overarching aims of this thesis are: a) to explore how older persons express their worries to nursing staff during home care visits, b) to investigate how the nurses and nurse assistants respond to the worries expressed, and c) to discuss the findings within a supportive communication framework and discuss whether current communication behaviour is likely to facilitate person-centred care delivery in home care services. These aims are achieved in three studies which are described in this thesis comprising three papers as well as a general discussion. Design, materials and methods: This study was part of an international research project with the acronym COMHOME, designed as a cross-sectional study. The material analysed included 195 audio-recorded home care visits in Norway collected from four units of home care during December 2013 and May 2014. The visits captured communication between 48 older patients (≥65 years) and nursing staff (n=33), including nurse assistants (n=17) and registered nurses (n=16). The visits collected varied in length, number of tasks and complexity to be managed during the visit, time of day and day of the week. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) was used to identify expressions of distress and the subsequent responses by providers. Two coders applied the system to the complete material. The inter-rater reliability, Cohen’s kappa, was >0.6. Data were subsequently analysed using both a qualitative and a quantitative approach. Drawing on the qualitative analysis, a coding scheme for thematic content in patients’ expressions of worries was developed. Paper I and paper III: Statistical testing explored associations between variables. Sum-categories were computed for the specific VR-CoDES categories covering patient expressions of worries and the nursing staff’s responses. VR-CoDES categories were clustered together based on the definitions provided by the system. Sum categories of patient expressions of worries included: a) verbal and non-verbal expressions referring to emotion, b) references to unpleasant states/circumstances, and c) contextual hints of emotion. The nursing staff’s responses were grouped based on communicative function and divided into emotion-focused responses, content-focused responses and responses ignoring/blocking the cue/concern. Group differences were analysed using Pearson’s chisquared test or Fisher’s exact test. In paper I, a logistic regression model was included to test which variables promoted responses that allowed further disclosure of emotion (emotion-focused responses). In paper III, adjusted residuals (cut-off set at ≥2/≤–2) were used to guide analysis of associations between what types of nursing staff responses were associated with specific themes and sub-themes of worries. Paper II: The qualitative analysis included a novel two-step approach, starting by deductively identifying expressions of worry using the VR-CoDES in 38 of the visits. Then these emotional moments in the communication, through studying the transcripts of the expressed emotions combined with listening to the whole of the conversations, were inductively approached using qualitative content analysis. Findings: Paper I showed that 74% of visits were identified with one or more expressions of distress as described by the VR-CoDES. Worries were usually expressed as hints to distress rather than as explicit statements in which a negative emotion was named. Nursing staff most often elicited expressions of distress (56%). Responses to distress included 48% emotion-focused responses, 32% aimed at the content of the emotional expression (content-focused responses), 20% ignored the emotional expression, and 0.2% blocked the patient (Ignoring or blocking responses). When controlling for the individual patient and nursing staff, the multivariate logistic regression model showed that nursing staff’s elicitation of the emotional expression (vs spontaneously expressed by the patient) and patients’ expression with a reference to an emotion (vs reference to unpleasant states or contextual hints) were both explanatory variables for emotion-focused responses. This is the pattern observed irrespective of whether the member of staff was a nurse or nurse assistant. Paper II showed that the emotional expressions were grouped under four main categories and a series of sub-categories: 1) worries about relationships with others, 2) worries about health care-related issues, 3) worries about ageing and bodily impairment and 4) life narratives and value issues. Several unpleasant emotions were revealed through the analysis of the expressions, visualised as a layer or layers influencing how expressions of worries were expressed and shared by individual older persons. Paper III showed that “ageing and bodily impairment” was the most frequent theme amongst worries expressed, covering 66% of all emotional expressions. “Health care-related issues” comprised 15% of the expressions, followed by “relationships with others” and “life narratives and value issues” which accounted for 9% of the expressions, respectively. Elicitation (facilitated by the nursing staff vs spontaneous expression by the patient) was associated with theme of worries. Nursing staff significantly more often elicited themes of worries which were especially prominent for “life narratives and value issues”. However, worries about “ageing and bodily impairment” was elicited equally often by the older persons as by the nursing staff. Themes of worries were significantly associated with how nursing staff responded. Adjusted residuals indicated that this association was based on features of the sub-themes found under two of the main themes: “ageing and bodily impairment” (coping with existential challenges vs expression of pain felt in the moment); and “relationships with others” (being a burden vs losing social ties). Conclusions: Emotional expressions by older persons come across mostly as hints and address several topics. Nursing staff are more likely to focus on the affective component of the worry in the instantaneous response when they elicit the emotional expression themselves and when the expressions include a reference to an emotion, a pattern unrelated to the status of being a nurse or a nurse assistant. The responses of nursing staff are associated with thematic content in general and expressions of pain in the moment are more often ignored as compared to other thematic content. The patterns characterising how nursing staff respond to worries are likely to influence level of support experienced by the older person and the type of information the nursing staff gather about an individual patient’s emotional state. This may have implications for how effective nursing staff manage to implement precepts of person-centred care in a given care situation. Implications for training: Recognition of the moments when the older person shares worries and ways nursing staff can provide support may be used as an approach to train nursing staff, students and other care providers in communication that may underpin person-centred care-delivery in home care services. Suggestions for further research: This thesis suggests a framework describing different ways nursing staff can engage in emotional communication by using supportive response behaviours when addressing the expressions of worry by older persons to reach personcentred communication outcomes. It should be noted that this framework requires further testing to establish its validity and practical use. Moreover, there is a need for establishing older person’s preferences when it comes to nursing staff’s response behaviours, and a need for investigating nursing staff’s perspectives on how to best engage in supportive communication when working in home care. This will help theory constructions as to which features are actually perceived as person-centred and supportive for older persons and nursing staff during emotional communication in this setting. Based on the findings presented in this thesis, further research investigating how best to address and support worries about “ageing and bodily impairment” seems especially important. Another important subject is whether nursing staff actually follow up on older person’s experiences of pain in the moment in a way that facilitates person-centred care during home care visits

Older persons’ worries expressed during home care and supportive communication: Analysing audio-recorded visits

Background: Person-centred care is advocated as the gold standard for delivering quality healthcare services for older persons in general, and for home care in particular. Personcentred care means being respectful of and viewing the person’s own preferences and understanding of his/her health and emotional well-being, values and spiritual beliefs, while planning, executing and evaluating healthcare. The moments when the older person shares and discusses his/her emotional well-being with the visiting nursing staff is termed emotional communication and this term may be used as a lens to explore features of communication relevant for person-centred care. There is currently a lack of insight into how emotional communication during home care visits is carried out, and how the discussion of emotions - in particular older persons’ worries - are discussed. Given that these aspects are essential to the well-being of older persons, the focus of this thesis is on exploring expressions of worries and the nursing staff’s responses to these worries. Aims: The overarching aims of this thesis are: a) to explore how older persons express their worries to nursing staff during home care visits, b) to investigate how the nurses and nurse assistants respond to the worries expressed, and c) to discuss the findings within a supportive communication framework and discuss whether current communication behaviour is likely to facilitate person-centred care delivery in home care services. These aims are achieved in three studies which are described in this thesis comprising three papers as well as a general discussion. Design, materials and methods: This study was part of an international research project with the acronym COMHOME, designed as a cross-sectional study. The material analysed included 195 audio-recorded home care visits in Norway collected from four units of home care during December 2013 and May 2014. The visits captured communication between 48 older patients (≥65 years) and nursing staff (n=33), including nurse assistants (n=17) and registered nurses (n=16). The visits collected varied in length, number of tasks and complexity to be managed during the visit, time of day and day of the week. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) was used to identify expressions of distress and the subsequent responses by providers. Two coders applied the system to the complete material. The inter-rater reliability, Cohen’s kappa, was >0.6. Data were subsequently analysed using both a qualitative and a quantitative approach. Drawing on the qualitative analysis, a coding scheme for thematic content in patients’ expressions of worries was developed. Paper I and paper III: Statistical testing explored associations between variables. Sum-categories were computed for the specific VR-CoDES categories covering patient expressions of worries and the nursing staff’s responses. VR-CoDES categories were clustered together based on the definitions provided by the system. Sum categories of patient expressions of worries included: a) verbal and non-verbal expressions referring to emotion, b) references to unpleasant states/circumstances, and c) contextual hints of emotion. The nursing staff’s responses were grouped based on communicative function and divided into emotion-focused responses, content-focused responses and responses ignoring/blocking the cue/concern. Group differences were analysed using Pearson’s chisquared test or Fisher’s exact test. In paper I, a logistic regression model was included to test which variables promoted responses that allowed further disclosure of emotion (emotion-focused responses). In paper III, adjusted residuals (cut-off set at ≥2/≤–2) were used to guide analysis of associations between what types of nursing staff responses were associated with specific themes and sub-themes of worries. Paper II: The qualitative analysis included a novel two-step approach, starting by deductively identifying expressions of worry using the VR-CoDES in 38 of the visits. Then these emotional moments in the communication, through studying the transcripts of the expressed emotions combined with listening to the whole of the conversations, were inductively approached using qualitative content analysis. Findings: Paper I showed that 74% of visits were identified with one or more expressions of distress as described by the VR-CoDES. Worries were usually expressed as hints to distress rather than as explicit statements in which a negative emotion was named. Nursing staff most often elicited expressions of distress (56%). Responses to distress included 48% emotion-focused responses, 32% aimed at the content of the emotional expression (content-focused responses), 20% ignored the emotional expression, and 0.2% blocked the patient (Ignoring or blocking responses). When controlling for the individual patient and nursing staff, the multivariate logistic regression model showed that nursing staff’s elicitation of the emotional expression (vs spontaneously expressed by the patient) and patients’ expression with a reference to an emotion (vs reference to unpleasant states or contextual hints) were both explanatory variables for emotion-focused responses. This is the pattern observed irrespective of whether the member of staff was a nurse or nurse assistant. Paper II showed that the emotional expressions were grouped under four main categories and a series of sub-categories: 1) worries about relationships with others, 2) worries about health care related issues, 3) worries about ageing and bodily impairment and 4) life narratives and value issues. Several unpleasant emotions were revealed through the analysis of the expressions, visualised as a layer or layers influencing how expressions of worries were expressed and shared by individual older persons. Paper III showed that “ageing and bodily impairment” was the most frequent theme amongst worries expressed, covering 66% of all emotional expressions. “Health care-related issues” comprised 15% of the expressions, followed by “relationships with others” and “life narratives and value issues” which accounted for 9% of the expressions, respectively. Elicitation (facilitated by the nursing staff vs spontaneous expression by the patient) was associated with theme of worries. Nursing staff significantly more often elicited themes of worries which were especially prominent for “life narratives and value issues”. However, worries about “ageing and bodily impairment” was elicited equally often by the older persons as by the nursing staff. Themes of worries were significantly associated with how nursing staff responded. Adjusted residuals indicated that this association was based on features of the sub-themes found under two of the main themes: “ageing and bodily impairment” (coping with existential challenges vs expression of pain felt in the moment); and “relationships with others” (being a burden vs losing social ties). Conclusions: Emotional expressions by older persons come across mostly as hints and address several topics. Nursing staff are more likely to focus on the affective component of the worry in the instantaneous response when they elicit the emotional expression themselves and when the expressions include a reference to an emotion, a pattern unrelated to the status of being a nurse or nurse assistant. The responses of nursing staff are associated with thematic content in general and expressions of pain in the moment are more often ignored as compared to other thematic content. The patterns characterising how nursing staff respond to worries are likely to influence level of support experienced by the older person and the type of information the nursing staff gather about an individual patient’s emotional state. This may have implications for how effective nursing staff manage to implement precepts of person-centred care in a given care situation. Implications for training: Recognition of the moments when the older person shares worries and ways nursing staff can provide support may be used as an approach to train nursing staff, students and other care providers in communication that may underpin person-centred care-delivery in home care services. Suggestions for further research: This thesis suggests a framework describing different ways nursing staff can engage in emotional communication by using supportive response behaviours when addressing the expressions of worry by older persons to reach personcentred communication outcomes. It should be noted that this framework requires further testing to establish its validity and practical use. Moreover, there is a need for establishing older person’s preferences when it comes to nursing staff’s response behaviours, and a need for investigating nursing staff’s perspectives on how to best engage in supportive communication when working in home care. This will help theory constructions as to which features are actually perceived as person-centred and supportive for older persons and nursing staff during emotional communication in this setting. Based on the findings presented in this thesis, further research investigating how best to address and support worries about “ageing and bodily impairment” seems especially important. Another important subject is whether nursing staff actually follow up on older person’s experiences of pain in the moment in a way that facilitates person-centred care during home care visits

Nursing staff’s responses to thematic content of patients’ expressed worries: observing communication in home care visits

Abstract Background The aim of the study was to explore the thematic content of older persons’ expressed worries in home care visits, and how nursing staff respond to different thematic contents. Methods The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff’s responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff’s responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson’s chi-squared test, Fisher’s exact test, and adjusted residuals. Results The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). “Ageing and bodily impairment” was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about “Relationships with others” (9%), “Health care-related issues” (15%) and “Life narratives and value issues” (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of “Ageing and bodily impairment”, Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher’s exact test, p< 0.001). For the sub-themes of “Relationships with others”, Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher’s exact test, p = 0.009). Conclusion “Ageing and bodily impairment” was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients’ spontaneous expressions of pain. Further research should explore the influence of nursing staff’s responses on quality of care and patient satisfaction

To keep or reject, that is the question - A survey on radiologists and radiographers’ assessments of plain radiography images

Introduction: This study aimed to survey radiographers and radiologists' assessment of plain radiographs to identify the imaging clinicians’ differences in acceptance of image quality. Method: An online, questionnaire was distributed among radiographers (n = 116) and radiologists (n = 76) in a hospital trust in Norway, including 30 clinical cases (one image and a short referral text) that were divided into 3 categories; keep, could keep and reject, based on European guidelines. When rejecting, the respondents identified the main reason by ticking a list (positioning, collimation, centering, artifact or exposure error). Group differences were explored using 2-tailed chi-squared test. Inter-subjectivity was measured using Cohen's kappa for multi-rater sample. Results: In total, 36% of the radiographers (n = 42) and 14% of the radiologists (n = 14) responded to the survey. Total response rate was 30% (56/192). Analysis showed significant difference between radiographers and radiologists in the categories of Reject (χ2 = 6.3, df = 1, p = 0.01), and Could keep (χ2 = 6.3, df = 1, p = 0.01), identifying radiologists as keeping more images compared to radiographers. Agreement among radiographers (Cohen's κ: 0,39; 95% CI: 0.30–0.48; p < 0.001) and radiologists (Cohen's κ: 0,23; 95% CI: 0.09–0.37; p < 0.001) respectively, is fair. The most common reason for rejecting an image is suboptimal positioning. Suboptimal collimation constituted 15% of the rejected images among radiographers, compared to 5% among radiologists. Centering, artifacts and exposure error showed quite similar rates as reasons for rejection. Conclusion: Radiographers and radiologists seem to agree on the assessment of good quality images, however, radiographers seem more reluctant to accept images of lower quality than radiologists. Implications for practice: Further research on reasons for differences in image quality assessment between radiographers and radiologists is needed. This could enable reduction in reject rates and increase image quality in conventional X-ray examinations

Exploring physicians' verbal and nonverbal responses to cues/concerns: Learning from incongruent communication

Objectives Explore physicians’ verbal and nonverbal responses to cues/concerns in consultations with older-patients. Methods Two teams independently coded a sample of Norwegian consultations (n = 24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients’ verbal emotional expressions were labeled ‘Acknowledging of patients’ emotional expressions’, and ‘Distancing from patients’ emotional expressions.’ Based on type and extent of nonverbal expressiveness, consultations were labeled ‘Affective’ and ‘Prescriptive.’ Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed. Results Types 1 and 2 consultations were described as ‘Congruent,’ i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered ‘Incongruent,’ i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients’ needs. Conclusions Frequently physicians’ display incongruent behavior in challenging situations. Older patients’ may perceive this as either alleviating or increasing distress, depending on their needs. Practice implications Type 3 consultations may shed light on reasons for physicians’ incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients’ perceptions of incongruent communication should be further explored. Gorawara-Bhat, R., et al. "Exploring physicians’ verbal and nonverbal responses to cues/concerns: Learning from incongruent communication." Patient education and counseling 100.11 (2017): 1979-1989. © 2017. This manuscript version is made available under the CC-BY-NC-ND 4.0 license

The use of supportive communication when responding to older people’s emotional distress in home care – An observational study

Abstract Background Responding to older people’s distress by acknowledging or encouraging further discussion of emotions is central to supportive, person-centred communication, and may enhance home care outcomes and thereby promote healthy aging. This observational study describes nursing staff’s responses to older people’s emotional distress, and identify factors that encourage further emotional disclosure. Methods Audio-recorded home care visits in Norway (n = 196), including 48 older people and 33 nursing staff, were analysed with the Verona Coding Definitions of Emotional Sequences, identifying expressions of emotional distress and subsequent provider responses. The inter-rater reliability (two coders), Cohen’s kappa, was >0.6. Sum categories of emotional distress were constructed: a) verbal and non-verbal expressions referring to emotion, b) references to unpleasant states/circumstances, and c) contextual hints of emotion. A binary variable was constructed based on the VR response codes, differentiating between emotion-focused responses and responses that distanced emotion. Fisher’s exact test was used to analyse group differences and determined variables included in a multivariate logistic regression analysis to identify factors promoting emotion-focused responses. Results Older people’s expressions of emotional distress (n = 635) comprised 63 explicit concerns and 572 cues. Forty-eight per cent of nursing staff responses (n = 638) were emotion-focused. Emotion-focused responses were observed more frequently when nursing staff elicited the expression of emotional distress from the patients (54%) than when patients expressed their emotional distress on their own initiative (39%). Expressions with reference to emotion most often received emotion-focused responses (60%), whereas references to unpleasant states or circumstances and contextual hints of emotion most often received non-emotion-focused responses (59%). In a multivariate logistic model, nursing staff’s elicitation of the emotional expression (vs patients initiating it) and patients’ expression with a reference to an emotion (vs reference to unpleasant states or contextual hints) were both explanatory variables for emotion-focused responses. Conclusions Emotion-focused responses were promoted when nursing staff elicited the emotional expression, and when the patient expression referred to an emotion. Staff responded most often by acknowledging the distress and using moderately person-centred supportive communication. More research is needed to establish generalizability of the findings and whether older people deem such responses supportive

Older persons’ expressed worries during nursing care at home: Do health complexity and nature of nursing care in the visit matter?

Objective: Older persons receiving home care express more cues and concerns compared to other clinical contexts. Increased health condition complexity requires a corresponding increase in nursing competence. The aim of this study was to explore how complexity of older persons’ health and nature of the visit influenced their expressed worries. Methods: In this cross-sectional explorative study, we analysed older persons’ expressed worries (n = 508) identified by the Verona Coding Definitions of Emotional Sequences (VR-CoDES) in 129 audio-recorded home care visits with older persons (≥65 years), collected in 3 city districts and 1 rural area in Norway. Results: Expressed worries of 45 older persons were included in the analysis: 18 had low health complexity, 5 moderate and 22 high health complexity. The nature of the visit affected the number of expressed worries, health complexity did not. Most of the worries were expressed during basic nursing care visits and/or medication administration. Conclusion: Findings suggest that home visit type may influence the older persons’ expressed worries. The complexity of the older persons’ health condition seems to have little impact on the expressed worries. Practice implications: Knowledge about communication in different complexity of visits is important when planning care for older persons

Emotional communication in home care : A comparison between Norway and Sweden

Objective: Given the free movement of workers across countries, knowledge regarding communication differences between countries is imperative. In this study, we explored and compared the supportive responses of nursing staff to older persons ? emotions in home care in Norway and Sweden. Methods: The study had an observational, cross-sectional, comparative design, which included 383 audio -recorded home -care visits. Communication was coded using Verona Coding De finitions of Emotional Sequences. Worries and responses were categorised with regard to reference, communicative function and level of person-centredness. Standard statistical tests were used to analyse the data. Results: The Swedish nursing staff provided space for further disclosure of worry more frequently than the Norwegian nursing staff (75.0 % versus 60.2 %, ?2 = 20.758, p &lt; 0.01). In all, 65 % of the responses were supportive. Multiple logistic regression analyses showed that highly person -centred responses were independently associated with worries phrasing an emotion, OR (95 % CI) 3.282 (1.524 -7.067). Conclusion: The level of person-centredness was associated with the way in which older persons expressed their distress. The Swedish nursing staff provided opportunities for further disclosure of worries more frequently than the Norwegian nursing staff. Practice implications: Findings of intercultural differences should be incorporated into the training of nursing staff