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

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

Vibeke Sundling

^a,b,c,

*, Linda Hafskjold

^a,c

, Jakob Håkansson Eklund

^d

,

Inger K. Holmström

^d,e

, Jessica Höglander

^d

, Annelie J. Sundler

^f

, Sandra van Dulmen

^c,g,h

, Hilde Eide

^c

aDepartmentofOptometry,RadiographyandLightingDesign,FacultyofHealthandSocialSciences,UniversityofSouth-EasternNorway,Norway

bNationalCentreforOptics,VisionandEyeCare,FacultyofHealthandSocialSciences,UniversityofSouth-EasternNorway,Norway

cScienceCentreHealthandTechnology,FacultyofHealthandSocialSciences,UniversityofSouth-EasternNorway,Norway

dSchoolofHealth,CareandSocialWelfare,MälardalenUniversity,Västerås,Sweden

eDepartmentofPublicHealthandCaringSciences,UppsalaUniversity,Uppsala,Sweden

fFacultyofCaringScience,WorkLifeandSocialWelfare,UniversityofBorås,Sweden

gNIVEL(NetherlandsInstituteforHealthServicesResearch),Utrecht,theNetherlands

hRadboudUniversityMedicalCenter,RadboudInstituteforHealthSciences,DepartmentofPrimaryandCommunityCare,Nijmegen,theNetherlands

ARTICLE INFO

Articlehistory:

Received12July2019

Receivedinrevisedform16January2020 Accepted1March2020

Keywords:

Worries

Supportivecommunication Person-centredcommunication Homecare

VR-CoDES

ABSTRACT

Objective:Giventhefreemovementofworkersacrosscountries,knowledgeregardingcommunication differencesbetweencountriesisimperative.Inthisstudy,weexploredandcomparedthesupportive responsesofnursingstafftoolderpersons’emotionsinhomecareinNorwayandSweden.

Methods:Thestudyhad anobservational,cross-sectional,comparativedesign, whichincluded383 audio-recorded home-care visits. Communication was coded using Verona Coding Deﬁnitions of EmotionalSequences.Worriesandresponseswerecategorisedwithregardtoreference,communicative functionandlevelofperson-centredness.Standardstatisticaltestswereusedtoanalysethedata.

Results:TheSwedishnursingstaffprovidedspaceforfurtherdisclosureofworrymorefrequentlythan theNorwegiannursingstaff(75.0%versus60.2%,χ2=20.758,p<0.01).Inall,65%oftheresponseswere supportive.Multiplelogisticregressionanalysesshowedthathighlyperson-centredresponseswere independentlyassociatedwithworriesphrasinganemotion,OR(95%CI)3.282(1.524–7.067).

Conclusion: The levelof person-centrednesswas associated with the way inwhich olderpersons expressedtheirdistress.TheSwedishnursing staffprovidedopportunitiesforfurtherdisclosure of worriesmorefrequentlythantheNorwegiannursingstaff.

Practiceimplications:Findingsofinterculturaldifferencesshouldbeincorporatedintothetrainingof nursingstaff.

1.Introduction

Thepopulationiscurrentlygrowingolderandaginginplace.

‘The ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or abilitylevel’[1]isanimportantprincipleinnumerouscountries.

Olderindividualswanttochoosewhereandhowtheyageinplace [2].Evenwhenhealthdeclines,itisimperativetoremainlivingin one’sownhome[3].Inthisrespect,homecareisessentialbothfor careand for companionship [4]. Home care differswithin and

between countries, and the approaches to national home care reforms differ [5,6]. Moreover, nursing staff members have different levels of education and competency [7]. Nonetheless, communication isa common competencyand it isessential to ensuringperson-centred,highqualitycare[8,9].

Thegoalofcareistosupportameaningfulandfunctionallife [10], which is essential for aging inplace. Person-centred care involves treating the patient as a person by noticing and respondingtohisorherperspective,focusingonhisorherneeds with respect and understanding, sharing decisions, providing holisticcare,comfort and empathyand fosteringresilienceand positivehealth[11–13].

Within-homecare,thekeyistobothrecognisethecareneeds of older individuals and tooffer emotional support. Emotional

*Correspondingauthorat:Postboks235,3603,Kongsberg,Norway.

E-mailaddress:vibeke.sundling@usn.no(V.Sundling).

https://doi.org/10.1016/j.pec.2020.03.002

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j o u r n al h o m e p a g e : w w w . el s e v i e r . c o m / l o c a t e / p a t ed u c o u

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wellbeingisstronglyassociatedwithhealth,anditisfacilitatedby socialsupport[14–16].Olderindividualsexperiencehighlevelsof stresswhentheyareunabletohandletheiremotions[15],andthey relyonnursingstaffforsupport[17].Sinceolderpeoplemostoften expressworriesashints[18,19],theseworriescanbedifﬁcultfor nursingstafftodetectandmanage[20].Nursingstaffalsoconfront challenges with respect to conﬂicting views on care and unforeseenturns in thecommunicationwiththe patients[20].

Duringhomecarevisits,olderindividuals’emotionsandexisten- tial feelings most frequently relate to ageing and bodily impairment[21].Itmayadverselyaffectthepatients’well-being andsenseofsecuritywhenthenursingstafffailstonoticeand respondtotheirperspectivesandneeds[22,23].

Providingcomfortwithinacaringperspectiveinvolvesboththe nursingstaffmember’sspontaneousresponsetodistressandhisor herprofessionallylearnedstrategies[24].Empathiccommunica- tion encourages patient trust, mutual understanding, social support,medicationadherence and self-efﬁcacy[25].A nursing staff’sempathicaccuracy, ‘abilitytoinferthespeciﬁccontentof another person’s thoughts and feelings’ [26], is essential to providingsupportivecommunication.Supportivecommunication canreduceemotionaldistress,enhancecoping,protecthealthand improvepersonalrelationships[27].

TheHierarchical Coding Systemfor Sensitivity ofComforting Strategies, which was developed to describe person-centred responses [28], has been adapted and used to classify nurses’ empathicresponses[29,30].Thecodingsystemhasthreelevels:1) denialoftheperson’sperspective,2)implicitrecognitionor approval of the person’s perspective and 3) explicit recognition and elaboration of the person’s perspective. Highly person-centred responseshavehighempathic accuracyandexplicitly recognise, acknowledgeandlegitimisefeelingsandperspective.Theyencour- ageelaborationandexplorationoffeelingstounderstandandplace theminameaningfulandbroadercontextaswell.Mediumaccuracy andmoderatelyperson-centredresponsesimplicitlyrecognisethe feelingsofothersbydivertingtheattentionawayfromtheworry,by acknowledgingthefeeling,albeitwithouthelpingtounderstandor cope or providing non-emotional centred explanations of the situation in an attempttoalleviatedistress. In comparison, responses thatdenythefeelingsofothersbycriticisingorchallengingtheir legitimacy,tellingtheotherhowtoactandfeelorignoringtheir feelings,arelowperson-centredandlackanempathicresponse.

Knowledge regarding supportive communication and the potentialdifferencesbetweencountriesmayhaveanimpacton nursing staff training and the provision of care. Knowledge is additionallyimportantgivenboththefreemovementofworkers withintheEuropeancountriesandthelargenumberofSwedish nursingstaffworkinginNorway.Inthisstudy,weaimtoexplore andcompare thesupportive responsesof nursingstaff toolder persons’emotionsandexistentialfeelingsinhomecareinNorway andSwedenandtoidentifytheassociationswithhighlyperson- centredresponses.

2.Methods 2.1.Design

Thestudy had anobservational cross-sectional, comparative design. It used data from audio-recorded home care visits in NorwayandSweden.Thetwo neighbouringEuropeancountries havesimilarhealthcaresystemsandnursingstaffeducation.

2.2.Sampleandsetting

Thestudyparticipantsincludedolderpersons(>65years)who werereceivinghomecareandnursingstaffwhowereproviding

homecarein 12homecareunits: fourin Norwayand eight in Sweden, see Table 1. The inclusion criteria for the home care receiverswerethattheywere65yearsorolderandNorwegian/

Swedish speaking. Older persons’ with speech or language difﬁculties(Swedenonly),orcognitivedecline,orwhoweretoo frailorunabletoprovideinformedconsentwereexcludedfrom participation.Theinclusioncriteriaforthenursingstaffincluded beingaNorwegianorSwedishspeakingregisterednurse(RN)or nurseassistant(NA),holdingapermanentpositionandproviding careinolderpersons’homes.Thesamplesineach countryonly includedpatientsandnursingstaffwhowerenationalcitizens.

2.3.Datacollection

The unit managers recruited the nursingstaff study partic- ipants. The unit mangers and the nursing staff both recruited participantcarereceivers.Thenursingstaffandthecarereceivers werebothgivenoralandwritteninformationaboutthestudy,and theyprovidedtheirwrittenconsenttoparticipate.Thedata(audio- recordings)wascollectedinNorwayfromDecember2013toApril 2014andinSwedenfromAugust2014toNovember2015.Adigital audiorecorder(H1Zoom),worn onthenursingstaffmember’s upperarm,recordedthecommunicationbetweentheolderperson and the nursing staff during the entire home care visit. The recordingstartedwhenthenursingstaffenteredtheolderpersons’ home,anditendedwhentheyleft.Intotal,383encounterswere recorded:195inNorwayand188inSweden,144and95ofthese, respectively,includedcuesandconcerns.TheRNorNAcouldmeet with the same older person in subsequent visits, the median (range)was1(1–4)and3(1–8)timesforNorwegianandSwedish nursing staff, respectively. The older person could encounter differentnursingstaffineachvisit,themedian(range)numberof nursing staff encountered was 1 (1–4) and 1 (1–4) for older NorwegianandSwedishpersons,respectively.

2.4.Codingandcategorisation

Thestudyanalysedthesequencesofemotionalcommunication duringthehomecarevisits,correspondingtothefirstphasesof supportivecommunication,specifically,therecipient’sexpression ofdistressorsupportseekingeffortsandthesupportiveresponse fromthehelper[27].Thesegmentsofemotionalcommunication wereidentifiedusingVR-CoDES[31,32].TheVR-CoDESsystemhas high ecological validity, capturing patients’ real experienced worries [33]. The units of analysis were the older persons’

Table1

CharacteristicsoftheolderpersonsandnursingstaffinhomecareinNorwayand Sweden.

Norway Sweden

Olderpersons,n 48 81

Men,n(%) 11(23) 23(28)

Womenn(%) 37(77) 58(72)

Age,mean(sd)years 84(8) 86

Age,rangeyears 65-94 65-103

Nursingstaff,n 33 31

Men,n(%) 6(18) 11(35)

Womenn(%) 27(82) 20(65)

Age,mean(sd)years 42(11) 45

Age,rangeyears 23-59 22-63

Registerednurse,n(%) 16(48) 11(35)

Nurseassistant,n(%) 17(52) 20(65)

Workexperience,mean(sd)years 17(11) 20.5

Workexperience,rangeyears <1-45 <1-41

InNorwayandSweden,registerednurseshaveaBachelor’sdegreeinnursingor equivalent,andnurseassistantshavesecondaryeducationandvocationaltraining incaring.

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emotional distressexpressed as cues or concerns [31] and the nursingstaffs’immediateresponsetotheemotionaldistress[32], Fig.1.

TheVR-CoDES–CuesandConcerndeﬁnea‘concern’as‘aclear andexplicitexpressionofcurrentorrecentemotion’.Theydeﬁnea

‘cue’as‘averbalornon-verbalhinttoanunderlyingunpleasant emotion’.Thecuesandconcernsareorganisedinsevenmutually exclusivecategoriesandfurtherdeﬁnedbywhetherthepatientor thehealthcareproviderpromptedtheexpression[31]. TheVR- CoDES–ProviderResponsecodestheimmediateresponsetothe concernorcue.Twodimensionsdeﬁnetheresponse:1)whether theresponserefersexplicitlytotheconcern/cuebyholdingthe wording or key elements of the patients’ expression and 2) whethertheresponseprovidesspacefor/byallowingthepatientto talkmoreabouttheirworries[32].Pairsofinvestigatorscodedthe materialtoreachacceptableinterraterreliability(Cohen’skappa>

0.6).Afterconsensuscoding,twosingleinvestigatorscodedthe remaining material [18,19,34]. During the coding process, the researchteamsinNorwayandSweden hadregularmeetingsto ensure comparable coding between the countries. However,

expressionsofmomentarypainwereonlycodedfortheNorwegian sample.

Theolderpersons’worriesandthenursingstaffs’responseswere thencategorised.First,theolderpersons’concernsandcueswere groupedinthreesum-categoriesofemotionaldistressdependingon whethertheexpressionphrasedanemotion,anunpleasantstateor circumstanceoracontextualhintofanemotion[19],Fig.2.Second, thenursingstaffs’responsesweregroupedinthreesum-categories basedonthefunctionoftheresponse,whethertheresponsefocused ontheemotion,thecontentorignored/blockedtheexpression[19], Fig.3a.Third,theresponsesweregroupedwithregardtothelevelof person-centredness,byadaptingBurleson’sdescriptionofsupport- ive communication (Burleson 1994, [29,30]. Three levels of supportivecommunicationsweredeﬁned:1)lowperson-centred responses that ignore or deny elaboration of the emotion, 2) moderatelyperson-centredresponsesthatimplicitlyrecognisethe emotionbyfocusingonthecontentand3)highlyperson-centred responsesthatexplicitlyrecognisetheemotionaldistressandallow furtherdisclosure,Fig.3b.Highlyperson-centredresponseswere deﬁnedasadvancedsupportivecommunication.

Fig.1.SequentialanalysisofemotionalcommunicationusingVR-CoDES.

Concern,aclearandunambiguousexpression,theemotionisexplicitlyverbalized.Cue,averbalornon-verbalhintofanunderlyingunpleasantemotion.Provide/reducespace, responseopens/closesfurthertalkabouttheexpressedworryExplicit/non-explicit,theresponseinclude/donotincludephrasingorkeyelementsoftheexpression.

Fig.2.ReferenceofworriesderivedfromVR-CoDEScuesandconcern.

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2.5.Dataanalysis

WeusedIBMSPSSStatistics,version25.0(IBMCorp,NewYork, USA) for the statistical analyses. The data were analysed in

summation andfrequency tables.Groupdifferencesandassoci- ationswereanalysedusingstandardstatisticaltests: chi-square andbivariateandmultivariatelogisticregression.Thesigniﬁcance levelwassetat<5%.Variableswithasigniﬁcancelevelof<25%in Fig.3. a)CommunicativefunctionoftheresponsesasderivedbysumcategoriesofVR-CoDESresponses.b)Supportivecommunication-VR-CoDESresponsescategorised accordingtoBurlesonslevelsofperson-centredresponse.

E-PS;explicit–providespace,NE-PS;non-explicit–providespace,E-RS;explicit–reducespace,NE-RS;non-explicit–reducespace.

Table2

Olderpersons’expressionsofworriesinhomecareinNorwayandSwedenbycuesandconcerns*andfocusofphrasing.**.

Olderpersons’worry,n(%) Norway

(n=638)

Sweden (n=316)

Worriesphrasinganemotion 225 (35.3) 77 (24.4)

Concern,clearandunambiguousexpressionofanunpleasantemotion 63 (9.9) 24 (7.6)

Cuea,vagueorunspeciﬁcworddescribingemotion 109 (17.1) 50 (15.8)

Cuef,non-verbalclearexpressionorhintofnegativeemotions*** 35 (5.5) 1 (0.3)

Cueg,verbalizedreferencestoemotionsinthepast 18 (2.8) 2 (0.6)

Worriesphrasingastate/circumstance 398 (62.4) 222 (70.3)

Cueb,verbalhinttohiddenconcerns*** 390 (61.1) 202 (63.9)

Cuec,word/phraseemphasizinganunpleasantstate 8 (1.3) 2 (6.3)

Worriesphrasingacontextualhint 15 (2.4) 17 (5.4)

Cued,neutralexpressionofpotentialemotionalimportance 4 (0.6) 6 (1.9)

Cuee,repetitionofapreviousneutralexpression 11 (1.7) 11 (3.5)

StatisticallysigniﬁcantdifferencebetweenNorwegianandSwedisholderpersons’expressions;*χ²(7)=46.435,p<0.001forcuesandconcerns,**χ²(7)=46.435,p<0.001for phrasinganemotion,astate/circumstanceoracontextualhint,***Including130expressionsofmomentarypainintheNorwegiansample,1concern,4cuea,27cuefand98 cueb.

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thebivariatelogisticregressionwereincludedintheanalysisfor themultivariatelogisticregression[35].

2.6.Ethicalconsiderations

Thestudyfollowedtheethicalprinciplesformedicalresearch involvinghumansubjects[36].TheNorwegianSocialScienceData ServicesID36017andtheSwedishRegionalEthicsCommitteeDnr 2014/018approvedthestudymethod.Allofthestudyparticipants gavewritteninformedconsenttoparticipate.Theolderpersons andthenursingstaffcouldbothwithdrawfromthestudyatany timewithoutconsequencetohomecare.Wede-identiﬁedthedata materialbeforetheanalyses.

3.Results

3.1.Olderpersons’worries

Thematerialincluded954expressionsofworries,from144and 95homecarevisitsinNorwayandSweden,respectively,Table2.

Therewasasigniﬁcantdifferencebetweenhowolderpersonsin NorwayandSwedenexpressedworries(χ²(7)=46.435,p<0.001).

This difference was particularly evident when the expressions weregroupedaccordingtothephrasingof thedistress(χ²(2)= 16.359, p < 0.001). In Norway, older persons expressed their emotionaldistressmorefrequentlywithareferencetoanemotion, whereasolder personsinSweden expressed emotionaldistress morefrequentlywithreferencetoastateorbycontextualhints.

3.2.Nursingstaffs’responsetotheolderpersons’worries

In all, 622(65 %) of the responses recognised the patients’ emotionalperspective,implicitlyby492(51.4%)andexplicitlyby 130(13.6%)addressingtheworry,Table3.Therewasasigniﬁcant difference in the responses between the Norwegian and the Swedishnursingstaff.TheSwedishnursingstaffmorefrequently provided space for further disclosure of the worry than the Norwegiannursingstaffdid(75.0%versus60.2%,χ²=20.758,p<

0.01). When addressing the patient’s emotional distress, the Swedish nursing staff more frequently did so by implicit recognitionofthedistressthantheNorwegiannursingstaffdid (90.3 % versus 72.3 %, χ² = 20.03, p < 0.01). When grouping responseswithrespecttothefunctionoftheresponse,theSwedish nursingstaffresponded totheemotionalaspectof thedistress morefrequently(68.7%versus47.6%),whereas theNorwegian nursingstaff responded more frequently to thecontent of the

distress(31.8%versus22.2%)orblocked/ignoredtheexpression (20.5%versus9.2%)(χ²(2)=41.059,p<0.01).

3.3.Levelofsupportivecommunication

Intermsofthelevelofsupportivecommunication,3%ofthe responses were highly person-centred, 62 % were moderately person-centredand35%werelowperson-centred.TheSwedish nursing staff used moderately person-centred responses more frequentlythantheNorwegiannursingstaff(74%versus56%), whereastheNorwegiannursingstaffusedthelow(40%versus25

%) or highly (4% versus 1%) person-centred responses more frequently (χ2(2) = 31.335, p < 0.01). Highly person-centred responses wereassociated with how the worrywas expressed (type of cue/concern), Fig. 4. The multiple logistic regression analysis showed that expressions phrasing an emotion were independentlyassociatedwithhighlyperson-centredresponses, OR (95 % CI) 3.282 (1.524–7.067) when adjusted for the care recipientandthenursingstaffatanindividuallevel,Table4.There wasnosigniﬁcantdifferenceinthelevelofsupportivecommuni- cationbetweenmaleandfemalenursingstafforbetweenSwedish nurses and nurse assistants. However, there was a signiﬁcant differencebetweenthenursingstaffinNorwayandSwedenaswell asbetweenthenursesandnurseassistantsinNorway.InNorway, thenurseassistantsshowedahigherproportionofhighlyorlow person-centredresponsesthanthenursesdid(6and42%versus1 and38%,respectively).Intotal,thenurseassistantsprovided24of the29highlyperson-centredresponses(83%)inthesample.

4.Discussionandconclusion 4.1.Discussion

Tothebestofourknowledge,thisstudyistheﬁrsttoexplore and comparethesupportiveresponsesof nursingstafftoolder persons’expressionofemotionsandexistentialfeelingsinhome care in different countries. Two thirds of the nursing staff responses disclosedsome degreeof supportive communication byanexplicitornon-explicitresponseprovidingspaceforfurther disclosureoftheolderperson’semotionaldistress.Mostofthese responses were moderately person-centred, and only one in twentyresponsesdemonstrated thecharacteristicsofadvanced supportive communication[27]. Expressionswithanemotional reference were more likely to receive a highly person-centred response.

Inall,theSwedishnursingstaffprovidedsupportivecommu- nicationmore frequentlythan theNorwegiannursingstaffdid.

Thesefindingsarenoteworthy,andtheyraisequestions.Whydo Norwegian and Swedish nursing staff respond differently to worries?Whatisefficientsupportivecommunicationinahome care setting? What implications may these findings have for nursingstaffeducationandhomecareorganisation?

Theolderindividualsmostfrequentlyexpressedtheirworries asverbalhintstoemotions,unpleasantsituations,orunpleasant cognitiveorphysicalstates,andtheyrarelyaddressedtheemotion verballyornonverbally.Thenatureoftheexpressionsmayreﬂect thatdifferentapproachesandlevelsofsupportivecommunication arenecessaryinhomecare.EntwistleandWatt(2013)proposeda guidingideathat‘treatingpatientsaspersonsinvolvesrecognising andcultivatingtheirpersonalcapabilities’bypromotingrespect and compassion, ensuring that services work well for the individual and supporting persons to develop and use their autonomouscapabilities[11].Aperson’sexperienceofrelational issuesorthreatstopersonalhealthandwell-beingmaycausea needtoshare,discussandseekadviceandcomfortinothers[27].

Incaseswheretheolderindividualcallsattentiontoanemotion,a Table3

Nursingstaff’sresponsestoolderpersons’expressionsofworriesinhomecarein NorwayandSwedenbycharacteristics*andfunction**oftheresponse.

Nursingstaffresponse,n(%) Norway (n=641)

Sweden (n=316) Responsesaddressingemotion*** 304 (47.4) 217 (68.7)

Explicit,providespace 26 (4.1) 3 (0.9)

Non-explicit,providespace 278 (43.4) 214 (67.7) Responsesaddressingcontent*** 205 (32.0) 70 (22.2)

Explicit,providespace 81 (12.6) 20 (6.3)

Explicit,reducespace 48 (7.5) 2 (0.6)

Non-explicit,reducespace 76 (11.9) 48 (15.2)

Responsesignoring/blocking 132 (20.6) 29 (9.2)

Explicit,reducespace 1 (0.2) 0 (0.0)

Non-explicit,reducespace 131 (20.4) 20 (9.2)

StatisticallysigniﬁcantdifferencebetweenNorwegianandSwedishnursingstaff’s responsesthat*providespaceandreducespaceforfurthertalk(χ2(1)=20.758,p<

0.01),*explicitandnon-explicitaddresstheworry(χ2(1)=37.236,p<0.01)and

**addressemotion,content, orignore the worry (χ2(2) = 41.059, p < 0.01).

***Including130responsestoexpressionsofmomentarypainintheNorwegian sample,24responsesaddressingemotionand106addressingcontent.

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highly person-centred response that explicitly recognises, acknowledges and legitimises the feeling and encourages that persontoelaborateandexplorethefeelingscouldbeappropriate.

Incomparison,whentheemotionaldistresshasareferencetoa circumstance or state, a moderately person-centred response, whichprovidesexplanationsinanattempttoalleviatedistressand developanduseautonomouscapabilities,maybemoreefﬁcient.A nursing staff member’s ability to focus his or her response accuratelytoemotionorcontentisessentialtoprovidingoptimal supportivecommunication[16,25,37].Olderindividuals’experi- enceofwell-beingandlifesatisfactioncorrelateswithperceived good health, absence of worry and self-esteem [38]. Further researchis neededregarding what olderpersonsin homecare preferandperceiveassupportivecommunication.

TheSwedishnursingstaffprovidedsupportivecommunication morefrequentlythantheNorwegiannursingstaffdid.However, the Norwegian nursing staff displayed a higher proportion of highlyperson-centred responses.Thiscouldreﬂect thecultural differencesbetweenNorwayandSweden;sinceolderNorwegians expresstheirdistressmore frequentlywithanemotional reference,whereasolderSwedestendtoexpresstheirworrieswitha referencetoastateorcircumstance,theresponsestrategiesare consequentlytailoredtohowtheworryisexpressed.Fromasocio- dynamicperspective,cultureformstheemotionalexperiencesand emotionalinteractionestablishestheculture[39]:‘Cultureisnot onlyattheheartofemotions;emotionsmayalsobeattheheartof culture.’Culturemattersinmedicalcommunication;inwealthier countries, more psychosocial issues are discussed and the communication style is more ﬂexible than in countrieswith a lowpowerdifference[40].Businessresearchhasnotedthatthere areculturaldifferencesbetweentheNordiccountries.InNorway, thepowerdistanceislowerandthehumaneorientationishigher

thaninSweden[41],whichmayexplainbothwhyolderpeoplein Norway more frequently express distress with an emotional referenceandthehigherproportionofperson-centredresponses by Norwegian nursing staff. Therefore, the lower number of expressionsintheSwedishsamplemayreﬂectculturaldifferences in communication as well as the fact that expressions of momentarypainwerenotcodedfortheSwedishdata.

Thehighernumberoflowperson-centredresponsesamongthe Norwegiannursingstaffcouldbeexplainedbyahigherproportion ofexpressionsofmomentarypainandemotionsinthepast(cuef andg),amongtheolderpersonsinNorwayascomparedtothosein Sweden.Sincethereisariskofadverseeffectsonpatients’well- beingandsenseofsecuritywhenthenursingstaffignoresolder persons’ distress or denies them the possibility to share their feelings, thelow person-centredresponsescouldbeofconcern [8,15].Athematicexplorationofthecontentoftheworriesinthe Norwegiansample[21]demonstratedthatexistentialissueswere themostcommontopicofolderpersons’worriesinhomecare;

theseworrieswereequallyinitiatedbytheolderpersonsandthe nursingstaff.Worriesrelatedtorelationshipswithothers,health careissues,valueissuesandlifenarrativesweretriggeredmore frequently by the nursing staff. The nursing staff provided supportivecommunicationwhenaddressingcopingwithexisten- tialissues,fearsoflosingsocialrelationsandbeingaburden,but tended to ignore patients’ expressions of momentary pain, reflectingdifferencesinsensitivity toexistentialchallenges and expressionsofpain,butalsoalackofcompetencyandconfidence inmanagingchallengingcommunications[20].Thissupportsthe need for nursingstaff to have strategies tomanage existential issuesandpain[42,43].Althoughthepsychosocialaspectsofliving withchronicpainaresignificant,theyarefrequentlyoverlookedby health care providers, which mayadverselyaffectphysical and Fig.4.LevelofsupportivecommunicationbyreferencetotheexpressionofemotionaldistressinNorwegianandSwedishhomecarevisits.

*StatisticallysigniﬁcantdifferencebetweenNorwegianandSwedishhomecare(χ2(2)=31.335,p<0.01).

Table4

Factorsassociatedwithhighlyperson-centrednursingstaffresponses.

Crudeoddsratio Adjustedoddsratio*

OR(95%CI) p-value OR(95%CI) p-value

Typeofcue/concern(Emotional) 3.655(1.704–7.838) 0.001 3.282(1.524–7.067) 0.002

Thepatient 0.998(0.997to0.999) <0.001 1.002(0.999–1.005) 0.311

Thenursingstaff 0.999(0.999–1.000) <0.001 0.998(0.997–1.000) 0.021

* Adjustedforindividualolderpersonandindividualnursingstaff.

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psychological patient outcomes [44,45]. Increased sensitivity towards the patient’s experience of pain and efficient pain managementmaypreventorreducefunctionaldecline[46].This mayindicatea need foreducation and specificcommunication skillstraining toimprovesensitivityandconfidencetointerpret andrespondtoolderindividuals’needsinhomecare.

Thereisarelationshipbetweenthestructure,theprocessand theeffectsofhomecare.Donabedianmaintains,‘goodstructure increases the likelihood of good process, and good process increases the likelihood of good outcome.’ [47]. Moreover, McCormackandMcCance’sframeworkofperson-centrednursing suggeststhat,‘todeliverperson-centredoutcomes,accountmust betakenoftheprerequisitesandthecareenvironmentthatare necessaryforprovidingeffectivecarethroughthecareprocesses’ [48].Therefore,thenursingstaffs’effortandcapacitytoprovide supportive communication may not only be related to their competency,butalsotohowhomecareisstructured,speciﬁcally, the organisation of care, the workplace culture and the care environment,includingsuchfactorsastimeconstraints.However, itwasbeyondthescopeofthisstudytoexploretheeffectofhome carestructureonsupportivecommunication.

Thestrengthofthisstudyisintherelativelylargestudysample intwoneighbouringcountrieswithsimilarhealthcaresystems andnursingstaffeducation.Audio-recordeddataareavalidsource touseinobservationalstudiesofcommunicationbetweenpatients andhealthcareproviders[49,50],andtheVR-CoDESsystemhas highecological validity [33]. The coding teamsin Norway and Sweden had consensus meetings during the coding process to enhance reliability. However, the interpretation of the coding manual can induce systematic bias between study sites. Since expressionsofpainwerenotincludedinthedata,thenumberof lowperson-centredresponsesintheSwedishmaterialcouldbe underestimated.In the future, bilingual observers should code bothNorwegianandSwedishrecordingstopreventbias.Moreover, thedifferenceinthedistributionofnurseandnurseassistantsin theNorwegianandtheSwedishsamplesmayhaveoverestimated thedifferenceinthelevelofsupportivecommunicationbetween Norway and Sweden. Future studies should explore patient preferences for supportive communication, the effect of home care structure on supportive communication, ways to provide nursing staff with efﬁcient skills and strategies to manage challenging communication in home care and approaches to implementspeciﬁcknowledge,skillsandcompetencyinnursing staffeducation.

4.2.Conclusion

Themajorityofthenursingstaffresponsesinthiscurrentstudy were supportive. The level of person-centred response was associatedwiththewaydistresswasexpressedbyolderpersons;

distressexpressedwithareferencetoanemotionreceivedhighly person-centredresponsesmorefrequentlythandistressexpressed withreferencetoastateorbyrepetition.Swedishnursingstaff showedmoresupportivecommunicationthanNorwegiannursing staffdid,whichcouldrelatetocultural,interprofessionaland/or educational differences. Further research should explore these differences.

4.3.Practiceimplications

The ﬁndings regarding intercultural differences should be incorporatedinthetrainingofnursingstaff,suchaswithcross- cultural residencies. Future research should explore both the interculturalandtheinterprofessionaldifferencestoincreasethe understandingofcommunicationinhomecareandwhatpatients experienceassupportivecommunication.

Roleoffunding

TheResearchCouncilofNorwayfundedtheresearchProject number:226537.

The ResearchCouncil ofNorway had noinvolvementthein studydesign;inthecollection,analysisandinterpretationofdata;

inthewritingofthereport;andinthedecisiontosubmitthepaper forpublication.

DeclarationofCompetingInterest

Theauthorsdeclarethattheyhavenocompetinginterests.

Acknowledgements

TheResearchCouncilofNorwayfundedtheresearchProject number:226537.

Wethanktheolderpersonsandnursingstafffortakingpartin thestudy.

AppendixA.Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,inthe onlineversion,atdoi:https://doi.org/10.1016/j.pec.2020.03.002.

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