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