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  • Public defence: 2019-05-10 13:15 Beta, Västerås
    Höglander, Jessica
    Mälardalen University, School of Health, Care and Social Welfare.
    Home care communication: moving beyond the surface2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Communication is an essential part of care and human interaction. While communication within care entails both task-focused and socio-emotional elements, nurses are sometimes perceived as too task-focused. When in need of care, older persons want to be perceived and treated as individuals – to feel involved. However, nurses might lack the prerequisites for establishing individualised home care, which is often based on daily tasks rather than on older persons’ needs and wishes. Despite the importance of communication in nurse-patient interactions, knowledge about daily communication within home care is scarce. Therefore, the overall aim of this thesis was to explore the naturally occurring communication between nursing staff and older persons during home care visits, with a focus on emotional distress and from a person-centred perspective.

    This thesis is an observational, cross-sectional study of the communication in 188 audio-recorded home care visits, and is part of the international COMHOME project. In Study I, older persons’ expressions of emotional distress were coded and analysed using the Verona Coding Definitions of Emotional Sequences [VR-CoDES]. The results showed that older persons often express emotional distress in the form of hints at emotional concerns, which were defined as cues. Explicit expressions of emotional distress, which were defined as concerns, were uncommon. The responses of nursing staff to older persons’ cues and concerns were coded and analysed in Study II using VR-CoDES. Nursing staff often responded by providing space rather than reducing it for further disclosure of older persons’ emotional distress. In Study III, the communication of emotional distress and participants’ characteristics were analysed using generalised linear mixed model [GLMM]. The results revealed that most cues and concerns were expressed by older females and to female nursing staff. Furthermore, elicitations of expressions of emotional distress were influenced by native language and profession, and responses that provided space were more often given to older females and to older persons aged 65-84 years. Home care communication between registered nurses and older persons was coded and analysed in Study IV using the Roter Interaction Analysis System [RIAS]. The results revealed a high degree of person-centred communication, especially during visits lasting 8-9 minutes, and that socio-emotional communication was more frequent than task-oriented communication.

    Home care communication contains important aspects of person-centred communication, with nursing staff providing space for the older person’s narrative; however, there are also challenges in the form of vague and implicit expressions of emotional distress.


    Keywords: communication; home care services; nursing staff; older persons; person-centred care; RIAS; VR-CoDES

  • Public defence: 2019-05-24 09:30 Beta, Västerås
    Elvén, Maria
    Mälardalen University, School of Health, Care and Social Welfare.
    Clinical reasoning focused on clients’ behaviour change in physiotherapy: Development and evaluation of the Reasoning 4 Change instrument2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    With the recognition of the impact of lifestyle behaviours on health and the evidence of incorporating behavioural considerations in physiotherapy, there is a need to advance the clinical reasoning of physiotherapists. Clinical reasoning encompasses the thinking and decision-making processes guiding client management and is a core competency of physiotherapists. Enabling clinical reasoning advancements requires investigations in practice and education, which in turn require robust assessments. The overall aim of this thesis was to develop and evaluate an instrument to study physiotherapy students’ clinical reasoning focused on clients’ activity-related behaviour and behaviour change. 

    In study I, a conceptual model was developed based on exploration of existing research, theory and views of physiotherapists and students. The data resulted in the clinical reasoning model focused on clients’ behaviour change with reference to physiotherapists (CRBC-PT). Studies II and III included instrument development and evaluation in four phases. Phase 1 included determination of the instrument structure and item generation based on the CRBC-PT model, evidence in clinical reasoning assessment and existing measures. Phase 2 included cognitive interviews with students to assess item understanding and resulted in revisions of item problems and approval of feasibility. Phase 3 included a Delphi study with physiotherapists with expertise in behavioural medicine to evaluate item relevance. The findings demonstrated a high level of consensus regarding content relevance. The final version of the Reasoning 4 Change (R4C) instrument included four domains, namely, Physiotherapist, Input from client, Functional behavioural analysis, and Strategies for behaviour change. In phase 4, the reliability and validity of the instrument were evaluated. Physiotherapists with expertise in behavioural medicine and students responded to the web-based R4C instrument and the Pain Attitudes and Beliefs Scale for Physiotherapists. The analyses showed excellent inter-rater reliability, satisfactory construct validity, internal consistency and test-retest reliability. In study IV, final-semester students (n=151) from all physiotherapy programmes in Sweden completed the R4C instrument. Hierarchical multiple regression analyses were conducted with three dependent variables, namely, Input from client, Functional behavioural analysis, and Strategies for behaviour change. All included independent variables explained 37% of the variance in Input from client. Cognitive and metacognitive skills explained 22%, attitudes 15% and curriculum with behavioural medicine competencies 3%. Only the variable curriculum with behavioural medicine competencies explained the variance in Functional behavioural analysis (4%) and Strategies for behaviour change (5%).

    In conclusion, the in-depth description of clinical reasoning focused on clients’ behaviour change may contribute to expanded understanding of the complexity and multidimensionality in reasoning processes that incorporate factors related to human behaviours, analyses of what factors motivate or hinder behaviours, and interventions to support behaviour change. Such knowledge is valuable for the teaching of and learning clinical reasoning. The R4C instrument helps fill the need for well-tested instruments and can support investigations and evaluations in physiotherapy education and research. To develop students’ clinical reasoning competence, cognitive and metacognitive skills, positive attitudes and the incorporation of behavioural medicine competencies into physiotherapy curricula should be targeted. Further attention to complex reasoning, including analysis and intervention, is warranted.