articles

Nurses’ perceptions of communicating with minority parents in a neonatal nursery: a communication accommodation theory approach. Liz Jones, Nicola Sheeran , Hanna Lanyon, Karina Evans and Tatjana Martincovic

School of Applied Psychology, Griffith University, Brisbane, Australia

ABSTRACT Background: Communication is a central part of providing family centred care in neonatal nurseries and is associated with a range of positive outcomes for families. However, previous research has indicated that communication is more problematic between health professionals and minority groups of patients and families, although much of this research is atheoretical. The current study used communication accommodation theory to examine nurses’ perceptions of effective and ineffective interactions with typical parents, culturally and linguistically diverse parents (CALD), and adolescent parents in neonatal nurseries. Method: We conducted semi-structured interviews with nurses from two tertiary hospitals in Australia. Twelve nurses from one hospital were asked about interactions with typical parents, and twenty-nine nurses from the other hospital were asked about interactions with CALD and adolescent parents. Interviews were coded for communication strategy and accommodative stance, using a coding system based on communication accommodation theory. Results: Descriptions of interactions with typical parents (who were perceived as Anglo- Australian) differed from those with CALD and adolescent parents. Interactions with CALD parents focused mostly on comprehension and cultural differences, with limited mention of other strategies. Interactions with adolescent parents were regarded as particularly problematic, and involved greater focus on face management than for other groups of parents. Generally, interactions with minority groups were based on a narrower range of strategies, and were more intergroup than interpersonal in focus. Conclusions: Our findings show the importance of studying health professionals’ perceptions of interactions with people from different minority groups. We discuss the implications for our understanding of communicating with diverse patients and families, and educating health professionals, including the utility of communication accommodation theory as a guiding framework for training.

KEYWORDS Adolescent parent; neonatal nursing; healthcare communication; communication accommodation theory; cultural diversity; linguistic diversity; cultural competence; culturally effective care; family- centered care; bias

Introduction

Communication is central to providing patient-centred care, and is associated with positive outcomes for patients, including patient and family satisfaction, com- pliance with treatment, improved clinical outcomes, and enhanced prevention [1]. While there has been much focus on communication skills deficits as the explanation for poor communication by health pro- fessionals [2], there has been growing interest in how an intergroup perspective, which focuses on how the sociopsychological factors associated with a person’s social group memberships influences their communi- cation, may increase our understanding of the under- lying causes of ineffective health communication [3]. In particular, researchers have been using communi- cation accommodation theory (CAT) to study health communication [4]. CAT constructs interpersonal inter- actions as grounded in the social identity(ies) of the interactants, and predicts communication is influenced by the ‘group’ memberships that are salient for each participant [5].

In health care, these identities/groups include patients and their families, and a range of health pro- fessionals, but may also include other cross-cutting identities, such as ethnicity or age. Researchers have found both more problematic communication and poorer outcomes for patients from minority groups [6–8], suggesting health communication scholars should consider more the interplay between the mul- tiple social group memberships of health professionals and patients. Yet to date, there is limited health com- munication research using intergroup theories to examine communication between health professionals and patients from minority groups [4]. We use CAT to examine, in a neonatal nursery, nurses’ perceptions of communication with parents with different cross- cutting identities.

Neonatal nurseries provide an interesting context for examining the role of cross-cutting identities. Infants may be admitted for a lengthy period of time, and thus parents both have extended contact with a range of health professionals, and must negotiate

© 2018 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Liz Jones [email protected] School of Applied Psychology, Griffith University, 176 Messines Ridge Rd, Mt Gravatt, QLD 4122, Australia

JOURNAL OF COMMUNICATION IN HEALTHCARE 2018, VOL. 11, NO. 3, 175–185 https://doi.org/10.1080/17538068.2018.1460959

their role as a carer for their infant [9]. We interviewed nurses, as they are the coordinators of communication between patients, families, and other health pro- fessionals [10], and, in a neonatal nursery, a key source of information and support for parents [11,12].

We focused on parents who were either adolescent or culturally and linguistically diverse (CALD), because they are two minority groups in Australia who experi- ence poorer perinatal outcomes, and greater disadvan- tage in accessing health services [13]. We use the term CALD to encompass parents who are not Anglo-Austra- lian, i.e. from an ethnic minority group, who may also speak English as a second language. We argue both adolescents, and/or those who are CALD, are, to some extent, stigmatized, and hence their interactions with health professionals are often doubly intergroup [3,14]. In particular, there is a potentially increased power differential between nurses and parents who are not the typical adult and Anglo-Australian parent. This may be compounded by socioeconomic/social class differences, whereby CALD and, in particular, ado- lescent mothers are more likely to be economically dis- advantaged [15]. However, these groups also differ in how they are stereotyped, and the problems they experience in health communication.

Communication between health professionals and patients or families who are CALD or adolescent

Health professionals, including nurses, experience a range of difficulties when interacting with people from a CALD background. Language barriers, in par- ticular, affect patients’ access to obtaining health care. Health professionals acknowledge less favourable impressions and poorer communication with patients from a different race or ethnicity [16]. Jirwe et al. [17] found in cross-cultural encounters, nurses were con- cerned about giving insufficient information about pro- cedures, the lack of social interaction, care becoming mechanistic and impersonal, more misunderstandings, and difficulties with accessing interpreters. Dressler and Pils [18] found being an ethnic minority patient in Austria, who did not speak German, affected patients’ understanding, resulted in longer interactions with health professionals, hindered or completely impeded some therapies, and affected assessment, particularly of functional capacities. Nurses report that language barriers are exacerbated by their lack of cul- tural awareness, and their knowledge and skills to respond to people from a different cultural background [19–22]. Cioffi [20] found that while many Australian nurses were motivated to be empathic and respectful, others were frustrated with patients who could not speak English, while other researchers have found that difficulties in communication are more evident for nurses with more negative attitudes toward

migrants [17,22]. Importantly, Haider et al [23] ident- ified that while relatively few American nurses demon- strated explicit bias, many exhibited implicit bias against non-white patients.

The perceptions of patients from a CALD back- ground concur to some extent. For example, Garrett et al. [24] found non-English speaking patients expressed particular difficulties, including their limited English proficiency, which resulted in feeling power- less, anxious, fearful, lacking in confidence, and a sense of dependency, which led to problems in care, administration of medications, compliance, and treat- ment. Patients also report less positive consultations, less satisfaction, and lower levels of trust when their health professional is from a different race or ethnicity [25,26].

Adolescents also experience difficulties communi- cating with health professionals. Adolescents value health professionals explaining things and giving infor- mation in an understandable way, 2-way communi- cation where health professionals listen to them, and health professionals who are kind, caring, understand- ing, non-patronizing, and non-judgemental [27]. However, both health professionals and adolescents report difficulties in their communication, with Drury [14] arguing explanations for difficulties include the power imbalance between health professionals and adolescents, and communication being one-sided, with a lack of respect for the adolescent’s point of view. For example, adolescents report that in commu- nicating with their doctor they are not listened to, and they are patronized, lectured, and given unsoli- cited advice [28].

Sheeran et al. [29] found that in neonatal nurseries, in contrast to adult mothers, adolescent mothers described interactions with nurses making them feel watched and judged, and lacking power and auton- omy, which inhibited their ability to parent. Adolescent mothers perceived they were labelled and treated as adolescents who did not know how to parent, rather than as mothers. Peterson et al. [30] also found young women inpatients perceived nursing care as more positive when they were treated the same as adult patients, whereas being treated differentially due to age hindered development of an effective nurse-patient relationship. The perceived stigmatiza- tion and feelings of discrimination in the hospital setting appears similar to that experienced by adoles- cent mothers in the general community [31,32]. There has been less research examining health professionals’ perceptions of interactions with adolescent patients or parents.

Communication accommodation theory

While previous research has identified differences in how health professionals communicate with people

176 L. JONES ET AL.

who are CALD or adolescent, this research has mostly been atheoretical, and has rarely compared different minority groups. The current study used CAT to examine the strategies and accommodative stance nurses report when interacting with parents from different social groups. CAT affords attention to the intergroup nature of interactions, including how the activation of group-based stereotypes in intergroup interactions shapes the behavior and perceptions of interactants [33]. A number of communication strat- egies are described in CAT, as well as how interactants use them to facilitate social interactions, and to reduce or increase social distance [34]. Changes in verbal or nonverbal behavior to become more or less like the other interactant is referred to as approximation. The way a speaker adapts their behavior to make it more understandable (or not) is referred to as interpretabil- ity. Discourse management refers to how the process of the interaction is managed, including the sharing of topic selection and turn-taking. Interpersonal control is about the roles enacted in an interaction, whereby interactants may attempt to establish a common role or may seek to keep themselves and others in a particular role. Face management strategies take account of a person’s need to be liked and respected and have their wishes appreciated (positive face), and their need to be independent, free of demands or impositions (negative face). Finally, emotional expression involves interactants responding to the emotional or relational needs of the other person, including reassurance, and support [4].

CAT uses the term accommodative stance to refer to how each interactant uses these strategies to adapt their communicative behavior to appropriately move towards, or respond to the needs of the other person (accommodating), or to be distinct from, or inappropri- ately move towards the needs of their speech partner (nonaccommodating) [35]. Nonaccommodation includes underaccommodation, where a speaker main- tains (or accentuates differences) in their behavior, or overaccommodation, where a speaker goes beyond the style necessary, using patronizing or ingratiating moves, or accommodating to a stereotype of the other person’s group. Accommodation is generally evaluated more positively than nonaccommodation, and in the health context is consistent with definitions of patient-centred care [36] and family-centred care [37]. Family-centred care is the primary model of care used in neonatal nurseries, and refers to putting the family at the centre of care, and recognising and valuing the unique contribution parents and/or families make in the life of the infant [38,39].

CAT has been used in a number studies of health pro- fessional-patient interactions, although the focus has generally been on doctors [4]. Relevant to the current study, Jones et al. [37] used CAT to examine parents’ per- ceptions of interactions with nurses. They did not,

however, examine nurses’ perceptions. While some CAT researchers may focus on examining behavioural adjustments, CAT emphasizes the importance of under- standing the psychological state of both interactants, as an interactant’s behaviour is predicted by their initial orientation (the goals and beliefs they bring to inter- actions, including intergroup relations) and their percep- tions and attributions of their own and their partner’s behaviour. Thus, CAT researchers emphasize that it is equally important to examine the perceptions of interac- tants and how they differ [5]. In our study we will be able to compare the extent to which the perceptions of nurses concur with the perceptions of parents [37].

In the current study, we used CAT to examine nurses’ perceptions of self-reported effective and inef- fective interactions with parents in the neonatal nursery. We investigated ‘How do nurses’ perceptions of communication strategies and accommodative stance differ when describing interactions with parents from different social groups?’ Our interest was whether nurses’ perceptions of communication changed depending on which minority group they were interacting with, compared to their perceptions of interactions with parents where no specific additional group membership was primed. We label the latter parents ‘typical parents’, who Perloni [40] found nurses described as adult and Anglo-Australian. We hypothesised that:

(H1) Effective interactions would be perceived as more accommodative and ineffective interactions as nonaccommodative;

(H2) Interactions with CALD parents would focus more on interpretability, with a focus on level of understand- ing; and,

(H3) Interactions with adolescents would focus more on underaccommodation on discourse management (e.g. lack of 2-way interaction), interpersonal control (e.g. treating as an adolescent rather than an individ- ual), and face strategies (e.g. nurse critical or disrespectful).

Method

Participants

Nurses working full-time or part-time in the Neonatal Special Care Nursery were recruited from two tertiary hospitals in Australia. Special Care Nurseries provide care for infants with lower acuity than Neonatal Inten- sive Care Units. The hospitals were similar in size of the nursery and the acuity of infants, as well as having a significant population of CALD patients and parents. The data were collected in two phases, as two separate student projects in 2013 and 2015.

Phase 1. Twelve nurses (11 female and one male) were recruited from the first tertiary hospital, who had worked in the nursery for 6 months to 23 years

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(M = 7.3 years, SD = 6.8 years). The majority of the nurses were of Anglo-Australian ethnic background, with one each from UK and New Zealand. These nurses were asked about their interactions with parents, without reference to any specific group of parents. We describe these parents as typical parents in our results.

Phase 2. Twenty-nine nurses (all female) were recruited from the second tertiary hospital, who had worked in the nursery for 1.5 to 38 years (M = 16.27, SD = 9.69). The majority were of Anglo-Australian ethnic background, with two from south-east Asia and one from South Africa. These nurses were asked specifically about their interactions with both CALD and adolescent parents.

Recruitment and data collection

Prior to data collection ethical approval was obtained from hospital and university Human Research Ethics Committees. We attended regular in-service sessions for staff in each nursery, and left information sheets in key areas of each unit. Nurses were then approached and invited to participate in the study, and asked to sign a participant information and consent form. Nurses were interviewed at a convenient time and location (e.g. meeting room at hospital or a quiet area in a café).

The interviews were semi-structured. In Phase 1, the interview questions asked nurses about interactions with parents, while in Phase 2 the interview questions referred to a CALD or adolescent parent specifically. Note, in an Australian context the term adolescent refers to a person 13–19 years of age. For example, ‘Can you think about an interaction or a time when you have talked with a (CALD) parent and it was par- ticularly difficult or challenging?’ Prompts: ‘When you felt you didn’t communicate effectively with a CALD parent?’ Or ‘Can you think about a time or interaction when you talked with a (teenage) parent and it went particularly well/felt really good?’ Prompts: ‘When you felt like you communicated effectively with a teenage parent?’ Interview questions about CALD and adoles- cent parents were counterbalanced. Interviews were on average 30 min, and were digitally recorded and transcribed.

Analysis

We used the coding scheme for six CAT strategies (interpretability, discourse management, interpersonal control, emotional expression, positive face, and nega- tive face) that Jones et al [38] developed to examine parents’ perceptions of effective and ineffective inter- actions with nurses in neonatal nurseries. Each partici- pant’s whole description of effective or ineffective communication was content coded for whether the participant mentioned each strategy, and whether their description was accommodative, under-accom- modative, or over-accommodative. Descriptions could be about the nurse’s behavior, the parent’s behavior, or both. Moreover, while nurses were asked to talk about specific interactions, their interviews included both descriptions of specific interactions and state- ments about interactions with parents or the relevant group of parents in general. We coded both. For some participants, a description mentioned only one strategy (rarely), for others up to five strategies. Some participants made only one reference to a particular strategy and stance (e.g. underaccommodative) in their description of effective or ineffective communi- cation, whereas others mentioned the same strategy and stance up to three times. The coding system is

Table 1. Communication strategies coding scheme. Strategy Type Levela Examples

Discourse Management

Over Letting others direct conversation, passiveness, avoiding talking to mother, waiting for them to initiate conversation

Accom Asking questions, asking opinions, chatting, listening, openness to suggestions

Under Dominate conversation, do not listen or let them speak, gives unsolicited advice, controls, bombards with questions

Emotional Expression

Over Too much sympathy, exaggerated need to understand parent, extra effort to get to know them

Accom Reassure mother, show empathy, supportive, recognises and adjusts for parent’s emotional needs

Under Nurses not empathetic or understanding, unsupportive

Interpretability Over Too simple, patronising, assuming no knowledge, spoken down to like children

Accom Clear, direct, honest, explain situation, check understanding, provide sufficient and accurate information, adjust appropriately to cognitive and psychological level

Under Not bothering/giving up explaining, using complex medical terms, not adjusting sufficiently to help understanding, withholding information

Interpersonal Control

Over Be too personal or familiar, treat like best- friend, denigrate others, over self- disclose, over-nurturing toward mother

Accom Treat each other as equal individuals, disregard roles, develop shared identity, get to know as individual

Under Emphasis on professional status, too formal, treat like parent, treat everyone the same instead of as individuals, applying generic or impersonal approach

Negative face Over Nurses ask by putting themselves down, denigrating self, puts self-down with humour

Accom Does not demand/impose mother, approaches at appropriate time, considerate of mothers’ wishes

Under Demand or order parents, nurses prioritises her own needs

Positive face Over Try to counteract prejudice, avoid negative information, give special treatment, overly encouraging or optimistic

Accom Polite, respectful, encouraging, showing interest in individual, promotes confidence

Under Criticise parent, condescending, put them down, rude toward parent, disrespectful

aOver = Over-Accommodation, Accom = Accommodation, Under = Under- Accommodation.

178 L. JONES ET AL.

presented in Table 1. For each phase the students on the project were trained by the first author, with 10% of the transcripts coded initially by both coders to establish consistency in coding. Thirty percent of the data for each student was also coded by a second coder, with interrater reliability of .82 using Cohen’s kappa for Phase 1 and .91 for Phase 2. All coding was then reviewed by the first author and an independent coder to ensure consistency in coding across the two phases.

The analysis confirmed descriptions of interactions with parents in Phase 1 were almost exclusively about typical parents, with only two statements in Phase 1 mentioning a minority group membership. This suggests when we don’t prime nurses for a min- ority group they talk about adult Anglo-Australian het- erosexual parents.

Consistent with Jones et al [38], in our analysis we initially calculated the percentage of participants who mentioned each CAT strategy, for effective and ineffec- tive interactions, for each of the three groups of parents (see Table 2). The Freeman-Halton extension of the Fisher exact probability test was then conducted to examine differences between nurses’ perceptions of the CAT strategies and stance used in effective inter- actions, and in ineffective interactions, with CALD, ado- lescent, and typical parents (the Freeman-Halton extension is appropriate when the contingency table is larger than 2 × 2). We then undertook a more detailed qualitative analysis of how participants described using different strategies with the three different groups of parents. We integrate the findings from this more detailed analysis with our reporting of the results of the quantitative analysis.

Results

Effective interactions

Overall, as predicted, most descriptions of effective interactions involved an accommodative stance. Key topics were provision of information, enabling parent- ing, and the nurse’s or parent’s interpersonal style. A detailed description of these topics is provided in Jones et al [11]. There were, however, differences in which strategies nurses reported being used in effec- tive interactions with typical, adolescent, and CALD parents, as well as how many strategies they mentioned.

Typical parents. When describing effective inter- actions with typical parents, nurses frequently men- tioned discourse management and emotional expression, followed by interpretability, interpersonal control, and positive face. The rates for discourse man- agement and emotional expression were significantly higher than for other groups of parents. Nurses’ use of discourse management included making time to

talk to parents, listening to them, jointly making decisions, and following up on their discussions. Nurse 11 reflected the use of emotional expression: ‘building rapport is important … [as is] giving [parents] an opportunity to voice how they feel’. Most nurses mentioned accommodative interpretability in relation to explaining and clarifying information. Nurse 9, for example, said ‘it was her first time and just explaining to her the right way to breastfeed and attachment’. Nurses also frequently mentioned inter- personal control, emphasising the importance of treat- ing parents as equals. Finally, positive face was less frequently mentioned, with a typical quote being Nurse 5 describing ‘giving a mum positives to hang on to, to come back with the next day to try again’.

CALD parents. Fewer strategies were mentioned with CALD parents. Interpretability was the most frequently mentioned strategy. This primarily involved nurses checking understanding, adapting their language style, slowing and simplifying speech, using gestures to assist in explanations, and accessing outside resources, such as interpreters and written materials, to facilitate understanding. For example, Nurse 13 describes

non-verbal communications, smiling, eye contact, sign language, things like that, if it is nothing important, just nappy changes or things like that … . But if it is impor- tant stuff, I think you need interpreter.

In general, the focus was on language comprehension rather than other cultural differences in communication.

The only other strategies reported with some fre- quency were interpersonal control and positive face. A small number of the comments about positive face were similar to those for typical parents, such as Nurse 18 talking about ‘being able to facilitate skill building in parents to care for the baby’. However, the majority of nurses used positive face to show inter- est in the parent as a person from a CALD background, such as Nurse 22 ‘asking questions to learn about their culture in order to understand their needs’. In using interpersonal control, nurses used informal communi- cation, including talking about cultural issues (‘we hit it off and started talking about cultural things as well’ Nurse 20). Nurses generally focused on the parent as a person from a CALD background rather than as a parent or an individual, and, surprisingly, there was only one reference in their accounts to particular CALD groups.

Adolescent parents. Descriptions of effective inter- actions with adolescent parents were more often described in general terms than specific interactions. When describing effective interactions with adolescent parents a wide range of strategies were mentioned, with face (both positive and negative), interpersonal control, and interpretability mentioned most fre- quently. The rates for accommodative interpretability,

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discourse management, and emotional expression were lower than for typical parents, whereas negative face was mentioned more frequently for adolescent parents than both other groups. The focus for nurses when using negative face was about not putting demands on adolescent mothers. Nurse 24 says ‘if they don’t want to sit and talk to me I don’t push it in their face’ and Nurse 26 stated

If they’re on the phone texting … friends here … you’ve just got to choose your moment and say ‘well I’ll come back when you’ve got a minute to listen’. There’s no point because the environment’s not right.

Comments about positive face were similar to those for typical parents, in describing giving them positive feed- back and encouraging them in their parenting, but some also included an assumption that you need to be ‘mindful of how you speak to them’ (Nurse 33). Nurses talked about using interpersonal control to encourage adolescent parents to adopt the parenting role. This was not a way interpersonal control was used with other parents.

While the numbers are small there was also a general pattern across strategies of more frequent use of under or overaccommodation with adolescent parents, compared to CALD and typical parents, which is consistent with nurses viewing these inter- actions as more intergroup. Examples include com- ments such as ‘be a bit self-effacing’ (Nurse 28) and ‘sometimes they need a bit of mothering themselves’ (Nurse 26). While some comments about interpretabil- ity mirrored those for typical mothers, there were also comments that were more overaccommodative, where adolescent parents were seen to be difficult and needing to be spoken to like a child, for example, Nurse 36 says

interactions tend to go well when you answer what- ever nonsense questions they have … . Because they feel relieved if all their questions are answered even if it is a nonsense question.

Overall, nurses perceived overaccommodative approaches to be effective, because they regarded teenage mothers as requiring substantially more support than other mothers and being more difficult.

Ineffective interactions

Overall, as predicted, ineffective interactions were more frequently described as involving under, or to a lesser extent overaccommodation, than accommo- dation. In contrast to descriptions of effective inter- actions, most descriptions of ineffective interactions involved only one or two strategies. Key topics again included provision of information, enabling parenting, and the nurse’s or parent’s interpersonal style. In addition, nurses talked about managing the enforce- ment of policies. There were fewer differences between the three groups of parents for nurses’ descriptions of ineffective interactions, although there were differences in the specific behaviors nurses described themselves and parents using in enacting the different strategies.

Typical parents. When describing interactions with typical parents, interpretability, discourse manage- ment, and interpersonal control were frequently men- tioned. Underaccommodative interpretability was the most frequently mentioned, with nurses identifying how ineffective communication often involved mothers being given inconsistent, unclear, or conflict- ing information, particularly by different nurses, for example ‘I think it was even a day later before anyone realised that the parents didn’t understand

Table 2. Percentage of nurses mentioning each communication strategy for effective and ineffective communication with CALD parents, adolescent parents and adult parents.

Strategy Version

Effective Ineffective

CALD (N = 29) Adolescent (N = 29) Adult (N = 12) CALD (N = 29) Adolescent (N = 29) Adult (N = 12)

Disc Manage Over – – – 6.9b 24.1 27.3 Accom 6.9a 17.2 90.9 –b – 27.3 Under – –b 20.7 36.4

Emot Express Over 3.4 6.9 – – – – Accom –a 24.1 90.9 – – – Under – 3.4 – – 10.2 9.1

Interpretability Over 17.2 24.1 – 6.9 – – Accom 65.5a 31 72.7 20.7b 3.4 36.4 Under – 3.4 – 55.1a 6.9 45.5

Int Control Over – 13.8 – – 13.8 9.1 Accom 31 48.3 63.6 – – 9.1 Under – 6.9 9.1 10.2c 34.5 36.4

Positive Face Over 3.4 3.4 – – 17.2 – Accom 34.5 44.8 54.5 – – 9.1 Under – – – – –

Negative Face Over – 3.4 – – – – Accom 6.9b 27.6 – – – – Under – 6.9 – 3.4a 34.5 –

ap < .05 comparing CALD, adolescent and adult. bp < .01. cp < .08. Over = Over-accommodation; Accom = Accommodation; Under = Under-accommodation.

180 L. JONES ET AL.

that the baby was having this new medication’ (Nurse 10). Underaccommodative discourse management involved ‘cutting parents off’ according to Nurse 1, or being ‘short with [parent]’ as mentioned by Nurse 3. Similarly, underaccommodative interpersonal control was mentioned by several nurses, who described behaving in a formal and professional manner; often to avoid further ineffective interactions. For example, Nurse 5 described how she was later ‘more reserved and standoffish’ after an initial unplea- sant interaction with a parent. Overall, nurses said they had few ineffective interactions with typical parents, and there was a mix of attributing responsibility for the interaction to themselves, the parent, and the situation.

CALD parents. Interpretability was the most fre- quently mentioned strategy for interactions with CALD parents, with almost no other strategies men- tioned. Mostly this was underaccommodative inter- pretability, where nurses described failing to check understanding, failing to adjust their communication style to facilitate understanding (‘I think they get it eventually; we just keep hammering them I guess’, Nurse 34), or recognising that their communication partner had not understood and failing to take any further action (‘you tend to just leave your shift and think oh god she really didn’t understand that’, Nurse 28). Nurses recognised that mothers nodding did not mean that they were understanding, making it difficult to know whether the mother had understood them. Nurses also talked about the difficulties of accessing interpreters, which was of particular concern when the mother was distressed, and how ‘if the information is not interpreted correctly, it can lead to misunder- standings about the baby’s health, which can then increase the mother’s distress’ (Nurse 20).

Underaccommodative interpretability could also be combined with underaccommodative interpersonal control where, for example, Nurse 25 states

I really don’t have the time to just chat, like I do with other parents about anything, because I am not going to sit there and try to explain in hand sign language, ‘like do you watch Master Chef?’ It’s not worth my time.

There were also instances of overaccommodative inter- pretability, ‘I had noticed people talking to her in a louder voice, saying the same English words in a louder voice’ (Nurse 13). In contrast to interactions with other parents, nurses also spoke about fathers from particular cultural backgrounds as the source of difficulties in interactions with CALD parents, particu- larly around interpreting. This included questioning whether fathers were interpreting accurately (e.g. where the father didn’t want his wife examined by a male doctor) or a father refusing to work with a formal interpreter.

Adolescent parents. In describing interactions with adolescent mothers, nurses talked less about interpret- ability, instead talking about interpersonal control, dis- course management, and negative face. In describing the use of discourse management, nurses talked about adolescent mothers as not wanting to listen nor engage with you (‘she said “I don’t want to talk about it with you anymore”’ Nurse 13), or not expres- sing their preferences or asking for help, (‘I find a lot of them to be quiet … you have to drag information out of them’ Nurse 28). In addition, nurses spoke about adolescents underaccommodating on negative face, whereby nurses were critical of adolescent mothers who ‘think they know it all’ (Nurse 25) and are ‘fully aware of their rights, they throw it into you face and know exactly how to use the system’ (Nurse 20). There was more mention of negative face for ado- lescent parents than other parents, with nurses per- ceiving adolescent mothers as putting their own needs first, (‘teens are quite self-centred’ Nurse 35). Nurses demonstrated less empathy towards adolescent parents. It was noteable in descriptions of ineffective interactions with adolescent parents that the adoles- cent mother was frequently positioned as difficult and as responsible for the difficulties in the interaction, rather than nurses acknowledging any contribution to difficulties. There were also considerably more refer- ences to adolescent mothers as a group, rather than descriptions of interactions with individual mothers.

There were also instances of nurses describing the same behavior by an adolescent parent as a CALD parent, but making different evaluations of that behav- ior, that implied different strategies. For example, with CALD parents, nurses would say ‘you’ve got to be aware that they might be nodding at something but they don’t really get it’ [because their behavior isn’t consistent with what has been told to them] (interpret- ability), whereas inconsistencies between what the nurse asked an adolescent mother to do and the ado- lescent mother’s behavior were seen as deliberate non- compliance (underaccommodative face).

Discussion

Overall, consistent with the perceptions of parents in neonatal nurseries [37], descriptions of effective com- munication were mostly associated with use of an accommodative stance and descriptions of ineffective communication with a nonaccommodative stance (mostly underaccommodation). Our findings show nurses describe different communication strategies being used when interacting with parents from differ- ent minority social groups compared to typical parents in the nursery. Moreover, there were simi- larities and differences in the strategies and stance used in interactions with adolescent and CALD parents. Interactions with typical parents were

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described in more interpersonal terms, whereas inter- actions with CALD and adolescent parents were described in more intergroup terms, and hence less consistent with family centred care.

For both CALD and adolescent parents, nurses’ descriptions were less about discourse management and emotional expression than for typical parents. Instead, as predicted, for CALD parents there was more focus on interpretability than other strategies, with a particular focus on comprehension. This is con- sistent with previous research regarding how health professionals change their behavior when interacting with CALD patients [41], and how health professionals are concerned in cross-cultural encounters about giving sufficient information, the level of misunder- standings occurring, and the difficulties accessing interpreters [17,19,21]. It is noteworthy how little nurses reported using discourse management, inter- personal control, and emotional expression, despite these strategies being consistent with family centred care, that is policy in the nurseries [38], and which pre- vious research has identified as strategies important to parents [11,37].

While nurses’ descriptions of effective interactions with CALD were mostly about language comprehen- sion, there was also some limited discussion of cultural differences in both effective and ineffective inter- actions, including issues such as infant care practices and family involvement. The focus for use of positive face was also primarily about doing so in a culturally appropriate way, with evidence of goodwill by some, but not all nurses toward CALD parents (similar to 20). This is further evidence of the narrow focus of nurses when interacting with CALD parents, where interactions were described as intergroup, with culture highly salient, which may mean other com- munication needs of these parents are neglected. Moreover, while culturally competent care is part of the premises of family centred care (42), there was evi- dence in our study that a number of nurses were not attempting to provide culturally competent care, with potential implications for parental well-being and infant care. Future research needs to consider how CALD parents perceive this focus on language, in par- ticular, and culture, and what its impact is.

Nurses emphasised different strategies when inter- acting with adolescent parents compared to typical parents and, to some extent, CALD parents. Moreover, while for all groups there was more focus on inter- actions with mothers than fathers, descriptions of inter- actions with adolescents parents were almost entirely focussed on interactions with mothers. Interactions with adolescent parents were also the most intergroup, whereby they were seen more as adolescents than as parents, which is consistent with adolescent mothers’ viewpoints [29]. In describing effective interactions nurses focused on their own behaviour, talking about

adolescent mothers’ need for independence or freedom from imposition, and the careful balancing work required by nurses to attend to adolescent mothers’ face needs. Some nurses talked about mothering adolescent parents, whereas others focused more on chastising or controlling adolescent parents.

In describing ineffective interactions nurses focused on the adolescent mothers’ behaviour, which saw nurses label them as unassertive, or aggressive and dif- ficult (negative face). The greater focus on an under and overaccommodative stance is consistent with ado- lescents’ reports of negative communication with health professionals in neonatal nurseries [29], and in healthcare more generally [14]. The implication of this is that adolescent parents describe disengaging with parenting in the nursery in response to such negative communication [29]. In turn, this may reinforce nurses’ accommodative stance, where adolescent parents need mothering or chastising.

Nurses’ limited focus on discourse management and emotional expression in describing effective inter- actions is inconsistent with adolescents’ desire for health professionals explaining things in an under- standable way (interpretability), two-way communi- cation (discourse management), and health professionals who are kind, caring, and understanding (emotional expression) [27]. Moreover, nurses’ descrip- tions of interactions with adolescent parents ignored the role of the power difference between them. Notice- able in the nurses’ descriptions was positioning the adolescent parent (mostly mother) as responsible for ineffective interactions, in contrast to descriptions of interactions with CALD and typical parents. Nurses’ descriptions of interactions with adolescent parents were consistent with the pervasive deficit view of ado- lescent parenting, which stereotypes adolescent parents as less warm and competent than adult parents [43]. Adolescent mothers are aware of these negative stereotypes, which result in them avoiding seeking help with their parenting [29].

Our findings show the importance of studying how health professionals interact with people from different minority groups. As predicted by CAT, nurses in our study approached interactions with minority group parents with a different initial orientation, based on stereotypes of these groups. In turn, nurses described different strategies being used with CALD and adoles- cent parents compared to typical parents, and the interactions were primarily intergroup. These differ- ences are inconsistent with patient or family centred care models (and therefore culturally competent care), and may mean the needs of these parents are not being met, with potential implications for parents’ engagement in infant care, and their well- being and help-seeking [29]. We need to ensure health professionals are aware of how they stereotype

182 L. JONES ET AL.

patients and families, and how this may influence their communication. We know from the work of Haider et al [23] that nurses may not be aware of their biases. Health professionals also need to be educated about how non-accommodation creates a challenging inter- actional position for patients and families [33]. Pitts and Harwood [44] proposed that accommodative com- petence (based on CAT principles) might provide a new approach to communication skills training, with its focus on adapting to the contextual and relational fea- tures of specific interactions. In turn this would enhance the ability of nurses to provide family centred care. We argue our coding system and our find- ings could provide a framework for training neonatal nurses in accommodative competence, particularly for working with parents from minority groups. Such training needs to include a focus on perspective- taking for interactional partners as both individuals and members of social groups (see [45]).

Our findings for typical parents also highlight the importance of considering the perspectives of nurses, as well as parents about what constitutes effective and ineffective communication. Nurses’ descriptions of effective and ineffective interactions with typical parents were mostly consistent with the Jones et al. [37] study, in which parents frequently mentioned interpretability, discourse management, and emotional expression for effective interactions, and discourse management and interpretability for ineffective inter- actions. However, there were some potentially impor- tant differences, with parents in the Jones et al study talking more about positive face in both effective and ineffective interactions, and more about emotional expression in ineffective interactions. This emphasises the importance of looking at the perceptions of both nurses and parents, to identify discrepancies, which may reflect different emphases about what is impor- tant in nurse-parent interactions. Nurses may be less aware of, or underestimate the impact of when their communication is unsupportive, and given the impor- tant role of nurse support for both parental well- being and satisfaction [12], as well as their parenting [11], the different emphasis of nurses may be consequential.

Limitations

Our study only gathered nurses’ perceptions of their interactions with parents. Future research should examine the perceptions of parents from minority groups. While there is previous research on what strat- egies typical parents prefer, CAT provides a useful fra- mework to identify what CALD and adolescent parents describe as effective or ineffective communi- cation with nurses. We also don’t know to what extent the differences identified in this study are pro- blematic or not for CALD and adolescent parents, but

we suggest there may be effects on both their well- being and parenting. While there is some evidence adolescents value patient or family-centred care, there has been less discussion about the applicability or not of these models of care for people from different cultures. In our study we did not discriminate between CALD parents from different cultures (nor generally did our interview participants), however cultures differ in their conceptions of illness and health, as well as com- munication norms.

Future research should also examine whether our findings generalise to other health professionals. In our studyeffectivecommunicationwasgenerally accommo- dative. Research using CAT with doctors shows less con- sistency in the findings. Ahmed and Bates [46] for example, found that patients do not prefer accommo- dation by doctors on all strategies. While patients were more satisfied with doctors who accommodated on interpretability, their patients were more satisfied with doctors who did not accommodate on interpersonal control. This is a reminder that education in communi- cation effectiveness must, as proposed by CAT, take account of both interactants’ identity/ies and the context within which interactions occurs.

We only coded for strategies and accommodative stance. Future research should systematically examine the goals or motives underlying strategy choice, as any intervention with health professionals will need to understand these, including whether nonaccommo- dation is intentional or unintentional (see [33]). There continues to be limited research examining the behav- ior of nurses and patients or families, to understand the extent to which nurses’ perceptions of their inter- actions are reflected behaviorally. Ideally, we would examine both the behavior and perceptions of both nurses and parents concurrently; providing a dyadic perspective. CAT is an ideal theory to use for such research, as CAT predicts how peoples’ initial orien- tation and accommodative stance may affect both their behavior, and their perceptions and evaluations of their interactional partner.

Conclusion

While patient- and family-centred care have become the dominant philosophies of care in many health facili- ties, our findings show many nurses are not practising family-centred care in interactions with families from minority groups. Overall, the findings also show the value of communication accommodation theory in explicating how health communication is shaped by the social group memberships of patients and families, which in turn may guide new approaches to improving health communication, particularly with patients and families who are members of minority groups. We argue interactions between any health professional and a patient or family are, in part, intergroup. Using

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our CAT coding scheme in training could highlight how the different communication strategies health pro- fessionals use may affect patients or families, enable an exploration of the their motives and beliefs that underlie their communication, and give ideas of new strategies health professionals can use to enhance their communication with patients and families.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Liz Jones, PhD (Uni of Qld), is an Associate Professor and Director of Organisational Psychology. Her research interests are in an intergroup approach to health and organisational communication, and Communication Accommodation Theory. She is interested in both health practitioner-patient communication and interprofessional practice, with a particu- lar interest in giving voice to those from non-dominant groups.

Nicola Sheeran, PhD (Griffith Uni), is a lecturer in psychology and a clinical psychologist. Her research focuses on women and family mental health, and the intersection of clinical, health and social psychology. Current research interests include communication between adolescent mothers and health professionals, long term outcomes for adolescent mothers, and stereotypes, attitudes, stigma and discrimi- nation of adolescent parents.

Hanna Lanyon, BPsychSci Hons (Griffith Uni), is undertaking her Masters in Clinical Psychology at Queensland University of Technology. Her Honours thesis investigated nurses’ per- ceptions of effective and ineffective interactions with teenage mothers in the newborn care unit. Findings from her thesis are included in this paper.

Karina Evans, BPsychSci Hons BCrim (Griffith Uni), works for Queensland Corrections. Karina’s Honours thesis investigated nurses’ perceptions of communicating with culturally and lin- guistically diverse parents in the neonatal nursery. Findings of her thesis are included in this paper.

Tatjana Martinovic, PhD (Griffith Uni), works for Queensland Health. Her interests are in improving health service delivery and effective interprofessional practice.

ORCID

Nicola Sheeran http://orcid.org/0000-0003-0527-8549

References

[1] Ruben BD. Communication theory and health communi- cation practice: the more things change, the more they stay the same. Health Comm. 2016;31(1):1–11. doi: http://doi.org/10.1080/10410236.2014.923086

[2] Wright KB, Sparks L, O’Hair HD. Health communication in the 21st century. Maldon (MA): Blackwell; 2008.

[3] Watson B, Gallois C, Hewett D, et al. Culture and health care: intergroup communication and its consequences. In: Jackson J, editor. The Routledge handbook of language and intercultural communication. New York (NY): Routledge; 2012. p. 510–522.

[4] Watson B, Jones L, Hewett D. Accommodating health. In: Giles H, editor. Communication accommodation theory: negotiating personal relationships and social identities across contexts. Cambridge (UK): Cambridge University Press; 2016. p. 152–168.

[5] Giles H, editor. Communication accommodation theory. Negotiating personal relationships and social identities across contexts. Cambridge (UK): Cambridge University Press; 2016.

[6] Diette GB, Rand C. The contributing role of health-care communication to health disparities for minority patients with asthma. Chest. 2007;132:802S–809S.

[7] Kreps GL. Communication and racial inequities in health care. Am Behav Sci. 2006;49:760–774.

[8] Meeuwesen L, Harmsen J, Bernsen R, et al. Do dutch doctors communicate differently with immigrant patients than with Dutch patients? Soc Sci Med. 2006;63:2407–2417.

[9] Fenwick J, Barclay L, Schmied V. Struggling to mother: a consequence of inhibitive nursing interactions in the neonatal nursery. J Perinat Neonatal Nurs. 2001;15 (2):49–64.

[10] Moreland JJ, Apker J. Conflict and stress in hospital nursing: improving communicative responses to endur- ing professional challenges. Health Comm. 2016;31:815–823. doi:http://doi.org/10.1080/10410236. 2015.1007548

[11] Jones L, Taylor T, Watson B, et al. Negotiating care in the special care nursery: parents’ and nurses’ perceptions of nurse-parent communication. J Pediatr Nurs. 2015;30(6): e71–e80. doi:http://doi.org/10.1016/j.pedn.2015.03.006

[12] Reis MD, Rempel GR, Scott SD, et al. Developing nurse/ parent relationships in the NICU through negotiated partnership. J Obstet Gynecol Neonatal Nurs. 2010;39:675–683. doi:10.1111/j.1552-6909.2010.01189.x

[13] Australian Institute of Health and Welfare. Maternal and perinatal data. 2014 Retrieved from http://www.aihw. gov.au/mothers-and-babies/

[14] Drury J. Identity development in adolescent-adult com- munication. In: Giles H, Reid S, Harwood J, editors. The dynamics of intergroup communication. New York (NY): Peter Lang; 2010. p. 53–64.

[15] Bradbury B. Disadvantage among Australian young mothers. Aust J Labour Econ. 2006;9:147–171.

[16] Street RL, Gordon H, Haidet P. Physicians’ communi- cation and perceptions of patients: is it how they look, how they talk, or is it just the doctor? Soc Sci Med. 2007;65:586–598.

[17] Jirwe M, Gerrish K, Emami A. Student nurses’ experi- ences of communication in cross-cultural care encoun- ters. Scand J Caring Sci. 2010;24:436–444. doi:10.1111/ j.1471.6712.2009.00733.x

[18] Dressler D, Pils P. A qualitative study on cross-cultural communication in post-accident in-patient rehabilita- tion of migrant and ethnic minority patients in Austria. Disabil Rehabil. 2009;31:1181–1190.

[19] Boi S. Nurses’ experiences in caring for patients from different cultural backgrounds. J Res Nurs. 2000;5:382– 389.

[20] Coiffi J. Communicating with culturally and linguistically diverse patients in an acute care setting: nurses’ experi- ences. Int J Nurs Stud. 2003;40:299–306.

[21] van Eechoud IJ, Grypdonck M, Beeckman D, et al. Oncology health workers’ views and experiences on caring for ethnic minority patients: a mixed method sys- tematic review. Int J Nurs Stud. 2016;53:379–398. http:// doi.org/10.1016/j.ijnurstu.2015.09.007

184 L. JONES ET AL.

[22] Vydlingum V. Nurses’ experiences of caring for South Asian minority ethnic patients in a general hospital in England. Nurs Inq. 2006;13:23–32.

[23] Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class biases among registered nurses: vign- ette-based study using implicit association testing. J Am Coll Surg. 2015;220:1077–1086. http://doi.org/10. 1016/j.jamcollsurg.2015.01.065

[24] Garrett P, Dickson H, Whelan L, et al. What do non- english-speaking patients value in acute care? Cultural competency from the patient’s perspective: a qualitat- ive study. Ethn Health. 2008;13:479–496.

[25] Cooper LA, Roter DL, Johnson RlL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–915.

[26] Garcia JA, Paterniti DA, Romano PS, et al. Patient prefer- ences for physician characteristics in unviersity-based primary care clinics. Ethn Dis. 2003;13:259–267.

[27] Freake H, Barley V, Kent G. Adolescents’ views of helping professionals: a review of the literature. J Adolesc. 2007;30:639–653. doi:10.1016/j.adolescence.2006.06.001

[28] Wrate RM. Talking to adolescents. In: Myerscough PR, editor. Talking with patients: a basic clinical skill (2nd ed.). Oxford (UK): Oxford University Press; 1992.

[29] Sheeran N, Jones L, Rowe J. The relationship between maternal age, communication and supportive relation- ships in the neonatal nursery for mothers of preterm infants. J Neonatal Nurs. 2013;19:327–33610. doi:http:// doi.org/10.1016/j.jnn.2013.01.006

[30] Petersen WE, Sword W, Charles C, et al. Adolescents’ per- ceptions of inpatient postpartum nursing care. Qual Health Res. 2007;17:201–212. doi:10.1177/ 1049732306297414

[31] Fessler KB. Reclaiming a spoiled maternal identity: young mothers’ experiences and rejection of stigma (Ph.D.). Michigan: University of Michigan; 2008.

[32] Hanna B. Negotiating motherhood: the struggles of teenage mothers. J Adv Nurs. 2001;34:456–464. doi:10. 1046/j.1365-2648.2001.01774.x

[33] Gasiorek J. The “dark side” of CAT: nonaccommodation. In: Giles H, editor. Communication accommodation theory. Negotiating personal relationships and social identities across contexts. Cambridge (UK): Cambridge University Press; 2016. p. 85–104.

[34] Dragojevic M, Gasiorek J, Giles H. Accomdative strat- egies as core of the theory. In: Giles H, editor. Communication accommodation theory. Negotiating personal relationships and social identities across con- texts. Cambridge (UK): Cambridge University Press; 2016. p. 36–59.

[35] Gallois C, Ogay T, Giles H. Communication accommo- dation theory: a look back and a look ahead. In: Gudykunst W, editor. Theorizing about intercultural commmunication. Thousand Oaks (CA): Sage; 2005. p. 121–148.

[36] Epstein RM, Street RL. The values and value of patient- centered care. Ann Fam Med. 2011;9:100–103. doi:10. 1370/afm.1239

[37] Jones L, Woodhouse D, Rowe J. Effective nurse parent communication: a study of parents’ perceptions in the NICU environment. Patient Educ Counsel. 2007;69:206–212. doi:10.1016/j.pec.2007.08.014

[38] Griffin T. Family-centered care in the NICU. J Perinat Neonatal Nurs. 2006;20:98–102.

[39] Newton MS. Family-centered care: current realities in parent participation. Pediatric Nurs. 2000;26:164–168.

[40] Perolini J. Adolescent or adult, indigenous or Anglo Australian: how the age and the ethnicity of a mother influences how they are perceived [Honours thesis]. Griffith University; 2015.

[41] Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ and Counsel. 2006;64:21–34.

[42] Doherty L. An exploratory study examining Australian attitues toward adolescent fathers [Honours thesis]. Griffith University; 2016.

[43] Pitts MJ, Harwood J. Communication accommodation competence: the nature and nurture of accommodative resources across the lifespan. Language and Comm. 2015;41:89–99.

[44] Giles H, Gasiorek J. Parameters of non-accommodation: refining and elaborating communication accommo- dation theory. In: Forgas J, Vincze O, László J, editors. Social cognition and communication. New York (NY): Psychology Press; 2013. p. 155–172.

[45] Ahmed R, Bates B. To accommodate, or not to accom- modate: exploring patient satisfaction with doctors’ accommodative behavior during the clinical encounter. J Comm Health. 2016;9:22–32.

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