Comunicação Emocional em Saúde: Apresentando a Ferramenta de Codificação de Verona de Sequências Emocionais (VR-CoDES) / Emotional Communication In Healthcare: A Tool for Verona Coding Definitions to Emotional Sequences (VR-Codes)

A comunicação clínica, com foco nas competências emocionais, é uma habilidade que requer treinamento devido à necessidade de reconhecer expressões emocionais dos pacientes e dar uma resposta adequada. O objetivo deste estudo é apresentar uma ferramenta para avaliação da comunicação emocional dos profissionais de saúde, abordando as principais definições teóri-cas sobre a temática e pesquisas baseadas em evidências que aplicaram a ferramenta Codifica-ção de Verona para Sequências Emocionais(VR-CoDES). Baseado numa pesquisa de levantamen-to bibliográfico, o estudo analisa a comunicação emocional dos profissionais de saúde e o uso dessa ferramenta, tendo em vista que a comunicação é a componente chave na alta qualidade do tratamento, com impacto na satisfação e adesão dos pacientes. O estudo discute a impor-tância do reconhecimento de pistas e preocupações emocionais de pacientes em tratamentos de saúde e destaca as lacunas e desafios sobre os treinamentos de habilidades de comunicação emocional nos contextos de saúde. (AU)

Emotional communication in health is a tool to improve communication skills regarding the need to recognize patients’ emotional expressions and give them an adequate response. This study aims to show a tool to assess the emotional communication of health professionals, ad-dressing the main theoretical definitions and evidence-based research that applied the Verona Coding Definitions of Emotional Sequences (VR-CoDES) methodology. Based on bibliographic research, the study analyzes the use of the VR-CoDES on emotional communication of health professionals, considering that communication is the key component in the high quality of treatment, with an impact on patient satisfaction and compliance. The study discusses the importance of recognizing patients’ emotional cues and concerns in health care and highlights the gaps and challenges in training emotional communication skills in health contexts. (AU)

The role of the emotive, moral, and cognitive components for the prediction of medical students' empathic behavior in an Objective Structured Clinical Examination (OSCE).

OBJECTIVES: Investigate whether medical students' emotive abilities, attitudes, and cognitive empathic professional abilities predict empathic behavior in an Objective Structured Clinical Examination (OSCE). METHODS: Linear and multiple regressions were used to test concurrent validity between Interpersonal Reactivity Index (IRI), Jefferson Scale of Physician Empathy (JSPE-S), Situational Judgement Test (SJT-expert-based score (SJT-ES), SJT-theory-based score (SJT-TS)) and empathic behavior in an OSCE measured by Berlin Global Rating (BGR) and Verona Coding Definitions for Emotion Sequences (VR-CoDES). RESULTS: Highest amounts of explained variance of empathic behavior measured by VR-CoDES were found for the SJT-ES (R2 = 0.125) and SJT-TS (R2 = 0.131). JSPE-S (R2 = 0.11) and SJT-ES (R2 = 0.10) explained the highest amount of variance in empathic behavior as measured by BGR. Stepwise multiple regression improved the model for BGR by including SJT-ES and JSPE-S, explaining 16.2% of variance. CONCLUSIONS: The instrument measuring the emotive component (IRI) did not significantly predict empathic behavior, whereas instruments measuring moral (JSPE-S) and cognitive components (SJT) significantly predicted empathic behavior. However, the explained variance was small. PRACTICE IMPLICATIONS: The instrument measuring the emotive component (IRI) did not significantly predict empathic behavior, whereas instruments measuring moral (JSPE-S) and cognitive components (SJT) significantly predicted empathic behavior. However, the explained variance was small. In a longitudinal assessment program, triangulation of different instruments assessing empathy offers a rich perspective of learner's empathic abilities. Empathy training should include the acquisition of knowledge, attitudes, and behavior to support learner's empathic behaviors.

Coding the negative emotions of family members and patients among the high-risk preoperative conversations with the Chinese version of VR-CoDES.

BACKGROUND: Little is known about family members' and patients' expression of negative emotions among high-risk preoperative conversations. OBJECTIVES: This study aimed to identify the occurrence and patterns of the negative emotions of family members and patients in preoperative conversations, to investigate the conversation themes and to explore the correlation between the negative emotions and the conversation themes. METHODS: A retrospective study was conducted using the Chinese version of Verona Coding Definitions of Emotional Sequences (VR-CoDES-C) to code 297 conversations on high-risk procedures. Inductive content analysis was used to analyse the topics in which negative emotions nested. The χ2 Test was used to test the association between the cues and the conversation themes. RESULTS: The occurrence rate of family members' and patients' negative emotions was very high (85.9%), much higher when compared to most conversations under other medical settings. The negative emotions were mainly expressed by cues (96.4%), and cue-b (67.4%) was the most frequent category. Cues and concerns were mostly elicited by family members and patients (71.6%). Negative emotions were observed among seven themes, in which 'Psychological stress relating to illness severity, family's care and financial burden' (30.3%) ranked the top. Cue-b, cue-c and cue-d had a significant correlation (p < .001) with certain themes. CONCLUSIONS: Family members and patients conveyed significantly more negative emotions in the high-risk preoperative conversations than in other medical communications. Certain categories of cues were induced by specific emotional conversation contents. PATIENT CONTRIBUTION: Family members and patients contributed to data.

How physicians respond to negative emotions in high-risk preoperative conversations.

OBJECTIVE: To investigate physicians' responses to negative emotions in high-risk preoperative conversations; and to explore the influencing factors of these responses. METHODS: One hundred and sixty-two audio recordings were coded using the Chinese Verona Coding Definition of Emotional Sequences (VR-CoDES). Big Five Personality Inventory Brief Version and Emotional Intelligence Scale were administered to explore the influencing factors of physicians' responses. SPSS 24.0 and R 3.6.3 LME4 Package were used for data analysis. RESULTS: Reduce Space (83%), referring to physicians' responses reducing the opportunities of patients to disclose emotions, was physicians' most frequent response to patients or families' emotions. The main responses were Information-advice (ERIa) and Ignoring (NRIa). Younger age, female, Agreeableness and Openness were factors positively associated with Explicit Provide Space (EP); Neuroticism was negatively correlated with EP. Extroversion was negatively correlated with Explicit Reduce Space (ER); Conscientiousness was negatively correlated with both EP and ER responses. Emotional intelligence had no significant influence on physicians' responses. CONCLUSION: The majority of physicians were inclined to reduce space by providing information advice or ignoring. Physicians' responses were correlated with their gender, age and personality traits. PRACTICE IMPLICATIONS: The trainees' gender, age and personality should be considered when conducting doctor-patient communication skills training.

Preliminary assessment of a tool for measuring relationship-centred communication in veterinary consultations (adapted VR-COPE).

This article was migrated. The article was marked as recommended. Relationship-centred communication is considered a desirable goal in veterinary medicine, and a number of different tools have been developed to measure relationship-centred communication. This study was designed as an initial assessment of an adapted version of the Verona Patient-centred Communication Evaluation (VR-COPE) scale, originally developed for medical communication research, to evaluate its potential for measuring relationship-centredness in veterinary consultations. Fifty-five consultations in the United Kingdom and United States of America were videotaped and analysed. The median VR-COPE total score (out of a potential 100 points) was 76.00 for all consultations. The highest overall score was for "Structuring" (of the consultation), whereas the lowest scores were for "Client Worries," "Psychological Impact," and "Empathy." This initial assessment of the adapted VR-COPE suggests it may be helpful in measuring content, process, and structuring skills related to relationship-centredness in veterinary consultations. It may also help uncover aspects of relationship-centredness that are unique from those uncovered by other tools. Further research is needed to fully assess the role of VR-COPE in veterinary communication research and the contributions it can make to relationship-centredness in veterinary consultations.

Development and piloting of a Situational Judgement Test for emotion-handling skills using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

OBJECTIVE: Emotion-handling skills are key components for interpersonal communication by medical professionals. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) appears useful to develop a Situational Judgment Test (SJT) for assessing emotion-handling skills. METHODS: In phase 1 we used a multi-stage process with expert panels (npanel1 = 16; npanel2 = 8; npanel3 = 20) to develop 12 case vignettes. Each vignette includes (1) video representing a critical incident containing concern(s) and/or cue(s), (2) standardized lead-in-question, (3) five response alternatives. In phase 2 we piloted the SJT to assess validity via an experimental study with medical students (n = 88). RESULTS: Experts and students rated most of the 'Reduce space' responses as inappropriate and preferred 'Explicit' responses. Women scored higher than men and there was no decline of empathy according to students' year of study. There were medium correlations with self-assessment instruments. The students' acceptance of the SJT was high. CONCLUSION: The use of VR-CoDES, authentic vignettes, videos and expert panels contributed to the development and validity of the SJT. PRACTICE IMPLICATIONS: Development costs were high but could be made up over time. The agreement on a proper score and the implementation of an adequate feedback structure seem to be useful.

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

OBJECTIVE: Given the free movement of workers across countries, knowledge regarding communication differences between countries is imperative. In this study, we explored and compared the supportive responses of nursing staff to older persons' emotions in home care in Norway and Sweden. METHODS: The study had an observational, cross-sectional, comparative design, which included 383 audio-recorded home-care visits. Communication was coded using Verona Coding Definitions of Emotional Sequences. Worries and responses were categorised with regard to reference, communicative function and level of person-centredness. Standard statistical tests were used to analyse the data. RESULTS: The Swedish nursing staff provided space for further disclosure of worry more frequently than the Norwegian nursing staff (75.0 % versus 60.2 %, χ2 = 20.758, p < 0.01). In all, 65 % of the responses were supportive. Multiple logistic regression analyses showed that highly person-centred responses were independently associated with worries phrasing an emotion, OR (95 % CI) 3.282 (1.524-7.067). CONCLUSION: The level of person-centredness was associated with the way in which older persons expressed their distress. The Swedish nursing staff provided opportunities for further disclosure of worries more frequently than the Norwegian nursing staff. PRACTICE IMPLICATIONS: Findings of intercultural differences should be incorporated into the training of nursing staff.

Applying Chinese Verona Coding Definitions of Emotional Sequences (VR-CoDES) in ophthalmic consultations: An observational study.

OBJECTIVE: Apply Chinese VR-CoDES in ophthalmic setting and describe patients' worries and the doctor's responses. Explore cultural differences in coding. METHODS: 102 audio-taped consultations of 84 patients were coded by Chinese version of VR-CoDES. The intra-class correlation coefficient (ICC) was used to test inter/intra-rater reliability, and inductive content analysis was conducted. RESULTS: The ICCs of inter-rater reliability for cues/concerns and responses were 0.78 and 0.81, and intra-rater reliability were 0.87 and 0.99, respectively. Cues were more frequent than concerns and elicited often by patients. Explicit Reduce Space (ER) was the most frequent response. Interruptions and the doctor's repetitions were evident. Some expressions were not specified in the coding manual. Patients concerned about treatment effect (22 %), expenses (18 %), risk of operation (14 %), and pain (10 %). CONCLUSION: The Chinese VR-CoDES can be applied to clinical consultations in China. Ophthalmic patients often expressed cues which were frequently elicited by themselves. The ophthalmologist preferred to give ER response. Interruptions and the ophthalmologist's repetitions were difficult to code. More Chinese expressions should be collected to reduce cultural difference when coding. PRACTICE IMPLICATION: VR-CoDES will be helpful in doctor-patient communication and medical education. VR-CoDES should undergo cultural adaptions in China.

Pharmacists' responses to cues and concerns of polypharmacy patients during clinical medication reviews-A video observation study.

OBJECTIVE: The research questions of this study are 1) How do pharmacists respond to negative emotions of patients during a clinical medication review (CMR)? 2) How do patients express negative emotions during a CMR? 3) Who (pharmacist or patient) initiates a negative emotion to be discussed during a CMR? METHODS: We used video-recordings to observe 132 CMR interviews of 49 pharmacists. Videos were coded with the Verona coding definitions on emotional sequences(-provider responses) (VR-CoDES(-P)). RESULTS: In total 2538 negative emotions were identified, mainly expressed as cues (95.0 %). Often cues were expressed as verbal hints to hidden concerns (33.2 %) or were related to cognitive or physical causes (28.3 %).Three-quarters of the negative emotions were elicited by patients. 2670 pharmacists' responses were coded. The most common response was non-explicit providing space (77.6 %) and the least common response was explicit reducing space (5.8 %). CONCLUSION: Pharmacists are mainly non-explicitly providing space in their responses. While this hinders their ability to capture patients' problems it also may enable patients to initiate topics. PRACTICE IMPLICATIONS: Pharmacists are able to respond to patients' negative emotions. Training should focus on developing pharmacist's skills to be more explicit in their responses to get more in-depth knowledge of patients' problems.

Factors related to the expression of emotions by early-stage breast cancer patients.

OBJECTIVE: (1) To report the number and type of emotional expressions (cues/concerns) raised by breast cancer patients; (2) to identify the influence of setting, patient characteristics, and doctor-patient interaction on emotional expression. METHODS: 308 Italian-speaking female patients were recruited at their first breast cancer consultation. The visits were audio-recorded and analysed for number and type of emotional expressions (VR-CoDES). Oncologists' interaction skills were rated by the VR-COPE. Socio-demographic, clinical and personality variables were gathered before the consultation. Clinical variables and oncologists' evaluations of the patient were collected after. RESULTS: Breast cancer patients raised emotional issues mainly as cues. The setting (centre where the consultations took place), the oncologist's attribution of anxiety, regardless of anxiety test screening (STAI-X1) score before the consultation, and the oncologist's ability to pick up on patient's worries, handle emotional needs or understand psychosocial condition were all positively related with the number of emotional expressions. More tightly structured consultations had fewer emotional expressions. CONCLUSION: Both contextual and interactional aspects have an impact on patient emotional expressions. PRACTICE IMPLICATIONS: Oncologists need to be trained to manage both the content and the process of medical consultation. Work organization of the consultation setting needs to be taken into account.

Can Verona Coding Definitions of Emotional Sequences (VR-CoDES) be applied to standardized Chinese medical consultations? - A reliability and validity investigation.

OBJECTIVE: To investigate the reliability and validity of the Chinese version of VR-CoDES. METHODS: The VR-CoDES was translated into Chinese, and a focus group was held to discuss its cultural adaptation. Video consultations between 75 fourth-year medical students and 2 standardized patients (SPs) were coded by two raters with the Chinese VR-CoDES. Inter-rater reliability was tested by using ICC. To obtain validity, the SPs reviewed the video consultations to confirm the cues and concerns. RESULTS: ICC was 0.79. Specificity and sensitivity were 0.99 and 0.96 respectively. The SPs expressed considerably more cues (mean = 7.00) than concerns (mean = 0.32). Half of the responses of medical students were explicit reducing space. Focus group participants raised some cultural considerations, and some interactions were difficult to code due to cultural differences. CONCLUSION: The Chinese VR-CoDES obtained good reliability and validity. Due to differences in the expression of emotions and other differences such as different medical systems between China and Western countries, the Chinese VR-CoDES needs further cultural adaptation. PRACTICE IMPLICATION: More consultations in real clinical settings need to be gathered to further support the Chinese VR-CoDES both on validation and cultural adaptation.

Effectiveness of a brief training program in relational/communication skills for medical residents.

OBJECTIVE: To assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents. METHODS: This longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters' score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3). RESULTS: After the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3. CONCLUSION: This study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents' ability to respond appropriately to patients' cues and concerns and to conduct a breaking bad news encounter. PRACTICE IMPLICATIONS: Brief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs.

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

OBJECTIVES: Explore physicians' verbal and nonverbal responses to cues/concerns in consultations with older-patients. METHODS: Two teams independently coded a sample of Norwegian consultations (n=24) on verbal and nonverbal dimensions of communication using VR-CoDES and NDEPT instruments. Consultations exploring older-patients' verbal emotional expressions were labeled 'Acknowledging of patients' emotional expressions', and 'Distancing from patients' emotional expressions.' Based on type and extent of nonverbal expressiveness, consultations were labeled 'Affective' and 'Prescriptive.' Congruency of verbal and nonverbal communication was assessed and categorized into four types. Incongruent consultations were qualitatively analyzed. RESULTS: Types 1 and 2 consultations were described as 'Congruent,' i.e. both verbal and nonverbal behaviors facilitate or inhibit emotional expressions. Types 3 and 4 were considered 'Incongruent,' i.e. verbal inhibits, but nonverbal facilitates emotional expressions or vice versa. Type 3 incongruent encounters occurred most often when it was challenging to meet patients' needs. CONCLUSIONS: Frequently physicians' display incongruent behavior in challenging situations. Older patients' may perceive this as either alleviating or increasing distress, depending on their needs. PRACTICE IMPLICATIONS: Type 3 consultations may shed light on reasons for physicians' incongruent behavior; therefore, independent measurement and analyses of verbal and nonverbal communication are recommended. Older-patients' perceptions of incongruent communication should be further explored.

VR-CoDES and patient-centeredness. The intersection points between a measure and a concept.

OBJECTIVE: The Verona Coding Definitions of Emotional sequences (VR-CoDES) system has been applied in a wide range of studies, in some of these, because of its attention on healthcare provider's ability to respond to patient emotions, it has been used as a proxy of patient-centeredness. The paper aims to discuss how the VR-CoDES can contribute to the broader concept of patient-centeredness and its limitations. METHODS: VR-CoDES and patient-centeredness concept are briefly described, trying to detect commonalities and distinctions. The VR-CoDES dimensions of Explicit/non explicit responding and Providing or Reducing Space are analysed in relation to relevant aspects of patient-centred communication. RESULTS: Emotional aspects are encompassed within patient-centeredness model, but they represent only one of the numerous dimensions that contribute to define patient-centeredness as well as Explicit/non explicit responding and Providing or Reducing Space serve different functions during communication. CONCLUSION: The VR-CoDES can contribute to operationalize the description of emotional aspects emerging in a consultation, by inducing coders to adopt a factual attitude in assessing how health providers react to patient's expression of emotions. PRACTICE IMPLICATIONS: To better define empirically which measure affective aspects and dimensions of health provider responses are relevant and may contribute to patient-centeredness in different clinical settings.

Registered Nurses' and nurse assistants' responses to older persons' expressions of emotional needs in home care.

AIM: This study aims to explore nurse assistants' and Registered Nurses' responses to older persons' expressions of emotional needs during home care visits. BACKGROUND: Communication is a central aspect of care. Older persons might express different emotions and needs during home care visits and such expressions can be challenging to respond to. Little is known about communication in home care or nursing staff responses to older persons' expressed emotional needs. DESIGN: Descriptive, cross-sectional design on nursing staff responses to older persons' negative emotions in home care. METHODS: Collected data consisted of audio recordings of home care visits between older persons and nursing staff. Data were collected between August 2014-November 2015. The nursing staff responses to older persons' negative emotions in the communication were analysed with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). RESULTS: The nursing staff most often give non-explicit responses, providing space for further disclosure of older persons' expressed negative emotions. Such responses were more frequent if the nursing staff had elicited the older persons' expressions of a negative emotion than if such expressions were elicited by the older persons themselves. Most frequent types of responses were backchannel, active invitation or information advice. CONCLUSION: The nursing staff responses were mainly non-explicit responses providing space for older persons to tell more about their experiences. Such responses can be discussed in terms of person-centred communication and is important for the comfort of emotional concerns.

Applying the Verona coding definitions of emotional sequences (VR-CoDES) to code medical students' written responses to written case scenarios: Some methodological and practical considerations.

OBJECTIVE: To investigate whether the Verona Coding Definitions of Emotional Sequences to code health providers' responses (VR-CoDES-P) can be used for assessment of medical students' responses to patients' cues and concerns provided in written case vignettes. METHODS: Student responses in direct speech to patient cues and concerns were analysed in 21 different case scenarios using VR-CoDES-P. RESULTS: A total of 977 student responses were available for coding, and 857 responses were codable with the VR-CoDES-P. In 74.6% of responses, the students used either a "reducing space" statement only or a "providing space" statement immediately followed by a "reducing space" statement. Overall, the most frequent response was explicit information advice (ERIa) followed by content exploring (EPCEx) and content acknowledgement (EPCAc). DISCUSSION: VR-CoDES-P were applicable to written responses of medical students when they were phrased in direct speech. The application of VR-CoDES-P is reliable and feasible when using the differentiation of "providing" and "reducing space" responses. Communication strategies described by students in non-direct speech were difficult to code and produced many missings. PRACTICE IMPLICATIONS: VR-CoDES-P are useful for analysis of medical students' written responses when focusing on emotional issues. Students need precise instructions for their response in the given test format.

Analysing how negative emotions emerge and are addressed in veterinary consultations, using the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

OBJECTIVE: To explore the applicability, need for modifications and reliability of the VR-CoDES in a veterinary setting while also gaining a deeper understanding of clients' expressions of negative emotion and how they are addressed by veterinarians. METHODS: The Verona Coding Definitions of Emotional Sequences for client cues and concerns (VR-CoDES-CC) and health provider responses (VR-CoDES-P) were used to analyse 20 audiotaped veterinary consultations. Inter-rater reliability was established. The applicability of definitions of the VR-CoDES was identified, together with the need for specific modifications to suit veterinary consultations. RESULTS: The VR-CoDES-CC and VR-CoDES-P generally applied to veterinary consultations. Cue and concern reliability was found satisfactory for most types of cues, but not for concerns. Response reliability was satisfactory for explicitness, and for providing and reducing space for further disclosure. Modifications to the original coding system were necessary to accurately reflect the veterinary context and included minor additions to the VR-CoDES-CC. CONCLUSION: Using minor additions to the VR-CoDES including guilt, reassurance and cost discussions it can be reliably adopted to assess clients' implicit expressions of negative emotion and veterinarians' responses. PRACTICE IMPLICATIONS: The modified VR-CoDES could be of great value when combined with existing frameworks used for teaching and researching veterinary communication.

Using fundamental frequency of cancer survivors' speech to investigate emotional distress in out-patient visits.

OBJECTIVE: Emotions, are in part conveyed by varying levels of fundamental frequency of voice pitch (f0). This study tests the hypothesis that patients display heightened levels of emotional arousal (f0) during Verona Coding Definitions of Emotional Sequences (VR-CoDES) cues and concerns versus during neutral statements. METHODS: The audio recordings of sixteen head and neck cancer survivors' follow-up consultations were coded for patients' emotional distress. Pitch (f0) of coded cues and concerns, including neutral statements was extracted. These were compared using a hierarchical linear model, nested for patient and pitch range, controlling for statement speech length. Utterance content was also explored. RESULTS: Clustering by patient explained 30% of the variance in utterances f0. Cues and concerns were on average 13.07Hz higher than neutral statements (p=0.02). Cues and concerns in these consultations contained content with a high proportion of recurrence fears. CONCLUSION: The present study highlights the benefits and challenges of adding f0 and potential other prosodic features to the toolkit of coding emotional distress in the health communication setting. PRACTICE IMPLICATIONS: The assessment of f0 during clinical conversations can provide additional information for research into emotional expression.

Older persons' worries expressed during home care visits: Exploring the content of cues and concerns identified by the Verona coding definitions of emotional sequences.

OBJECTIVE: Little is known about how older persons in home care express their concerns. Emotional cues and concerns can be identified by the Verona coding definitions of emotional sequences (VR-CoDES), but the method gives no insight into what causes the distress and the emotions involved. The aims of this study are to explore (1) older persons' worries and (2) the content of these expressions. METHODS: An observational exploratory two-step approach was used to investigate audiotaped recordings from 38 Norwegian home care visits with older persons and nurse assistants. First, 206 cues and concerns were identified using VR-CoDES. Second, the content and context of these expressions were analysed inductively. RESULTS: Four main categories emerged: worries about relationships with others, worries about health care-related issues, worries about aging and bodily impairment, and life narratives and value issues, with several subcategories showing the causes of worry and emotions involved. CONCLUSION: The two-step approach provides an in-depth knowledge of older persons' worries, causes of worries, and their related emotions. PRACTICE IMPLICATIONS: The subcategories described in a language close to the experience can be useful in practice development and communication training for students and health care providers.

Do multimorbidity and deprivation influence patients' emotional expressions and doctors' responses in primary care consultations?--An exploratory study using multilevel analysis.

OBJECTIVE: To explore whether and how patient multimorbidity and socioeconomic deprivation might influence patients' emotional expression and doctors' responses in the general practice (GP) consultations. METHODS: Video recordings of 107 consultations (eight GPs) were coded with the Verona Coding Definitions of Emotional Sequences (VR-CoDES). Multilevel logistic regressions modelled the probability of GP providing space response, considering patient multimorbidity, deprivation conditions and other contextual factors. Further multinomial regressions explored the possible impact of multimorbidity and deprivation on expression of and specific responses to patients' emotional distress. RESULTS: It was less likely for GPs to provide space as the consultation proceeded, controlling for multimorbidity and deprivation variables. Patients with multimorbidity were less likely to express emotional distress in an explicit form. GPs were more likely to provide acknowledgement to emotions expressed by patients from more deprived areas. CONCLUSION: Multimorbidity and deprivation may influence the dynamics of the GP consultations in specific ways. Rigorous methodologies using larger samples are required to explore further how these two variables relate to each other and influence cue expression, provider response and subsequent patient outcomes. PRACTICE IMPLICATIONS: Understanding how multimorbidity and deprivation impact on GP consultations may help inform future service improvement programmes.