
==== Front
PEC Innov
PEC Innov
PEC Innovation
2772-6282
Elsevier

S2772-6282(24)00075-X
10.1016/j.pecinn.2024.100327
100327
Articles from Special issue on Family Integrated Neonatal Care: Innovative developments in health promotion, education, and communication; Edited by Nanon H.M. Labrie, Nicole R. van Veenendaal and Anne A.M.W. van Kempen
Formulating parents' feelings: Analyzing parent-nurse conversations in family-integrated neonatal care to develop communication training
van Burgsteden Lotte l.m.van.burgsteden@vu.nl
a⁎
Lamerichs Joyce j.m.w.j.lamerichs@windesheim.nl
b
Hoogerwerf Annemarie a.hoogerwerf@asz.nl
c
te Molder Hedwig h.f.m.te.molder@vu.nl
a
de Jong Miranda m.dejong@asz.nl
d
a Department of Language, Literature and Communication, Vrije Universiteit Amsterdam, De Boelelaan 1105 1081, HV, Amsterdam, the Netherlands
b Knowledge Center Health and Wellbeing, University of Applied Sciences Windesheim Zwolle, Campus 2, 8017, CA, Zwolle, the Netherlands
c Department of Neonatology, Albert Schweitzer Hospital Dordrecht, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
d Department of Pediatrics, Albert Schweitzer Hospital Dordrecht, Albert Schweitzerplaats 25, 3318, AT, Dordrecht, the Netherlands
⁎ Corresponding author. l.m.van.burgsteden@vu.nl
30 7 2024
15 12 2024
30 7 2024
5 10032729 12 2023
23 7 2024
28 7 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Objective

The novel concept of Family-Integrated Care (FICare) requires nurses to be parents' partners in neonatal care. We combined analyses of real-life parent-nurse conversations and interviews to elucidate nurses' role in providing psychosocial support to parents. Findings inform the development of communication training on topicalizing parents' feelings.

Methods

Conversation analysis of 15 audio-recorded parent-nurse conversations, and thematic analysis of interviews with 2 nurses.

Results

In parent-nurse conversations, nurses showed a “balancing act” in formulating parents' feelings, revealing the complexities of addressing parents' feelings. Overall, parents confirmed nurses' formulations, but also expanded or modified them, or indicated restricted conversational space. In the interviews, nurses discussed four purposes of conversations with parents, emphasizing elaborating on parents' feelings, while discussing associated challenges.

Conclusion

Our conversation analysis revealed a continuum of nurses' formulations of parents' feelings, and nurses' reflections illuminated how and when the formulations were used to invite parents' “feelings talk”.

Innovation

This study is the first to use conversation analysis to analyze parent-nurse conversations. Additionally, it pioneers combining these analyses with interviews, inviting nurses to reflect on how to incorporate the findings into FICare. This combination strongly informs the development of tailored communication training, drawing from real-life conversations and nurses' articulated needs.

Highlights

• This study analyzes parent-nurse conversations in neonatal care.

• It uses a combination of a conversation-analytic and an interview-led approach.

• Both methods shed their own light on demands of family-integrated care.

• One challenging demand is how to address parents' feelings in appropriate ways.

• Insights from both methods are used to inform communication training for nurses.

Keywords

Family-integrated care
Neonatal care
Neonatal nurses
Conversation analysis
Formulations
Communication training
==== Body
pmc1 Introduction

Newborns' admission to the neonatology department occurs in a challenging and emotionally charged context. Parents experience emotions like anxiety, guilt and helplessness during their infants' hospital admission [[1], [2], [3], [4]]. Since hospitalization has a profound and long-lasting impact on parents, Family-Integrated Care (FICare) approaches were introduced more than a decade ago to provide the best care for newborns, while also addressing parents' psychosocial needs [5,6]. FICare in neonatal care recognizes the vital role of parents in the care process. It includes four pillars: a neonatal environment fostering prolonged parental presence, staff education, parent education to increase medical knowledge and skills, and offering psychosocial support to parents [[6], [7], [8], [9]]. Implementing FICare still presents challenges, for instance when parents' emotional needs and providers' support are misaligned [8].

This study aims to contribute insights specifically to the fourth pillar: providing psychosocial support to parents. Adopting FICare especially redefines nurses' roles, shifting from their traditional role as primary caregivers for neonates to adopting a multifaceted role as partners in taking care of the infant [10,11]. Recognizing and addressing parents' feelings is deemed essential in this partnership, as is the value parents give to receiving emotional support and empathy [8,9,12]. Nevertheless, both parents and nurses find this challenging. For instance, parents sometimes feel a lack of acknowledgement of their feelings [[13], [14], [15]]. Nurses, on their part, balance being close to parents while maintaining professional boundaries [10,16]. Occasionally, they struggle to navigate parents' conflicting feelings and offering support [17].

While previous studies stress the importance of studying actual conversations between healthcare providers and parents [18,19], most studies center on retrospective reflections. They conduct interviews or surveys with nurses and parents [17,20,21], or code and quantify analyst-defined communicative behaviors, like nurses' “empathic responses” [22]. What remains unexamined, are real-time practices in parent-nurse conversations, i.e. how parents' feelings are addressed, and what parents themselves treat as an “empathic response” or an “invitation to share feelings”. Such an inductive analysis offers valuable insights for training healthcare professionals, based on what happens in real life, including what happens in subtle but nevertheless crucial details of talk [18,23].

This study is the first to combine two methods to analyze parent-nurse conversations in neonatal care:1. Using conversation analysis (CA), we micro-analyze recorded parent-nurse conversations, highlighting nurses' real-life challenges and solutions to talking about parents' feelings.

2. Using a participatory approach to develop tailored communication training, we interview nurses to reflect on the recorded conversations and nurses' needs.

Given our focus on how nurses provide psychosocial support to parents, the ways nurses formulate parents' feelings attracted our analytic attention. With formulations, speakers summarize, gloss, or develop the gist of prior speakers' statements [24]. Prototypical examples are “So you're saying X?” or “So you feel X", which require recipients to (dis)confirm the information [25,26].

Research in CA has shown that formulating another person's feelings can be a conversational challenge given that people have epistemic authority over their own feelings [[26], [27], [28], [29]]. In the field of CA, the study of “epistemics” centers on how knowledge claims are made, disputed, and defended in conversations [27]. We demonstrate this challenge, by showing how nurses formulate parents' feelings by cautiously presenting parents' feelings—treating parents as having epistemic authority over their feelings. We also show situations where nurses assert independent access to parents' feelings, positioning themselves as having epistemic access to what parents feel.

In using both inductive (CA) and participatory (interviews) methods, this research further contributes to work on “applied conversation analysis” [30]. Research within this field uses CA to address a question or practical problem in interaction. By employing these methods, our study not only deepens our understanding of how participants negotiate on claiming epistemic access to feelings [28], but also offers actionable insights for improving communication within healthcare settings.

2 Methods

2.1 Data

The dataset consists of audio-recorded parent-nurse conversations, and video-recorded interviews with nurses.

2.1.1 Recordings of parent-nurse conversations

To analyze real-life parent-nurse conversations, 15 audio-recordings were collected of conversations between 13 parents (10 mothers, 3 fathers), 5 nurses, and 4 neonatologists/pediatric residents in two Dutch hospitals with a post-intensive care/high care neonatal ward. Both hospitals have been increasingly applying FICare principles for over 10 years. We asked nurses to make audio-recordings of their conversations with parents (without researchers present), with participants' consent. Recordings were made between December 2021 and September 2022, and reflected various activities, including nurses being present during doctor visits, discussing the infant's condition, and daily care actions like diaper change. The recordings had an average duration of 26 min, totaling 6 h and 30 min (see Appendix A).

Nurses were informed about our study and were invited to participate. Upon their agreement, nurses signed an informed consent form, after which they approached parents, informing them about the study and asking for their involvement. Once parents had granted their consent, they signed an informed consent form. Nurses then requested parents' permission to record the conversations during their visits.

The recordings were transcribed using the Jefferson [31] transcription-system (Appendix B), capturing nuances of speech delivery, including emphasis, pitch, and pauses. These details enable analysts to discern when conversations are flowing smoothly and when, and how, challenges arise [18]. Transcripts presented in this paper are translated from Dutch to English (see Appendix C for Dutch transcripts).

The recordings were then analyzed using conversation analysis (CA), an inductive method used to examine how participants demonstrate their understanding of one another [32]. The analyses are firmly grounded in the turn-by-turn development of parent-nurse conversations, paying close attention to the actions achieved by participants (e.g., complimenting, comforting), and the sequences of speaking turns through which actions get realized [33]. The initial analysis was conducted by two conversation analysts (LvB,JL). The analyses were revised and refined through meetings with another conversation analyst (HtM). In initial conversations with nurses, they highlighted the complexity of addressing parents' conflicting feelings, prompting our focus on how nurses dealt with “feelings talk”. Initial observations revealed that nurses formulated parents' feelings, but did so in different ways, claiming more, and less access to parents' feelings. After all these formulations were collected, the specific ways nurses formulated parents' feelings were identified. This involved an iterative analytical procedure with multiple rounds of analysis, examining individual instances, and considering common features of nurses' formulations.

2.1.2 Interviews with nurses

For the participatory approach to tailoring communication training, nurses were interviewed about the purposes and challenges of their interactions with parents in the FICare-context, building on the analysis of recorded parent-nurse conversations. The interviews were conducted in the exploratory phase, so as to inform the development of the training. Two nurses participated in four audio-stimulated interviews [34,35]. These experienced nurses were specifically interviewed, as they were intensively involved in the project from the start. They were able to switch between the recordings they made, their experiences in talking to parents about (conflicting) feelings during hospitalization and (team) discussions about putting FICare principles in practice. It was the specific aim to invite these reflections, alongside the findings from the analysis of parent-nurse conversations. The aim of the interviews, therefore, was not to test the accuracy of the findings of the CA study or to form a representative sample, but to start a conversation of whether and how nurses recognized the analyses. Upon reviewing recordings of their conversations with parents, nurses were prompted to describe their conversational purposes, motivations, and challenges. The interviews, video-recorded with permission, lasted 51 min on average, and totaling 3.5 h. The semi-structured interview protocol is based on prior work on stimulated interviewing [34,35] and insights from the analyses of parent-nurse conversations (see Appendix D).

Thematic analysis [36], was used to investigate nurses' descriptions of purposes, motivations and challenges when addressing parents' feelings. For this purpose, recorded interviews were verbatim transcribed, (re)read, and systematically coded in ATLAS.ti (version 23). In the following phase, LvB identified two overarching themes encompassing all codes and created code groups. After JL had coded the data, code groups were further refined. All code groups were reviewed through multiple discussions. In the final phase, a detailed interpretative analysis of the codes was carried out (see Appendix E) and written up. In line with the particular interview purposes, the thematic analysis centered on how interview topics aligned with the conversation-analytic findings, and how nurses' reflections contributed to developing tailored FICare communication training. Further development of the training is based on principles from the Conversation-Analytic Role-play Method (CARM [37]) and the Discursive Action Method (DAM [38]).

2.2 Ethics

The project was submitted to the Medical-Ethical Committee of the Amsterdam UMC, location VUmc, who decided that the study is not subject to the Medical Research Involving Human Subjects Act (2019.596). Moreover, the governing board of the hospitals in which the research was conducted approved the study.

3 Results

3.1 Nurses' formulations of parents' feelings

We found nurses to vary in the degree of caution with which they used formulations to claim access to parents' feelings. Nurses sometimes claimed more independent knowledge of parents' feelings, while at other times nurses' formulations shifted the balance towards more epistemic authority for parents.

We found that nurses' formulations can be placed on a continuum ranging from “cautious formulations” to “assertive formulations” of parents' feelings (Fig. 1).Fig. 1 Nurses' formulations of parents' feelings.

Fig. 1

In this section, we elucidate the four types of nurse formulations and provide an example for each one.

3.1.1 Cautious “My-side”-formulations

One type of formulation nurses used to “cautiously” formulate parents' feelings, were “my-side”-formulations. “My-side” formulations have been extensively investigated in conversation-analytic work [39,40] as situations where speakers express their own sensations to make claims about another person's experiences (e.g., “That seems terrifying to me”). In our dataset, nurses formulated their own feelings or perspectives in a way that suggests knowledge of parents' feelings without claiming the right to (further) define these feelings. In doing so, nurses navigated the epistemic challenges associated with claiming feelings that are not your own [29].

See Extract 1, where a nurse is talking to a mother of a girl (born at 26.3 weeks of gestation). The baby had initially been admitted to another hospital before being transferred to the current one. The nurse references the mother's “setbacks” at the previous hospital when the baby's condition deteriorated (lines 1–2), inquiring whether she has encountered similar setbacks here (line 4). The mother indicates that she experienced a setback just last week when the baby required high flow1 and CPAP2 again (lines 5–7), stating they experienced this “all the time” in the prior hospital (line 10). Using a euphemism (“a little bit of a bummer”, line 14) and laughter [41], she downplays the complaint and avoids any appearance of being eager to complain [42]. The mother's euphemism enables the nurse to tailor her subsequent response to the mother's experience: the nurse provides a “my-side”-formulation, “That seems a little bit discouraging or something to me” (line 17). Using this type of formulation, and explicitly claiming that she is speaking on someone else's behalf (line 18), the nurse orients to the difficulty of claiming epistemic access to someone else's experience.

Extract 1 Recording of parent-nurse conversation [O1]

Unlabelled Table01	Nurse	And in the- in the [Name Hospital] you also had quite	
02		some setbacks again every now and then?	
03	Mother	<yes,>	
04	Nurse	Do you have that here as well?	
05	Mother	.mt uh no only last week then=uh (0.5) when	
06		that u::h high flow needed to return again?	
07		[and the CPAP?	
08	Nurse	[Yes.	
09	Mother	but uh (0.4) in general=uh	
10		that’s what we had there all the time.	
11	Nurse	[Yes	
12	Mother	[with all those uh beep=uh from CPAP	
13	Nurse	Yes.	
14	Mother	that was a little bit of °°a bummer°° .hh °hehe°	
15		(2.1)	
16	Mother	((to baby)) we’re going to put you on your belly girl,	
17	Nurse	That seems a little bit discouraging or something to me=	
18		=yes now I’m putting words in your mouth	
19	Mother	[That’s it.	
20	Nurse	[but-	
21	Mother	That’s it.	
22	Nurse	Yes.	
23		((sound of rubbing hands)) (1.4)	
24	Mother	because then they keep on saying (.) “well: we- we’re	
25		going one step lower again”=and then you think “uh huh?”	
26		(0.4)	
27	Nurse	“Yeah, sure”.	
28	Mother	“of course.” (.) seeing is believing.	

Rather than merely confirming the nurse's formulation, the mother emphatically confirms it (line 19). By repeating this (line 21), she shows that the nurse has formulated exactly what she feels. The mother shows her epistemic authority in reporting on her feelings by expanding on the formulation and discussing her skeptical attitude towards cues by previous healthcare providers (lines 24–28).

3.1.2 Cautious formulation + tag

Nurses also employ “cautious formulations” coupled with a tag to show caution in formulating parents' feelings. “Tags” are brief phrases used by speakers to elicit recipients' confirmation, agreement, or response [43]. These are typically appended to the end of a statement, like “isn't it?” or “right?”. Nurses appended a tag to formulations to signal their lower epistemic status regarding parents' feelings.

This is shown in Extract 2, where a mother is talking about her and her partner's shifting thoughts during their son's hospitalization (born at 28.1 weeks of gestation). Initially hoping to go home without a feeding tube (lines 1–3), they later hoped for a discharge without the need for home oxygen (lines 5–6). The nurse responds by formulating the mother's feelings. She transforms the content of the mother's description [44], proposing that the mother “has been pushing her limits constantly” (lines 17–18). By adding a tag (“right”), the nurse indexes the mother's epistemic authority over her feelings, inviting her to confirm:Extract 2 Recording of parent-nurse conversation [A9]

Unlabelled Table

Instead of simply confirming the formulation, the mother emphatically confirms this (“certainly”, line 20), claiming her epistemic authority [45]. Her repeated confirmation (line 20), and her elaboration of the issue to further indicate her shifting thoughts (lines 23–28), assert more authoritative rights over the issue [45].

3.1.3 Modifications to formulations

Given that formulations preserve some elements of parents' talk, while unavoidably deleting or transforming other elements [24], parents not only expand but also modify nurses' formulations. See Extract 3, where a nurse is talking to a father and mother, who had twin girls (born at 33 weeks of gestation). We show how the mother responds to the nurse's formulation by confirming and modifying it.

Before, the nurse mentioned that the doctor had asked her to notify the parents about the upcoming discharge this weekend. The mother responded by resisting this announcement, explaining that she thought this to be “too soon”. In Extract 3, the mother continues to raise concerns: she mentions that her partner and her mother are both at work (lines 1–4) and suggests she would rather have someone at home with her when the twins come home (lines 6–7). The nurse responds to the father's question about the time of discharge by suggesting it can also be planned for in the afternoon (lines 10–12). The father agrees with the nurse's suggestion by indicating that either he or his mother-in-law would then be available (line 13). What is relevant next, is the mother accepting or rejecting this suggestion (e.g., “Okay, let's do that”). The mother, however, merely acquiesces, producing a neutral, softer pronounced and unelaborated “yes” (line 14) that still shows resistance. The subsequent long silence (line 15) also indicates a problem. The nurse takes the mother's words up as reluctant acquiescence, by pursuing information about the day that the infants can go home (line 16). Another extended silence (line 18), and a softly uttered “yes” by the mother (line 19) follow, which indicate reluctance. The nurse does not leave this unattended but formulates an inference from the mother's prior talk [25]: “>And you find it really scary right?”(line 20).

Extract 3 Recording of parent-nurse conversation [A1]

Unlabelled Table

The nurse's formulation (line 20) casts the prior interaction as having insufficiently dealt with what the “real problem” might be [46]. She thereby redirects the conversation from practical objections about the babies' discharge, to associated emotional aspects. The mother confirms that she finds it scary, but then also modifies the nurse's formulation. Adding she also “thinks it's soon” (line 24), the mother partly resists the nurse's formulation. Her modification challenges the idea that her resistance is solely about her feelings, emphasizing its connection to timing.

3.1.4 Summary cautious formulations

The prior two sections demonstrated cases where nurses exercise caution in claiming access to parents' feelings, revealing that parents, not nurses, hold greater epistemic authority over their feelings. Parents typically emphatically confirm and expand on nurses' formulations, claiming greater epistemic access to their feelings, or they modify nurses' formulations, indicating some resistance to the formulation's content.

3.1.5 Assertive formulations: claiming independent access

Nurses also employ assertive formulations that are less cautious, where nurses do not downgrade their claims, but rather claim independent access to parents' feelings [26]. Nurses thereby show their aggregated experience in the neonatal context: often marked by the adverb “of course”, nurses' formulations treat parents' feelings as recognizable and position nurses as having professional expertise.

See Extract 4, where a mother of a boy (born at 28.6 weeks of gestation), evaluates her experiences in the current hospital. Preceding this extract, she mentioned that she was not particularly concerned about her son's health, and was enjoying him greatly, mentioning she “just keeps on smiling” (line 1). When the mother does not continue (line 4), this signals her willingness to yield the floor to the nurse. The nurse formulates the mother's feelings (lines 5–6), transforming the mother's description of a mere facial expression to also represent a feeling of confidence: “of course that also gives you great peace of mind” (lines 9–10). Contrary to the cases in the prior section, the nurse does not downgrade her claims, but claims independent access to the mother's feelings:Extract 4 Recording of parent-nurse conversation [A9]

Unlabelled Table

The mother immediately displays agreement with the nurse's formulation, but also claims stronger epistemic access to her own feelings through an upgraded acknowledgement [47]: “Yes absolutely” and “Yes certainly” (lines 7,11,13). However, she modifies the formulation by indicating, while laughing, her awareness that she “shouldn't always view everything only from a positive perspective” (lines 15–17).

3.1.6 Assertive formulations: Claiming independent access + expansion

Nurses also claim independent access to parents' feelings by extensively ascribing feelings and thoughts to parents, thereby expanding their formulation. In this way, they claim even more epistemic authority over parents' feelings than ‘merely’ claiming independent access (see prior section). See Extract 5, where a nurse is talking to a mother of a girl (born at 26.5 weeks of gestation). The baby had been hospitalized in another hospital before being transferred to the current hospital, where the parents were assured that the baby would show improvement within forty-eight hours. However, the baby's condition actually worsened upon arriving at the current hospital. Before, the mother talked about the ineffective communication with the prior hospital. She mentions that, because of this, she “started off already behind” when entering the current hospital (line 1). She shows difficulty in formulating her feelings (lines 3,5), which is also how the nurse treats the mother's words. As in Extract 4, the nurse claims independent access to the mother's feelings, demonstrating her own experience with similar situations (lines 6–16). She does so by expanding her formulation in a way that extensively ascribes thoughts and feelings to the mother (lines 27–28,30-31,33-34,36,38-45,48–57):Extract 5 Recording of parent-nurse conversation [A8]

Unlabelled Table

The nurse starts by saying that “for me”, but corrects this into “for us” (line 6), suggesting that she is not expressing her personal view but rather an aggregate professional perspective, that of the hospital. In so doing, she suggests her experience with such situations, emphasizing that for health staff, these scenarios are routine and not as alarming. By mentioning “you have a certain image of a hospital of course” (lines 8–9), followed by “of course you will doubt everything because she's already so fragile and you don't want to lose her” (lines 15–16), the nurse claims access to the mother's inner experience. Using adverbs like “of course” (lines 9,15,48) and “logical” (line 48), she normalizes the mother's feelings, treating this as feelings any parent would have. She uses similar formulations to claim access to the mother's feelings when the baby was deteriorating (lines 19–21,27), which she expands with extensive and directly reported claims of the mother's feelings (lines 27–57). While the mother mostly provides listening tokens (“yes”), on several occasions she also provides more extensive confirmatory phrases (“Yes what is this”, line 29, “yes everything”, line 42), that not only show agreement but also convey stronger epistemic rights than the nurse concerning the issue. Moreover, the mother's extensive phrases indicate moving out of a recipient role and projecting further speaking [48]. This is also visible when she overlaps the nurse's speech (“yes that is-", line 54). She does not finish her sentence, given that the nurse continues talking—revealing the mother's limited speaking opportunities. The nurse concludes by asserting she “really gets” the mother (line 59), emphasizing it with repetition (line 61). In this way, she shows her strong understanding of the mother's feelings.

Notably, the mother does not show signs that the nurse's claims about the mother's feelings are unwarranted. However, the mother does claim stronger epistemic authority [47] when upgrading her acknowledgement of the nurse's formulation (lines 60,62).

3.1.7 Summary assertive formulations

The prior sections demonstrated cases where nurses assert access to parents' feelings without caution. Overall, parents treat nurses' claims of direct access to their feelings as unproblematic. However, parents do respond by claiming more epistemic access to their feelings than nurses, which becomes visible in parents' uptake, showing expansions and modifications of the nurses' formulated claims [47]. Nurses' expanded formulations may also limit parents' speaking opportunities.

3.2 Nurses' reflections on purposes and challenges

Our thematic analysis of the interviews revealed two overarching but intertwined themes relevant to “talking about parents' feelings”. The first theme was purposes of conversations with parents, which included 1a) building trusting relationships; 1b) helping parents articulate and understand their feelings; 1c) giving parents conversational space; and 1d) reaching a “deeper layer”. Reflections on purposes were closely linked to the second theme, experiencing challenges in conversations with parents, where we identified in particular: 2a) parents resisting nurses' conversational moves; 2b) parents holding (unrealistic) expectations, and 2c) experiencing boundaries to communicative conduct. We will now discuss these purposes, and their associated challenges, as articulated by nurses.

3.2.1 Building trusting relationships

Nurses stressed the importance of parents trusting them, as parents entrust them with the care of their newborn child, see Extract 6. Previously, the nurse emphasized the importance of her open communication with parents, ensuring they feel comfortable discussing anything. She also makes a distinction between the importance of a trusting relationship and the necessity of there being a special bond:Extract 6 Interview with nurse [A4-031123]

Unlabelled Table01	Nurse	So personally, I always find it very important that	
02
03
04		parents… well, they do not have to have a super connection with me, but they do need to have the trust that:
“my child is in good hands with you.”	

However, nurses also noted a challenge connected to this purpose. Despite their endeavors to foster trust, parents' resistance to nurses' conversational moves, such as their reluctance to respond to nurses' inquiries or invitations, does significantly impede nurses' efforts. This was also related to another challenge nurses mentioned, where they run into boundaries to their communicative conduct. Nurses mentioned that despite ongoing attempts, parents may not ratify nurses' efforts.

3.2.2 Helping parents articulate and understand their feelings

One central purpose nurses recognized when listening back to their conversations was helping parents articulate and understand their feelings. In Extract 7, the nurse reflected on her conversation with a mother whose baby had experienced unexpected deterioration (see Extract 5). We see how the nurse characterizes herself literally as “spokesperson”, helping the mother to articulate and understand her feelings and describes nurses' conversational role as “the words to parents' thoughts” (lines 8–9):Extract 7 Interview with nurse [A4-031123]

Unlabelled Table01	Nurse	This mother suppressed everything a bit.	
02		And e:hm (1.5) I think that if I wouldn’t express it in	
03		words, or if a colleague wouldn’t express it in words, it	
04		might eventually lead to an outburst where she would be	
05		so angry because the baby had become so ill in our	
06		hospital while she had expected that in our hospital she	
07		would do better.	
		[…]	
08		I think that very often we are the words to	
09		parents’ thoughts.	
10		For some parents, communication comes easily, and they	
11		express everything very easily, but this mother uhm she	
12		was kind of uhm… you could notice that she was angry.	
13		You could feel that when you were with her.	
14		But she didn’t express this, only occasionally with a	
15		comment, but for the rest, it didn't all come out.	

Nurses also highlighted two challenges associated with this role: parents' resistance to nurses' conversational moves and the boundaries to their communicative conduct. Nurses mentioned that there is “only so much they can do” to help parents articulate or understand their feelings. Nurses linked this to what they perceived as another challenge: parents' (unrealistic) expectations. For instance, nurses indicated a desire to assist parents in expressing their feelings, yet parents sometimes remained (unjustifiably) optimistic, even when their child likely required an extensive recovery period.

3.2.3 Giving conversational space

A central goal for nurses in conversations with parents is to give them conversational space. For instance, see Extract 8, where the nurse continues reflecting on the conversation in Extract 5. The nurse raises concerns about her formulation of the mother's feelings, mentioning “I hear myself talking the whole time” (line 1):Extract 8 Interview with nurse [A4-031123]

Unlabelled Table01	Nurse	At some point I hear myself talking the whole time.	
02		Then I think: “Let the mother do the talking” ((laughs))	
		[…]	
03		Yes, then I hear myself and then I think: “Oh, I	
04		should have kept my mouth shut for a while.”	

The nurse acknowledges the importance of allowing space for conversation, yet recognizes how in the recorded conversation, her communicative behavior is quite the opposite: she tended to dominate the conversation, restricting the mother's opportunity to speak. By doing so, the nurse orients to the norm of allowing parents to express themselves and engage actively in conversations. At the same time, nurses experience the challenge that parents may not articulate strong emotions such as anger, as they resist nurses' conversational efforts, which impedes the communicative goals nurses aim to achieve.

3.2.4 Reaching a “deeper layer”

A fourth purpose nurses mentioned upon reviewing their conversations was reaching a “deeper layer” regarding parents' feelings. In doing so, nurses expressed their motivation to make a transition from the things parents say, to exploring any underlying emotions of what is being said. In Extract 9, one nurse explicated this by referring to the mother's resistance to the practical solutions she was offering (see Extract 3). This led the nurse to think she was not “getting anywhere with practical solutions”, which was what made her believe there was “something underneath” (lines 6–7):Extract 9 Interview with nurse [A3-271023]

Unlabelled Table01	Nurse	I try to come up with practical solutions, like, you	
02		know, you can go home on Friday as soon as dad finishes	
03		work, it doesn’t matter. Yes, and then you can tell she's	
04		resisting it. That word “yes” was clearly a sign of	
05		resistance (laughs), I remember.	
06		And then I thought: “Okay, but I’m not getting anywhere	
07		with practical solutions. There’s something underneath.”	

The nurse further reflects on what the “layer underneath” would be:Extract 10 Interview with nurse [A3-271023]

Unlabelled Table01	Res1	I was also thinking about that layer underneath, if you	
02		had to give it a name, what is that layer? You just	
03		mentioned resistance, didn’t you? What do you think is	
04		underneath, if there is something?	
05	Nurse	The emotion of being anxious, well... How should I put	
06		it? You’re naturally focusing on the practical aspect,	
07		I always find that a rather superficial layer. Of course,	
08		you also need to think practically, but that’s quite	
09		superficial, and there are solutions for that.	
10		But with that deeper layer, she has to deal with it	
11		herself. I can have conversations with her, but she will	
12		have to do something about finding it scary.	

The nurse considers the “practical aspects” a “rather superficial layer” (lines 6–7), and a substitute for something else. Here, the mother's emotion of being anxious (line 5). In indicating that the mother will need to deal with that “deeper layer” herself (lines 10–12), the nurse emphasizes the need to balance between expressing empathy towards parents and empowering them.

Nurses also pointed out other challenges associated with this purpose, emphasizing parents' resistance to nurses' efforts to reach a “deeper layer”. For instance, nurses mentioned instances where parents seemed to be “holding back”. They also reflected on challenges involving boundaries of their communicative conduct. Nurses acknowledged that they cannot eliminate the fact that parents find the situation stressful, and that issues on this deeper level also imply solutions that extend the domain of conversations. A final challenge nurses mentioned in this respect was related to parents' holding (unrealistic) expectations. Nurses struggle to reach a “deeper layer” when parents fail to recognize ongoing challenges in caring for a preterm baby post-discharge.

4 Discussion

4.1 Discussion

This study used an innovative combination of two methods to focus on neonatal nurses' role in the fourth pillar of FICare: providing psychosocial support to parents. More so than for doctors, a core part of nurses' changing role is to provide such emotional support [49].

Our analyses of recorded parent-nurse conversations addressed how nurses formulate parents' feelings, revealing “balancing practices” in claiming more, or less epistemic access to parents' feelings. Moving beyond self-report data, these real-life conversations are evidence for the nurse's role in providing psychological support to parents. We found four different ways in which nurses formulated parents' feelings. The first two types showed that nurses claimed less epistemic access by cautiously produced, downgraded claims. These cautious formulations enable nurses to make claims about parents' feelings, while nevertheless giving parents the opportunity to make adjustments, and respecting parents' authority over their feelings. Conversely, the two other types of assertive formulations demonstrated nurses asserting direct access to what parents feel. Hence, while prior research implies that people usually treat others' feelings and experiences as “owned” by the other [28,43], and speakers exercise caution in making claims about them, our research shows situations where speakers assert stronger epistemic access to others' feelings. Comparable findings were found in conversation-analytic research on therapeutic communication, where therapists claimed direct access to clients' feelings without epistemic downgrading [26]. These similar findings suggest that therapists and neonatal nurses share a similar conversational (institutional) task of addressing (underlying) emotions [50].

Overall, parents responded by ratifying nurses' formulations, and most often did so quite readily. This shows that, especially in instances where nurses asserted having direct access to parents' experiences, nurses have a considerable “degree of latitude”: parents allow or tolerate nurses to claim what parents feel, even though such claims belong to parents' epistemic domain. In this FICare-context, where nurses offer psychosocial support to parents, this shows that nurses can help parents in articulating complex and conflicting feelings. However, as we demonstrated, claiming access to parents' feelings may lead them to claim stronger epistemic authority over their feelings through upgraded acknowledgements [45] and expansions on, or modifications of, nurses' formulations. This suggests parents' desire to articulate their feelings in their own terms. Moreover, nurses' formulations can sometimes dominate the conversation, limiting parents' opportunities to speak. Hence, these findings concerning the formulation of parents' feelings imply a potential risk. Such formulations might result in parents being preoccupied with elaborating on or altering the formulations' content, thereby impeding their ability to express their feelings in their own way.

Our findings contribute to work on parent-nurse conversations in the context of FICare. Past empirical research highlighted the need for healthcare providers to use language that provides emotional support, conveys empathy, and acknowledges parents' concerns [8,9,12,22,50]. These studies revealed that healthcare providers' communicative behavior does not consistently fulfill this need; a finding supported in systematic reviews on NICU communication [9,10,12]. Nurses sometimes find providing emotional support and dealing with parents' conflicting feelings challenging, due to a reported lack of proper training and guidelines [17]. Moreover, for parents to share their feelings may not be easy, nor self-evident [51]. Consequently, although nurses' formulations analyzed in the current study may carry risks, they can also serve as a tool to bring attention to parents' (implicit or alluded-to) concerns, and as conversation starters. Differences in the formulation's style (cautious versus assertive) also reflect these functions.

Using an innovative method to analyze parent-nurse conversations proved valuable for gaining insight into the “black box" of real-life parent-nurse conversations [18]. Examining how nurses articulate parents' feelings and delicately manage making such claims, highlights ongoing negotiations on what nurses are entitled to claim regarding parents' feelings within parent-nurse FICare “partnerships” [10,[52], [53], [54]]. Interviews where nurses reflected on their interactions provided additional insight into nurses' “balancing act” in addressing parents' feelings. This revealed key purposes and significant challenges, indicating focal points for a communication training we developed for neonatal nurses.

The communication training we developed based on our research is unique because it incorporates real-life conversations between parents and nurses, rather than hypothetical scenarios, and addresses the practical questions and issues nurses encounter in these interactions. This leads to greater recognition of what happens in these conversations and areas for improvement among nurses compared to other training programs. Future studies should evaluate the effectiveness of communication training that involves nurses reflecting on their actual interactions to enhance nurses' responses to parents discussing their feelings. Such work could, for instance, use controlled experimental designs, in which one group of neonatal nurses receives the communication training we developed, and a control group does not. The effectiveness of the training could then be measured by comparing outcomes between the two groups, such as the quality of “feelings talk” within nurse-parent interactions, parent satisfaction, and parents' emotional well-being. Additionally, qualitative feedback from nurses could provide deeper insights into the training's impact and the extent to which it addresses the specific questions or issues that nurses have, identifying areas for improvement and highlighting successful elements that could be further refined.

Our study contributes to work in “applied conversation analysis” [30], by providing more insights into how analyses of real-life conversations and interviews can be combined to develop communication training. There have been several academic discussions on the use of both interaction data and interviews, and their theoretical compatibility and affinity e.g., [55,56]. Importantly, in our study we have treated the analyses of real-life conversations as standing on their own. While nurses contextualized our analyses in the interviews, the insights gained from the interviews do not ‘compete’ with or ‘correct’ the insights obtained from the fine-grained interactional analysis [57,58]. Rather, both interviews and analyses of conversations contribute separate and unique insights to understand conversations between nurses and parents.

The study's limitations pertain to the fact that parent-nurse conversations were only audio-recorded, lacking insights into non-verbal communicative aspects that most probably also play a role in how formulations of feelings are presented and taken up in the conversations. Additionally, this study focused on an interesting phenomenon that involves “feelings talk” in neonatal care, but has only been able to address a few aspects of formulations of parents' feelings. This study, nevertheless, provides clear analytical entry points for further empirical investigations into interactions in neonatal care, and healthcare interactions more generally. Importantly, we only interviewed one “partner” in parent-nurse partnerships; future investigations should also include parents, to better understand their views on the real-time communicative practices in conversations with nurses, which could also provide insights for communication training, from parents' perspective.

4.2 Innovation

This research adds to the expanding literature on parent-provider communication in FICare [9,10,12]. Unlike previous studies, we uniquely explore nurses' real-life conversations with parents. This study pioneers the use of an inductive, conversation-analytic method to parent-nurse conversations and explores the communicative dynamics of FICare. Moreover, it is the first research combining these insights with interviews, collaborating closely with nurses to collect their reflections on purposes and challenges, alongside conversation-analytic findings. This rich and combined understanding has informed the development of communication training tailored to address nurses' needs, challenges, and interests, in their own terms.

5 Conclusion

Our analysis of “feelings talk” in parent-nurse conversations highlighted the continuum of nurses' formulations of parents' feelings, and nurses' reflections addressing the purposes and challenges related to “feelings talk”. Moving beyond mere self-report data, we analyzed nurses' real-time conversational practices. The subsequent interviews gave us a good insight into the communicative challenges in FICare, as expressed in nurses' own terms, and thus help us to tailor communication training to these complex and multifaceted demands.

Funding

This work was supported by the Van Coevorden Adriani Stichting (VU Vereniging), grant number AB/rk/2021/084 .

CRediT authorship contribution statement

Lotte van Burgsteden: Writing – review & editing, Writing – original draft, Visualization, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Joyce Lamerichs: Writing – review & editing, Visualization, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Annemarie Hoogerwerf: Writing – review & editing, Validation, Supervision, Resources, Investigation, Data curation. Hedwig te Molder: Writing – review & editing, Visualization, Validation, Methodology, Conceptualization. Miranda de Jong: Writing – review & editing, Validation, Resources, Investigation, Data curation.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Outline of recorded conversations

Unlabelled Table	Type of conversation	Participants	Baby, gestational age at birth	First child(ren)?	Duration	
	Discharge conversation	Nurse
Father
Mother	Twins, 33 weeks	Yes	21:00	
	Visit of Nurse	Nurse
Father
Mother	Boy, 28.1 weeks	No	5:38	
	Visit of Nurse	Nurse
Father
Mother	Boy, 37.1 weeks	No	19:30	
	Visit of Doctor	Neonatologist
Pediatric resident
Nurse
Father
Mother	Boy, 28.6 weeks	No	10:44	
	Visit of Doctor	Neonatologist
Pediatric resident
Nurse
Mother	Twins, 33.1 weeks	No	28:21	
	Visit of Nurse	Nurse
Mother	Boy, 33.1 weeks	No	8:09	
	Evaluation with Nurse	Nurse
Father
Mother	Twins, 33.1 weeks	No	25:06	
	Evaluation with Nurse	Nurse
Father
Mother	Girl, 26.5 weeks	No	35:34	
	Evaluation with Nurse	Nurse
Mother	Boy, 28.6 weeks	Yes	31:24	
	Changing diaper	Nurse
Father
Mother	Boy, 28.6 weeks	Yes	4:29	
	Visit of Nurse	Nurse
Mother	Girl, 26.3 weeks	No	20:29	
	Visit of Nurse	Nurse
Father
Mother	Boy, 28.1 weeks	No	21:22	
	Evaluation with Nurse	Nurse
Mother	Girl, 26.3 weeks	Yes	18:10	
	Visit of Doctor	Neonatologist
Nurse
Father
Mother	Girl, 27.8 weeks	No	25:59	
	Visit of Doctor	Neonatologist
Nurse
Father
Mother	Boy, 37.1 weeks	Yes	26:02	
					∼6.5 h	

Appendix B Transcription conventions

Based on Jefferson (2004).

(1.5) Silence with duration of indicated seconds in between brackets

(.) Silence shorter than 0,2 s

text= There is no observable silence in between two adjacent turns-at-talk

=text2 of two different speakers, or in between two adjacent turns-at-talk

of same speaker

[speaker1 these two conversation partners start their turn simultaneously

[speaker2 Falling intonation

 Slightly rising intonation

? Strongly rising intonation at the end of particular part of utterance

↑ Sharp rising intonation

↓ Sharp falling intonation emphasis

Underscore stress/emphasis

stre::tch Prolongation/stretching of sound

(h) Laughter

£ Smiley voice

HELLO Pronounced relatively loud

°hello° Pronounced relatively soft

hel- Speaker terminates production of a word or utterance-part abruptly

>word< Increased speaking rate (speeding up)

Decreased speaking rate (slowing down)

.Hh Hearable in-breath; every ‘h' indicates duration of app. 0,2 s.

Capital ‘H' indicates relatively louder in-breath

((moves)) Characterization of non-verbal activities or other remarkable

 phenomena

( ) Parentheses indicate inaudible speech

(something) Parentheses indicate uncertain word

Appendix C Original Dutch transcripts

Extract 1 Recording of parent-nurse conversation [O1] – Dutch.

Extract 101	Nurse	En in ‘t- in ‘t [Name Hospital] had je ook best wel	
02		af en toe toch nog weer een terugslag?	
03	Mother	<ja,>	
04	Nurse	Heb je dat hier nu ook?	
05	Mother	.mt eh nee alleen dan vorige week = eh (0.5) dat	
06		die e::h high flow weer terug moest?	
07		[en de CPAP?	
08	Nurse	[Ja.	
09	Mother	maar eh (0.4) over et algemeen = eh	
10		dat hadden we daar steeds.	
11	Nurse	[Ja	
12	Mother	[met al die uh piep = uh van CPAP	
13	Nurse	Ja.	
14	Mother	dat was een beetje °°jammer°° .hh °hehe°	
15		(2.1)	
16	Mother	((tegen baby)) we gaan jou lekker op je buikie leggen meissie,	
17	Nurse	dat lijkt me ook een beetje demoti↑verend of zo=	
18		=ja dat vul ik nu voor je in	
19	Mother	[Dat is het.	
20	Nurse	[maar-	
21	Mother	Dat is het.	
22	Nurse	Ja.	
23		((sound of rubbing hands)) (1.4)	
24	Mother	want dan zeggen ze steeds (.) “↑nou:: we- we gaan weer	
25		een stapje lager” = en dan denk je “hm hm?”	
26		(0.4)	
27	Nurse	“Het zal wel.”	
28	Mother	“Tuurlijk.” (.) eerst zien dan geloven.	

Extract 2 Recording of parent-nurse conversation [A9] – Dutch.

Extract 2

Extract 3 Recording of parent-nurse conversation [A1] – Dutch.

Extract 3

Extract 4 Recording of parent-nurse conversation [A9] – Dutch.

Extract 4

Extract 5 Recording of parent-nurse conversation [A8] – Dutch.

Extract 5

Extract 6 Interview with nurse [A4–031123] – Dutch.

Extract 601	Nurse	Dus zelf vind ik het altijd belangrijk dat ouders…	
02
03
04		ja ze hoeven niet een super klik met mij te hebben,
maar ze moeten wel het vertrouwen hebben van:
“mijn kindje is in goede handen bij jou.”	

Extract 7 Interview with nurse [A4–031123] – Dutch.

Extract 701	Nurse	deze moeder die kropte het allemaal wel een beetje op.	
02		En e:hm (1.5) ik denk als ik er geen woorden aan zou geven	
03		of als een collega er geen woorden aan zou geven, dan	
04		zou het misschien op een gegeven moment een ontlading	
05		worden waarbij ze zo boos zou zijn omdat eh het kindje zo ziek	
06		was geworden bij ons in het ziekenhuis terwijl ze juist had	
07
08		verwacht dat het bij ons juist in het ziekenhuis beter zou gaan.	
		[…]	
08		Ik denk dat wij heel vaak de woorden zijn van	
09		de gedachten van ouders.	
10		Sommige ouders zijn natuurlijk heel makkelijk in die	
11
12		communicatie, en die uiten alles gewoon heel gemakkelijk maar deze moeder e:hm die was een soort van ehm…	
12		je merkte aan haar dat ze zichbaar boos was.	
13		Dat voelde je als je bij haar was.	
14		Maar dat uitte ze niet, en dat was dan af en toe met een	
15		opmerking, maar voor de rest kwam het er niet allemaal uit.	

Extract 8 Interview with nurse [A4–031123] – Dutch.

Extract 801	Nurse	Op een gegeven moment hoor ik mezelf de hele tijd kletsen.	
02		Dat ik denk: Laat die moeder verder kletsen ((lacht))	
		[…]	
03		Ja dan hoor ik mezelf en dan denk ik: “Oh, ik had I	
04		wel even mijn mond mogen houden tussendoor.”	

Extract 9 Interview with nurse [A3–271023] – Dutch.

Extract 901	Nurse	Ik probeer dan praktische oplossingen mee te geven, van:	
02		weet je, je kan ook vrijdag naar huis zodra papa klaar is	
03		met werken, dat maakt niet uit. Ja, en dan merk je dat ze	
04		in de weerstand gaat. Dat woordje “ja” was echt in de	
05		weerstand ((lacht)), dat weet ik nog.	
06		En toen dacht ik: “Oké, maar ik kom er zo met praktische	
07		oplossingen niet uit. Er is een laagje onder.”	

Extract 10 Interview with nurse [A3–271023] – Dutch.

Extract 1001	Res1	Ik zat nog wel te bedenken: dat laagje eronder, als je	
02
03
04		daar nou een naam aan zou moeten geven, wat is dat laagje dan? Je zei net over weerstand, wat zit er dan voor laagje
onder volgens jou? Zit er iets onder?	
05	Nurse	De emotie van et spannend eh, ja… Hoe moet ik dat	
06		zeggen? Je blijft natuurlijk daarboven op het praktische	
07		zitten. Dat vind ik altijd een vrij oppervlakkig laagje.	
08		Tuurlijk moet je heel praktisch nadenken ook, maar dat is	
09		vrij oppervlakkig, en daar zijn oplossingen voor.	
10		Maar met dat laagje dieper moet ze zelf iets.	
11		Ik kan gesprekken met haar aangaan, maar daar zal zij zelf	
12		iets mee moeten doen.	

Appendix D Topic guide for interviews with nurses.

Unlabelled TableType	Topic	Prompts	
Introduction	• Catch up with nurse

• Introduction: We have organized this meeting to let you reflect on and discuss with you some of the conversations that you have had with parents. We will play the recording, alongside the transcript, and you can indicate to us what you see happening.

		
Listening to recorded conversation no.1	• Intro: We will now play the recording, and we will also let you read the transcript so that you can follow the conversation. And then we want to ask you to reflect on what you see happening in the conversation?

	• After nurse's response: Can you elaborate on what you mean with X?

• So if I understand you correctly, you say X.

• How do you evaluate X?

	
Listening to recorded conversation no.2	• Intro: We will now play another recording, and we will also let you read the transcript so that you can follow the conversation. And then we again want to ask you to reflect on what you see happening in the conversation?

	• After nurse's response: Can you elaborate on what you mean with X?

• So if I understand you correctly, you say X.

• How do you evaluate X?

	

Appendix E Codebook

This codebook presents the final themes with the corresponding codes.

Theme: Purposes of conversations with parents Unlabelled TableCode	Description	Example from transcript	
Building trusting relationships	Nurse describes a trusting relationship with parents as one of the purposes of conversations with parents	“So I always think it is very important that parents, yes, they do not have to have a great connection with me, but they do need to have trust that my child is in good hands with you.”	
Giving parents conversational space	Nurse describes giving parents conversational space as one of the purposes of conversations with parents	“Yes, then I hear myself and I think: ‘Oh, I should have kept my mouth shut for a while.’”	
Helping parents articulate and understand their feelings	Nurse describes formulating parents' thoughts and feelings as a way to help them understand their feelings	“This mother kind of bottled it all up. And, um, I think if I did not express it in words, or if a colleague did not express it in words, it might eventually lead to an outburst where she would be angry because her daughter became so ill in our hospital, while she had expected things to go better in our hospital.”	
Reaching a “deeper layer”	Nurse describes ‘reaching a deeper layer’ of parents' experiences as a way to reach a ‘deeper layer’ and make a connection with parents	“I am constantly sensing what parents need and you plug into that. Yes, you really have to make a connection to be able to have those good conversations, I think.”	

Theme: Challenges in conversations with parents Unlabelled TableCode	Description	Example from transcript	
Parents' (unrealistic) expectations	Nurse describes parents' (unrealistic) expectations (e.g., about what babies should be like) as a challenging factor in conversations with parents
	“And what I notice is that today's mothers (3.0 s of silence) erm (6.5 s of silence) when you bring home a premature baby, it is not an ordinary baby. And Instagram is full of normal babies who go from here to here and with the nicest bows and things and um… but many of our babies end up having eating problems, sleeping problems, crying a lot, because parents just don't get attuned to their child.”	
Parents resisting nurses' conversational moves	Nurse describes parents resisting nurses' attempts to reach a deeper layer of parents' experiences and feelings as challenging in conversations with parents	“Almost… you feel… they don't literally do it, but you feel that they are holding you back, because they are still in survival mode perhaps, I think that's the case. If I start there, then… ((makes a stop gesture)) then, no, you are not allowed to go there right now.”	
Nurses' boundaries to professional behavior	Nurse describes the boundaries of their own professional behavior as challenging in conversations with parents	“I can't take away the fact that she finds it stressful. I can have conversations with her, but she will have to do something with it herself.”	

Acknowledgements

We want to thank N.H.M. Labrie for her extensive help and advice in the project. We also thank the nurses, doctors and parents who participated in this study.

1 Respiratory support

2 Continuous positive airway pressure
==== Refs
References

1 Ionio C. Colombo C. Brazzoduro V. Mascheroni E. Confalonieri E. Castoldi F. Mothers and fathers in NICU: the impact of preterm birth on parental distress Eur J Psychol 12 2016 604 621 10.5964/ejop.v12i4.1093 27872669
2 Franck L.S. Cox S. Allen A. Winter I. Measuring neonatal intensive care unit-related parental stress J Adv Nurs 49 2005 608 615 10.1111/j.1365-2648.2004.03336.x 15737221
3 Lefkowitz D.S. Baxt C. Evans J.R. Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU) J Clin Psychol Med Settings 17 3 2010 230 237 10.1007/s10880-010-9202-7 20632076
4 Yaman S. Altay N. Posttraumatic stress and experiences of parents with a newborn in the neonatal intensive care unit J Reprod Infant Psychol 33 2 2015 140 152 10.1080/02646838.2014.990872
5 Gooding J.S. Cooper L.G. Blaine A.I. Franck L.S. Hows J.L. Berns S.D. Family support and family-centered Care in the Neonatal Intensive Care Unit: origins, advances, impact Sem Perinatol 35 1 2020 20 28 10.1053/j.semperi.2010.10.004
6 O’Brien K. Bracht M. Macdonell K. McBride T. Robson K. O’Leary L. A pilot cohort analytic study of family integrated Care in a Canadian neonatal intensive care unit BMC Pregnancy Childbirth 13 Suppl. 1 2013 S12 10.1186/1471-2393-13-S1-S12 23445639
7 Bracht M. O’Leary L. Lee S.K. O’Brien K. Implementing family-integrated care in the NICU: a parent education and support program Adv Neonatal Care 13 2 2013 115 126 10.1097/ANC.0b013e318285fb5b 23532031
8 Lorié E.S. Wreesmann W.W. van Veenendaal N.R. van Kempen A.A.M.W. Labrie N.H.M. Parents’ needs and perceived gaps in communication with healthcare professionals in the neonatal (intensive) care unit: a qualitative interview study Patient Educ Couns 104 7 2021 1518 1525 10.1016/j.pec.2020.12.007 33423822
9 Labrie N.H.M. van Veenendaal N.R. Ludolph R.A. Ket J.C.F. van der Schoor S.R.D. van Kempen A.A.M.W. Effects of parent-provider communication during infant hospitalization in the NICU on parents: a systematic review with meta-synthesis and narrative synthesis Patient Educ Couns 104 67 2021 1526 1552 10.1016/j.pec.2021.04.023 33994019
10 Brødsgaard A. Pedersen J.T. Larsen P. Weis J. Parents’ and nurses’ experiences of partnership in neonatal intensive care units: a qualitative review and meta-synthesis J Clin Nurs 28 2019 3117 3139 10.1111/jocn.14920 31112337
11 Patel N. Ballantyne A. Bowker G. Weightman J. Weightman S. Family integrated care: changing the culture in the neonatal unit Arch Dis Child 103 5 2018 415 419 10.1136/archdischild-2017-313282 29122741
12 Wreesmann W.W. Lorié E.S. van Veenendaal N.R. van Kempen A.A.M.W. Ket J.C.F. Labrie N.H.M. The functions of adequate communication in the neonatal care unit: a systematic review and meta-synthesis of qualitative research Patient Educ Couns 104 7 2020 1505 1517 10.1016/j.pec.2020.11.029 33341329
13 Wigert H. Dellenmark M.B. Bry K. Strengths and weaknesses of parent staff communication in the NICU: a survey assessment BMC Pediatr 13 2013 71 10.1186/1471-2431-13-71 23651578
14 Wigert H. Dellenmark Blom M. Bry K. Parents’ experiences of communication with neonatal intensive care unit staff: an interview study BMC Pediatr 14 2014 10.1186/s12887-014-0304-5
15 Serlachius A. Hames J. Juth V. Garton D. Rowley S. Petrie K.J. Parental experiences of family-centred care from admission to discharge in the neonatal intensive care unit J Paediatr Child Health 54 2018 1227 1233 10.1111/jpc.14063 29874396
16 Fegran L. Helseth S. The parent nurse relationship in the neonatal intensive care unit context - closeness and emotional involvement Scand J Caring Sci 23 4 2009 667 673 10.1111/j.1471-6712.2008.00659.x 19000088
17 Trajkovski S. Schmied V. Vickers M. Jackson D. Neonatal nurses’ perspectives of family-centred care: a qualitative study J Clin Nurs 21 17/18 2012 2477 2487 10.1111/j.1365-2702.2012.04138.x 22889445
18 Shaw C. Stokoe E. Gallagher K. Aladangady N. Marlow N. Parental involvement in neonatal critical care decision-making Sociol Health Illn 38 2016 1217 1242 10.1111/1467-9566.12455 27666147
19 Akkermans A.A. Lamerichs J. Schultz M.J.M. Cherpanath T. van Woensel J. van Heerde M.M. How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: a qualitative study Palliat Med 35 2021 1865 1877 10.1177/02692163211028079 34176357
20 Gilstrap C. Organizational sensegiving in family-centered care: how NICU nurses help families make sense of the NICU experience Health Commun 36 13 2021 1623 1633 10.1080/10410236.2020.1785373 32643420
21 Bry A. Wigert H. Psychosocial support for parents of extremely preterm infants in neonatal intensive care: a qualitative interview study BMC Psychol 7 76 2019 10.1186/s40359-019-0354-4
22 Bry K. Bry M. Hentz E. Karlssonm H.L. Kyllönen H. Lundkvist M. Communication skills training enhances nurses' ability to respond with empathy to parents' emotions in a neonatal intensive care unit Acta Paediatr 105 4 2016 397 406 10.1111/apa.13295 26648201
23 Stokoe E. Psychological matters in institutional interaction: insights and interventions from discursive psychology and conversation analysis Qual Psychol 7 3 2020 331 347 10.1037/qup0000162
24 Heritage J. Watson R. Formulations as conversational objects Psathas G. Everyday language: Studies in ethnomethodology 1979 Irvington Press New York 123 162
25 Bolden G.B. ‘Articulating the unsaid’ via and-prefaced formulations of others' talk Discourse Stud 12 1 2010 5 32 10.1177/1461445609346770
26 Weiste E. Voutilainen L. Peräkylä A. Epistemic asymmetries in psychotherapy interaction: therapists’ practices for displaying access to clients’ inner experiences Sociol Health Illn 38 4 2016 645 661 10.1111/1467-9566.12384 26574238
27 Heritage J. The epistemic engine: sequence organization and territories of knowledge Res Lang Soc Interact 45 1 2012 30 52 10.1080/08351813.2012.646685
28 Heritage J. Territories of knowledge, territories of experience: Empathic moments in interaction Stivers T. Mondada L. Steensig J. The morality of knowledge in conversation 2011 Cambridge University Press Cambridge 159 183
29 Hepburn A. Potter J. Crying receipts: time, empathy and institutional practice Res Lang Soc Interact 40 1 2007 251 290 10.1080/08351810701331299
30 Antaki C. Six kinds of applied conversation analysis Antaki C. Applied conversation analysis: Intervention and change in institutional talk 2011 Palgrave Macmillan London 1 14
31 Jefferson G. Glossary of transcript symbols with an introduction Lerner G. Conversation analysis: Studies from the first generation John Benjamins, Amsterdam 2004 13 31 10.1075/pbns.125.02jef
32 Sidnell J. Stivers T. The handbook of conversation analysis 2013 Wiley-Blackwell Oxford
33 Stokoe E. The (in)authenticity of simulated talk: comparing role-played and actual conversation and the implications for communication training Res Lang Soc Interact 46 2 2013 1 21 10.1080/08351813.2013.780341
34 van Braak M. de Groot E. Veen M. Welink L. Giroldi E. Eliciting tacit knowledge: the potential of a reflective approach to video-stimulated interviewing Perspect Med Educ 7 6 2018 386 393 10.1007/s40037-018-0487-9 30446951
35 Pomerantz A. Using participants' video-stimulated comments to complement analyses of interactional practices te Molder H. Potter J. Conversation and cognition 2005 Cambridge University Press Cambridge 93 113
36 Braun V. Clarke V. Using thematic analysis in psychology Qual Res Psychol 3 2 2006 77 101 10.1191/1478088706qp063oa
37 Stokoe E. The conversation analytic role-play method (CARM): a method for training communication skills as an alternative to simulated role-play Res Lang Soc Interact 47 3 2014 255 265 10.1080/08351813.2014.925663
38 Lamerichs J. te Molder H. Reflecting on your own talk: The discursive action method at work Antaki C. Applied conversation analysis: Intervention and change in institutional talk 2011 Palgrave Macmillan London 184 206
39 Pomerantz A. Telling my side: “limited access” as a fishing device Sociol Inq 50 3–4 1980 186 198 10.1111/j.1475-682X.1980.tb00020.x
40 Versteeg W. te Molder H. What my body tells me about your experience: ‘my side’ empathy formulations in ADHD coaching sessions Sociol Health Illn 105 2016 74 86 10.1016/j.pragma.2016.08.005
41 Shaw C. Hepburn A. Potter J. Having the last laugh: On post-completion laughter particles Glenn P. Holt E. Studies of laughter in interaction, Bloomsbury, London 2013 91 106 10.5040/9781472542069.ch-005
42 Jefferson G. Talking about troubles in conversation 2015 Oxford University Press Oxford
43 J. Heritage, G. Raymond, Navigating epistemic landscapes: Acquiescence, agency and resistance in responses to polar questions, in: J.P. de Ruiter (Ed.), Questions: Formal, Functional and Interactional Perspectives, Cambridge University Press, Cambridge, pp. 179–192. doi: 10.1017/CBO9781139045414.013.
44 Weiste E. Peräkylä A. A comparative conversation analytic study of formulations in psychoanalysis and cognitive psychotherapy Res Lang Soc Interact 46 2013 299 321 10.1080/08351813.2013.839093
45 Raymond G. Heritage J. The epistemics of social relations: owning grandchildren Lang Society 35 2006 677 705 10.10170S0047404506060325
46 van Burgsteden L. te Molder H. Raymond G. The turn-by-turn unfolding of “dialogue”: examining participants' orientations to moments of transformative engagement Lang Commun 82 2022 10.1016/j.langcom.2021.11.002
47 Heritage J. Raymond G. The terms of agreement: indexing epistemic authority and subordination in talk-in-interaction Soc Psych Quarterly 68 2005 15 38 10.1177/019027250506800103
48 Jefferson G. Notes on a systematic deployment of the acknowledgement tokens ‘yeah' and ‘Mmhm’ Pap Ling 17 2 1984 197 216 10.1080/08351818409389201
49 Turner M. Chur Hansen A. Winefield H. The neonatal nurses’ view of their role in emotional support of parents and its complexities J Clin Nurs 23 21/22 2014 3156 3165 10.1111/jocn.12558 24575971
50 C. MacMartin, Resisting optimistic questions in narrative and solution-focused therapy, in: A. Perakyla, C. Antaki S. Vehvilainen, I. Leudar (Eds.), Conversation Analysis and Psychotherapy, Cambridge University Press, Cambridge, pp. 80–99. doi: 10.1017/CBO9780511490002.
51 Fenwick J. Barclay V. Schmied V. ‘Chatting’: an important clinical tool in facilitating mothering in neonatal nurseries J Adv Nurs 6 6 2001 197 203 10.1046/j.13652648.2001.01694.x
52 Carlson E.B. Spain D.A. Muhtadie L. McDade-Montez L. Macia K.S. Care and caring in the intensive care unit: family members’ distress and perceptions about staff skills, communication, and emotional support J Crit Care 30 3 2015 557 561 10.1016/j.jcrc.2015.01.012 25682345
53 Axelin A. Ahlqvist-Björkroth S. Kauppila W. Boukydis Z. Lehtonen L. Nurses’ perspectives on the close collaboration with parents training program in the NICU MCN: Am J Matern Child Nurs 39 4 2014 260 268 10.1097/NMC.0000000000000061 24978006
54 Reis M.D. Rempel G.R. Scott S.D. Brady Fryer B. van Aerde J. Developing nurse/parent relationships in the NICU through negotiated partnership J Obstet Gynecol Neonatal Nurs 39 6 2010 675 683 10.1111/j.1552-6909.2010.01189.x
55 D. Maynard, Ethnography and conversation analysis: what is the context of an utterance? in: S. Hesse-Biber, P.L. Leavy (Eds.), Emergent Methods in Social Research, Sage, London, pp. 55–94.
56 Plejert C. Samuelsson C. Anward J. Conversation analysis and talk-extrinsic data in research on speech and language therapy Commun Med 14 2 2019 150 164 10.1558/cam.26886
57 Ford C.E. Clarity in applied and interdisciplinary conversation analysis Discourse Stud 14 4 2012 507 513 10.1177/1461445612450375
58 Pomerantz A. Do participants' reports enhance conversation analytic claims? Explanations of one sort or another Discourse Stud 14 4 2012 499 505 10.1177/1461445611434229
