Reconfiguring clinical communication in the electronic counselling context: The nuances of disruption

Abstract Aim This study expands on an earlier study about diabetes nurses’ experiences of the Guided Self‐Determination intervention in face‐to‐face consultations among people with type 2 diabetes. This current study investigates Guided Self‐Determination in an electronic format with the aim to explore what can be learned about the written form for health communication from the perspectives of diabetes nurses in primary care. Design The study has an explorative, qualitative design. Method Four diabetes nurses were individually interviewed after completing the electronic intervention. The analysis was guided by Interpretive Description. Results Small sample size apart, the rich empirical data and quality of dialogue point to the interviewees’ earlier contact, comfort and trust with the researcher. The written electronic communication could disrupt nurses’ possibilities for using basic and advanced communication skills. Findings also indicate that written electronic communication can foster thoughtful responses to patients and increase possibilities for a transparent counselling delivery process.

This study is extending on an earlier published study about how diabetes nurses in primary care experienced the process of learning to practise the intervention Guided Self-Determination in face-to-face consultations among people with type 2 diabetes (Oftedal, Kolltveit, Zoffmann, Hörnsten, & Graue, 2017). In this current study, we move from face-to-face consultation to Guided Self-Determination in an electronic format with the purpose of de-veloping knowledge about what may be needed to support nurses in shifting health intervention communications into the electronic format.

| BACKG ROU N D
The advances in technology and the potential benefits for health care have resulted in a variety of eHealth interventions in clinical practice. Most of these interventions refer to medical and health support that is personalized, interactive and based on data obtained from patients, in contrast to information that patients may get from generalized websites on health and disease (Elbert et al., 2014). Many eHealth interventions are based on asynchronous communication (refers to communication in delayed time such as e-mail and blogs), to foster communication whenever it is convenient for the healthcare professionals or patients, thus freeing the patient from the necessity of travelling to the clinic at a precise time to receive counselling (Huxley, Atherton, Watkins, & Griffiths, 2015). A systematic review (Ye et al., 2010) shows that the use of e-mail in patient-provider communication has the potential to improve health communication between patients and providers, thus increasing satisfaction and the quality of care. Other studies reveal that electronic communication between healthcare professionals and patients can improve patient-centred care (Cornwall, Moore, & Plant, 2008), facilitate patient information (Kinnane, Milne, Kinnane, & Milne, 2010), prevent dropout and deterioration of patients' health (Das, Faxvaag, & Svanaes, 2015). However, eHealth interventions for people with type 2 diabetes appear to vary widely in terms of follow-up, length and quality (Pal et al., 2013). Previous systematic review reveals the need for eHealth interventions based on a theoretical framework that would provide appropriate patient-tailored feedback from healthcare professionals (Pal et al., 2013). A recent study, using a theory-driven intervention, shows that diabetes nurses (DNs) experienced this Guided Self-Determination (GSD) intervention for type 2 diabetes as a constructive counselling method for stimulating patients' reflections and motivation for diabetes management (Oftedal et al., 2017). Based on these findings, we, in this current study, adapted the GSD approach to an asynchronous eHealth intervention based on written communication. However, incorporating eHealth in clinical practice may represent a disruptive change in the health care and work settings (Koivunen, Niemi, & Hupli, 2015) and a review has identified these challenges; lack of knowledge about the eHealth technology, perception of usefulness, lack of time, training or limited access (Ye et al., 2010). It is argued that if healthcare professionals are dissatisfied with the eHealth intervention, it is unlikely that an intervention would be implemented (Li, Talaei-Khoei, Seale, Ray, & Macintyre, 2013). Therefore, an effort should be made to investigate what is actually taking place when eHealth intervention is implemented in clinical practice. More specifically, it is important to investigate the unintended consequences of eCommunication among nurses in clinical setting (Melby & Hellesø, 2014). A systematic review stated that eCommunication between patients and nurses has not really been studied from the nursing professionals' point of view (Koivunen & Saranto, 2017). In addition, no studies have explored nurses' perspectives on the use of GSD intervention in written eCommunication portals geared towards people with type 2 diabetes in primary care.

| Aim
The aim was to explore what can be learned about the written form for health communication from the experiences of diabetes nurses using an asynchronous electronic Guided Self-Determination intervention for people with type 2 diabetes in primary care. Towards this end, the study was guided by the following question: From a nursing perspective, what is gained and what is lost through written electronic communication?

| Design/Method
This small exploratory study has a qualitative design with an Interpretive Description (ID) methodology (Thorne, 2016), which is a qualitative research strategy developed for the purpose of advancing knowledge in the applied disciplines. As ID is particularly relevant to questions arising from daily clinical practice and for developing new knowledge and insight about clinically topic that may generate changes in health care, the methodology was ideally suited to this study. The data were collected in 2016 by means of individual interviews with four DNs in general practice, representing rural and urban municipalities in south-western Norway.

| Electronic Guided Self-Determination intervention
In this study, the eHealth intervention was based on GSD developed for people with type 2 diabetes (Karlsen et al., 2016). The GSD is a theory-driven counselling approach founded in the synthesis of grounded theories, self-determination theory, life skills theory and humanistic values theory Zoffmann, Harder, & Kirkevold, 2008). The purpose is to guide patients and health professionals through mutual reflection (Zoffmann & Lauritzen, 2006) using a six-stage interaction process:

| Sample
A purposive sample of diabetes DNs was selected from general practitioners (GPs). However, potential recruits for this study were relatively few, as not many GPs in Norway employ Registered Nurses. Therefore, to obtain as many recruits as possible, the first author (BO) disseminated information about the study during a professional meeting for DNs and by telephone to GPs in south-western Norway, inviting them to participate. The inclusion criteria for nurses were as follows: Nurses must: (a) be Registered Nurses and employed in a general practice; (b) have more than 1 year of experience in diabetes care; (c) have completed a test about the GSD; and (d) be willing to use GSD in an electronic written format. The head of the practice approved the participation of the nurses in the study. Five Registered Nurses with particular diabetes expertise were invited to participate. One DN was reported sick. In total, four DNs consented to participate. All study participants were women, aged from 36 -56 years. The median duration of their experience in diabetes care was 7 years (ranging from 4 -22 years). Three of the four DNs had formal postgraduate education in diabetes care (60 ECTS) and all had been trained in the GSD method (Oftedal et al., 2017). However, none of the DNs had been trained in GSD on an eHealth platform.

| Data collection
Individual interviews were performed with the DNs after they had used the electronic GSD platform for patients with type 2 diabetes (spring 2016). The research BCHK, who is also a registered diabetes nurse, conducted the interviews and each interview took place at the University and was limited to 1 hr. A thematic semistructured interview guide was developed by the authors (BO & BCHK), including follow-up questions designed to make it possible for the study participants to highlight perspectives relevant for the research topic.
First, DNs were asked an initial question about their overall experience with the eGSD for patients with type 2 diabetes. This question was followed up by more specific questions concerning their experiences using written electronic communication with patients and how they experienced the patient relationship when counselling via Internet. The interviews were audiotaped and transcribed verbatim.
The text was imported into QSR International's NVivo 11™ software programme for analysis.

| Data analysis
The analysis was guided by Interpretive Description (ID; Thorne, 2016). An important factor in ID is to begin with an open-minded reading of the transcribed text to obtain the sense of the whole.
Three members of the research team (BO, BK and MG) read the text several times, without focusing too much on details at this early stage of the analysis, but roughly coding the sequences that were TA B L E 1 eGSD intervention process, the codes were initially grouped into tentative patterns. The research team discussed the patterns and the relationship between these patterns and sections in the material and concluded the analytic process by conceptualizing the findings in a form that illustrated the application of the GSD intervention based on written eCommunication from the perspective of these diabetes nurses.

| Ethics
The Norwegian Social Sciences Data Services approved the study (No. 39454). All respondents provided informed written consent before the individual interviews and were guaranteed confidentiality and the right to withdraw from the study at any time. The anonymity of participants was maintained by removing names from records and transcriptions.

| Findings
The main finding of this study was that nurses did find the written eCommunication to be a disruptive format in their capacity to deliver care. However, this disruption presented both advantages and disadvantages to the clinical context, which became apparent as they reflected on the gains and losses associated with this form of care delivery. Their interpretation of the nature of this disruption is presented here in the context of three major themes that emerged from their accounts, each of which reveals elements of the nuances of these changes. The following themes were identified: (a) Replacing basic and advanced communicative skills with written expressions; (b) Making process transparent; and (c) Creating space for reflection and insight. Quotations from the interviews are presented to illustrate how nurses expressed their experiences with the asynchronous GSD written eCommunication.

| Replacing basic and advanced communicative skills with written expressions
The nurses said that eCommunication, as a result of its reliance on electronic, written function, changed their way of communicating with the patients and represented other aspects than in an oral dialogue. One aspect that emerged from the analysis was that nurses experienced the electronic, written communication with patients to be challenging because the various layers of communication that occur during face-to-face encounter were lost in an written eCommunication. For example, emotional cues from vocal intonation or body language were missing. In particular, nurses highlighted that body language such as eye contact, posture and gesture, and facial expressions and the general non-verbal expression was lacking.
These expressions helped nurses identify the reactions, questions and needs of patients, which then facilitated nurses' understanding and informed their responses, often without words. They described the written eCommunication as "totally free of body language" due to the inability to read non-verbal expression. In the absence of such expressions and interaction with patients, nurses lost the opportunity to better align their messages with patients need. For example, one nurse expressed the following: I like eye contact and interpreting body language and moods. I cannot do that between the lines. When you speak to the patient, I can tell when they seem skeptical. This is not caught up online, because it is so fil- interactions with the patient. However, despite the use of creative writing, they found it difficult to use the advanced communication skills they had learnt as part of the GSD training. One nurse reported the following: "I tried with value clarification responses to the degree it was possible to use these tools, but it wasn't easy.
I was aware that this was the GSD I would be able to offer" (4).
Another aspect that characterized the nurses' experience of written eCommunication was how it changed their relationship with the patients. Nurses described the relationship with patients to be good and constructive, but also depicted is as being more distant.
As a result, closeness to the patient was lost as expressed by one nurse: "The relationship was good, but it was distanced. I felt like they (the patients) were out in the world and I was here. I felt like I was missing something-a sense of closeness both parties needed" (3).
Similarly, the asynchronous environment reduced nurses' feelings of "being there" with the patient, which could be potentially detrimental to building a therapeutic relationship. In this case, face-to-face contact offers richer stimuli, including auditory, visual, tactile and behavioural stimuli and smells and gestures, which were reported as being lost in the electronic environment with patients. On the other hand, nurses also reflected that written eCommunication with patients could sometimes be perceived as personal as expressed by one nurse: …I think that when it was in writing, it became personal. Here's someone who's at home and writing to me via e-mail or in my chart and responded with «Hi Peter», or whatever their name was. Kind regards, xx, turned into a friendly but not completely informal response, so I still think they felt considered (4).

| Making process transparent
This theme reflects on how using electronic written, instead of verbal communication, makes the counselling process transparent. The nurses reported that the written, electronic environment provided an easier means for following the patient's progress during the GSD, as the written text could be read repeatedly by both patients and nurses. Thus, this transparency extended in both directions. Some nurses noted that it could increase their ability to provide appropriate counselling and support. However, the analysis also revealed that other nurses perceived this process to be challenging, as text is irrevocable and they therefore lost the possibilities to change the text. They described certain difficulties in writing and reported that they often wrote, deleted and rewrote messages while reflecting on how patients would perceive the message. One nurse said the following: "At many points I would reconsider the responses I gave, but when you're talking with someone across from you, you don't spend nearly as much time considering what you should answer as you do when it is in writing" (2).
The nurses also stressed that written eCommunication is not a neutral tool and carries the risk of content being misinterpreted.
They were aware that text could be perceived as much harsher or more powerful than verbal communication. As a consequence, the nurses spent a lot of time constructing sentences and formulating the answer to reduce the risk or avoid misunderstandings that potentially could harm a constructive relationship with patients. Some nurses reported performance anxiety in regard to written eCommunication because they were afraid that their written text was not good enough. One nurse reported the following: However, some nurses reported that practicing communication in writing also led to awakening and better communication with the patients in face-to-face consultations.

| Creating space for reflection and insight
This theme highlights how the nurses perceived written eCommunication to be a tool for reflection, prompting them to take time in composing messages and reflecting on them before sending them to patients. Compared with face-to-face consultations, which require an immediate response to the patient, nurses found written eCommunication to result in messages that were well thought out and that was reflected on more deeply before responding to patients. The nurses reported that the eGSD approach had reoriented their support from giving diabetes advice and information to prompting patients' responsibility for their own health. They also stated that they spent a lot of time to reflect on how to stimulate patients' reflections, decision-making and choice in an electronic written format as expressed by one nurse: "I will constantly write what I think the patient should do"(2). Apparently, writing requires more attention, reflection and time than verbal expression. In this respect, all nurses reported that the written eCommunication was time-consuming. However, they also found time spent to be a constructive aspect. For instance, since eCommunication takes advantage of the delivery of asynchronous messages, nurses had time to obtain the information needed to respond to patients, including information they did have immediately at hand or in mind. Another aspect the nurses highlighted as an advantage was that asynchronous written eCommunication offers flexibility in regard to responding to patients. Nurses could thus respond to patients when they had time and without additional influencing factors.
For example, one nurse reported the following: The thing that was positive about it all was when I got the reflection sheets back from the patient. I could sit down in peace and quiet and read through without being disturbed by patients or others. What does it say between the lines? What does it really say? From that I could offer feedback. In one way it was easier when it was in digital formats than face to face (3).
On the other hand, they were concerned about how to maintain their professional role in written eCommunication. That was particularly expressed when they reflected over how asynchronous written eCommunication allowed them to be available 24/7 and thus responding to patients whenever they had time. Consequently, they were worried that responding to patients outside working hours could influence the nurses' professional role in a negative way.

| D ISCUSS I ON
The aim of this study was to explore what can be learned about the written form for health communication from the experiences of diabetes nurses using an asynchronous electronic Guided Self-Determination intervention for people with type 2 diabetes in primary care. The findings of this study challenge us to reflect on the potential and limitations of written electronic communication and to add to our understanding of what might be needed to support healthcare professionals in shifting health intervention communications into an electronic format.

| Rethinking the essence of communication
The to play in promoting the debate that will allow us to decide on best practices.
Another factor that was reported as lost when using asynchronous written eCommunication was the opportunity of using ad- Therefore, our findings support the findings of previous study reporting that there is a need to improve communication skills in written texts (Björk et al., 2017;van Houwelingen, Moerman, Ettema, Kort, & Cate, 2016) and that educational efforts to include written eCommunication in the nurse students curricula should be prioritized, as it is likely that text-based consultations will expand in the future (Booth, 2006). Healthcare professionals and clinical educators could be a key conduit for stimulating change and increasing the focus on eCommunication.

| Achieving a more transparent and reflective counselling
It is well known that electronic devices augment transparency and the findings of this current study support the position that written eCommunication may increase the opportunity of achieving a more transparent communication form in the counselling delivery process. Accordingly, the current findings become an important indicator that we will need to recognize and attend to electronic intervention as a factor contributing to a more transparent health- that several studies have revealed that many people cannot understand nor use written health information properly (Bailey et al., 2014;Jacobs, Lou, Ownby, & Caballero, 2016). It may, therefore, be assumed that written eCommunication could act as a reminder to help nurses become more conscious about the words and concepts they employ when consulting with patients. This interpretation is supported by a previous study (Björk et al., 2017) and our current study, which reveal that practicing written eCommunication can also lead to better communication skills in face-toface consultations. This interesting perspective should be further investigated.
Another important finding was that the asynchronous environment made it possible to support the reflective responses that are valuable in GSD counselling, as nurses could read and respond to patients' narratives when they were alone and not having face-toface consultations with patients. Consequently, the feedback to patients was well thought out and deeply reflected on. Therefore, it seems possible that asynchronous eHealth intervention could help surmount the disruptive factors that are often encountered in faceto-face counselling. These findings are supported by other studies, which reveal that text-based consultation gives healthcare professionals time to think, reflect and fine-tune their answers (Björk et al., 2017;Dunn, 2012), which is a unique opportunity that is rarely available in face-to-face interactions.

| Limitations
In this exploratory study, we acknowledge that the sample is small. Malterud, Siersma, and Guassora (2016) emphasize that a study with clear and focused dialogue between researcher and participants requires fewer participants to offer sufficient data material than a study with an unclear or vague communication. In our study, the researcher (BCHK) has interviewed the participants in an earlier study (Oftedal et al., 2017) and has thus, already established contact and trust in the dialogue. In addition, the researcher has knowledge of both the diabetic work at GP and the GSD intervention. We therefore consider the data material, consisting of rich and varied accounts, to be trustworthy. It permits a preliminary understanding that adds to our knowledge of what might be needed to support healthcare professionals while shifting health intervention communications into an electronic format. However, we could not preclude that a large number of participants might have thrown open different perspectives.
Another limitation is that the nurses in this study were born before 1980 and are, therefore, "digital immigrants" (Prensky, 2005).
That means that although many aspects of the technology might be adopted, just like those who learn another language later in the life, they retain an "accent." It is, therefore, possible that nurses born after 1980 might have identified other dimensions of asynchronous written communication. It is also unknown whether these findings related to eCommunication would have changed had the nurses used the written asynchronous communication over time.

| CON CLUS ION
The findings indicate that asynchronous written eCommunication could disrupt nurses' possibilities to use basic and advanced communication skills and that written expression may not currently be adequate for replacing the communication skills that are traditionally used in clinical practice. However, the findings also suggest that asynchronous written eCommunication can foster deep and thoughtful responses to patients and as nurses become more conscious of the words they employ when responding in writing, they may enhance their communication skills in subsequent face-to-face interactions. In addition, written eCommunication increases the possibilities for intensified transparency of the counselling delivery process. Although much remains to be learned with regard to reconfiguring health intervention communications into electronic formats, this study highlights the potential advantages and limitations of using asynchronous written eCommunication in primary care.

ACK N OWLED G EM ENT
We thank the diabetes nurses for their participation in this study.

CO N FLI C T O F I NTE R E S T S
We declare no conflict of interests.

AUTH O R CO NTR I B UTI O N S
BO, MG, VZ and BK designed the study. BO and B-CHK were involved in data collection. BO, MG, MK, ST, B-CHK and BK analysed the data. BO has mainly drafted the manuscript, but all authors have contributed to the drafting of the manuscript, revised it critically for scientific content, read and approved the final version.

E TH I C A L A PPROVA L
The Norwegian Social Sciences Data Services approved the study (No. 39454). All respondents provided informed written consent before the individual interviews and were guaranteed confidentiality and the right to withdraw from the study at any time.