This study investigated parents' views of interacting with PCHC nurses in PCHC services and revealed the social process of parents watchfully checking rapport with the PCHC nurse. The theoretical model illustrates an interactive process in which parents are checking the PCHC nurses' demeanour and checking for signs of being judged in order to find out whether it is possible to establish rapport. The main finding is the importance of parents perceiving rapport, i.e., sympathy and understanding being possible to establish with the PCHC nurse. Hence, it benefits the child's attendence in the PCHC services when parents feel convinced that the child's health check-ups at PCHC are useful. In contrast, if parents perceive rapport to be uncertain or impossible to establish, parents feel hesitant and/or unwilling to take the child to health check-ups.
In literature the noun rapport
is defined as 'a feeling of sympathy and understanding, emotional bond' [22
]. It is a concept used in patient-caregiver relations and psychotherapy [23
]. Rapport is described as 'key' in building or developing trust and in a positive perception of the interaction [25
]. Norfolk et al. stressed empathy as essential when establishing rapport [27
]. It involves verbal and nonverbal behaviour and Tickle-Degnen & Rosenthal delineated the nonverbal components of rapport as being consistent across a variety of contexts: these are mutual attentiveness, positivity and coordination between participants [23
]. Literature stressed the importance of establishing rapport, i.e., developing an alliance with the client to achieve effective treatment [28
] and to improve health care, e.g., treatment for substance abuse [29
], doctor and client consultation [27
], home care for the elderly [30
] and children [31
When parents in our study were watchfully checking rapport with the PCHC nurse it seemed to be a quite rapid process caused by feelings of exposure and anxiety for being misjudged as parents. They were extra observant of the PCHC nurses' facial expressions and body language and got a general impression of PCHC nurses being either open, unclear or closed. When this checking resulted in a belief that rapport could be attained, this might have features in common with 'moments of meeting' described by Stern et al. as an unconventional way of affective 'tuning in', a mutual recognition, mutual understanding transmitted by a glance, word or gesture, leading to a shared implicit relationship[32
Negative consequences caused by migration and language barriers suggest that it is very important to get sympathy and understanding from a health care provider. From literature it is well known that levels of stress are linked to migration. Heavy personal and socioeconomic losses [9
], exclusion due to language barriers, unemployment and bad housing [10
], and acculturation stress if accommodation to a dominant culture is forced are described [33
]. This seems to be consistent with what parents in our study expressed during the interviews. In addition, parents were anxious about being misjudged because of their foreign origin. Parents said they could understand that nurses might have difficulties with other parents who did not know the language and with whom it was difficult to communicate. They did not want PCHC nurses to generalise and categorisethem as one of 'those immigrants', and emphasised differences between immigrants in education, language skills, etc. Nor did they wish to be held responsible for 'wrong things' other immigrants did with their children. The conclusion of this is a call for education in cultural competence for health care providers to assist in developing a trusting client-nurse relationship, which is in line with well-known recommendations [34
A PCHC nurse's open demeanour was related to parents' positive perception of the interaction. Parents felt comfortable with the PCHC nurses, seemed to understand the nurses' professional role, considered them knowledgeableand interested in them as foreigners. This open demeanour, resulting in the establishment of rapport, is close to discussions in the literature regarding empathy [27
]. Ethnocultural empathy is considered a specific type of empathy, particularly in reference to different professional groups in their encounters with patients and clients of different cultural and ethnic origins [37
]. One could perhaps conclude that the PCHC nurses perceived by parents in our study as open and warm, willing to understand, giving feedback and communicating openly and straightforwardly, scored high in this type of empathy.
Differences in the cultural backgrounds of parents and PCHC nurses, e.g., implicit expectations and customs of how to respond to a healthcare provider, might explain feelings of insecurity and parents feeling questioned. In a study among Latinos, Flores et al. found that healthcare providers are expected to have a positive attitude. A relatively neutral attitude (possibly the same as unclear or closed demeanour) could be interpreted negatively [12
]. Moreover, one way for Mexicans to show respect to a healthcare provider is to not ask questions, since to do so is to question authority [38
]. This might lead to feelings of insecurity if the healthcare context of the majority of society is unclear to the client. Parents who felt that PCHC nurses had an unclear demeanour
might misunderstand the PCHC nurse's professional role, expecting to meet a medical expert who can prescribe medicine and not someone exploring their family situation.
PCHC nurses' psychosocial assessments of health risks for children is a task that may cause tension and ethical dilemmas [4
] and is experienced as difficult to perform for children with parents of foreign origin. When unsure they used different strategies to clarify the situation [3
]. However, some of these strategies may be experienced as fault-finding by the parents if not done in an open, warm and straightforward way and hence instigate a vicious circle of mutual hesitance and insecurity in the interaction between the parents and the PCHC nurse.
PCHC nurses perceived as unclear and/or closed caused disruptions in the interaction due to parents' being uncertain whether it was impossible to establish rapport. These parents became hesitant and/or unwilling to attend the child's health check-ups at the PCHC. This might have negative consequences: first, risk of health care disparities in a child that needs support and preventive health care from the PCHC services. Second, a risk for misuse of health care resources. Hence, it is known that parents who are poorly treated by health care providers are nearly twice as likely to have used emergency departments when seeking medical advice for their children [39
Credibility and limitations
Rigour was obtained by transcribing all interviews immediatly after the interview in addition to memos and by constantly comparing new categorires with raw data and new data with established categories, in the progressing analyses. The last ten parents giving interviews on 'fit, work and relevance' [21
] confirmed the social process to be relevant, and the model to be a new and useful way of describing their experiences. No new categories were derived from their reports. Therefore, the theoretical model could be regarded as consistent and clinically relevant in this specific setting. Saturation was judged to be reached, with certain limitations. The categories of unclear demeanour, closed demeanour, exploring and fault-finding could have been further explored by sampling parents who did not frequently attend the PCHC.
The first author has professional experience from the field, which is an advantage in terms of having knowledge of the health care context. On the other hand, preconception might constitute a bias. Therefore memos were written, collaborative analyses with researchers from other disciplines were undertaken and results were debated at several academic seminars.
Interviewing has its limitations and weaknesses especially when respondents are speaking a second language [40
]. To diminish these limitations, parents fluent in the Swedish language were prioritised. This strategic sampling may have had a significant impact on the results, which certainly is a limitation in need of more clarification and new research. In one interview an interpreter was used, giving data that did not essentially contribute with new or extended information to the model. Indeed, getting information from non-Swedish speaking parents would require thougtful consideration in the study design.
Moreover, the theoretical model of this study is a substantive theory applicable to the area from which it emerged, i.e., the experience of parents in relation to PCHC in a suburb of a large city in Sweden. It should be regarded, not as a tested hypothesis, but as a set of proposals that are very well grounded in and supported by empirical data. It is likely, however, that the model can be tested in similar settings and modified on detection of new variations.