Home Care Nurses at the Heart of the Communication Web: Communication Synchronicity and Effects on the Psychosocial Work Environment

Aim

This study investigated home care nurses’ communication practice. We were particularly interested in the characteristics of this practice and its effects on the psychosocial work environment. We approached this issue with a combined theoretical framework consisting of the Media Synchronicity Theory (MST) and the Job-Demand-Control-Support model (JDCS) (Dennis & Valacich, 1999; Dennis et al., 2008; Johnson & Hall, 1988; Karasek, 1979; Karasek & Theorell, 1990). Specifically, the aim of this study was:

Media Synchronicity Theory (MST)

The MST addresses “. . . the ability of media to support synchronicity, a shared pattern of coordinated behavior among individuals as they work together” (Dennis et al., 2008, p. 575). Some media can be used synchronously, which means that the parties are communicating at the same time. Other media are asynchronous, which means that the parties are not communicating at the same time. And still other media are either synchronous or asynchronous depending on how they are used. Dennis et al. (2008, p. 581) define a medium’s synchronicity as “the extent to which the capabilities of a communication medium enable individuals to achieve synchronicity.”

The MST highlights how media synchronicity can support two primary interpersonal communication processes: conveyance of information and convergence of meaning (Miranda & Saunders, 2003). Dennis et al. (2008, p. 580) define conveyance as “the transmission of a diversity of new information . . . to enable the receiver to create and revise a mental model of the situation.” They define convergence as “the discussion of preprocessed information about each individual’s interpretation of a situation, not the raw information itself.” Conveyance concerns the transfer and subsequent retrospective analysis of raw information. Convergence is about creating a compatible understanding of high-level abstractions, of what to communicate, and of what needs to be done. In other words, to establish and/or adjust shared mental models. Conveyance processes are better supported by media that offer low synchronicity. Convergence processes are better supported by media that offer higher synchronicity. We used MST to investigate how the dynamics and characteristics of communication media can provide home care nurses with conditions to convey or converge on information in their daily work.

Job-Demand-Control-Support Model (JDCS)

The JDCS model concerns the relationship between working conditions and stress (Johnson & Hall, 1988; Karasek & Theorell, 1990). The JDCS model is one of the most popular and well-researched models that describe job strain. According to the model, psychological strain (stress) is a result of multiple factors present in the work environment: demand, control (decision latitude), and support. These three factors can be arranged in a three-dimensional property space (see Figure 1). A work environment is considered to be healthy when people experience high enough levels of control and support to meet the demands presented by their work. As demands increase, so does the need for control. The support factor acts as a buffer when control decreases. Work becomes unhealthy, even dangerous, when workers are exposed to demand levels that they experience as being too high in combination with low levels of control and support. However, work demand levels that are too low are not considered to be beneficial either because this has a negative effect on work motivation.

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Figure 1.

The Job-Demand-Control-Support (JDCS) model after Karasek and Theorell (1990).

We used JDCS to investigate how demands, control, and support for home care nurses were facilitated through the communication practice used in their work.

Research Design

The research design of this qualitative study has much in common with a qualitative descriptive approach (Bradshaw et al., 2017). This approach fits the aim well as the study takes its departure in a description and exploration of the home care nurses communication practice. The design also was informed by ethnographic methods (Czarniawska, 2007; Emerson et al., 2011). Specifically, it resembles what sometimes is described as a focused ethnography, that is, an ethnography focused on specific aspects of the field rather than the field as a whole (Higginbottom et al., 2013).

Semi-structured interviews and field observations in the form of shadowing were used to explore the communication practice of Swedish home care nurses (Czarniawska, 2007; Kvale & Brinkmann, 2009). The study was conducted as part of a research project focused on interprofessional teamwork in municipal home care. The semi-structured interviews provided knowledge about the nurses’ thoughts and experiences of communication. The field observations, inspired by ethnographic methods, provided accounts of how communication took place in practice (Czarniawska, 2007; Emerson et al., 2011).

Sample and Data Collection

The data were collected from January to May 2020. The data set consisted of 22 semi-structured interviews and 10 field observations. All participants were employed in Swedish municipal home care.

Twenty interviews were conducted with one nurse at a time. Two were conducted with two nurses at the same time. In total, 24 nurses (3 men, 21 women) were interviewed by the first, second, and fourth authors. The interviews encompassed participants from four Swedish municipal home care organizations. They were recruited with the help of each home care organization’s unit manager. The interviews lasted between 27 min and 1 hr 19 min (total = 16 hr, mean = 43.6 min). The interviews were designed around the following topics: Mobility in work, Organizational change to mobile teams, Team composition, Change of work, Use of digital tools and eHealth systems. The semi-structured interviews were guided by a predefined interview guide consisting of questions about these topics. Some of the questions addressed communication directly, for example:

Communication could also be addressed indirectly as part of the conversation regarding other questions. The interviews were audio recorded. The interviews were conducted in person up to the beginning of March 2020. After that, they were replaced by telephone interviews. This transition was necessary to handle the COVID-19 outbreak. While the participating municipalities were mildly affected by the first wave of the pandemic, visits were strictly prohibited starting in March 2020.

The 10 field observations were conducted in two municipalities before being canceled due to visiting restrictions. The first author performed all the field observations. The documentation of the observations consisted of handwritten field notes taken while observing the nurses’ work. In total, 10 nurses (2 men, 8 women) were observed. Eight out of the 10 observations covered the nurses’ entire shift. One observation was split into two due to a switch of the home care nurse being shadowed. For the observations, the nurses were recruited by the first author during the interviews or through recommendation by the unit manager. The observations lasted between 3 hr 10 min and 9 hr 40 min (total = 79 hr 55 min, mean = 7 hr 59 min). The observations were guided by a list of predefined topics, including: Communication with colleagues, Support from colleagues and others, Obstacles at work, Use of digital tools and eHealth systems, and The importance of the teams for the work. Ethical considerations were continuously made of what and how to document, especially while following the nurses during home visits. The field notes were structured chronologically, i.e. it was noted when things happened during the shift.

Data Analysis

All the interviews were transcribed. The handwritten field notes were converted into digital form. There were two phases in the analysis process: a data driven phase consisting of qualitative content analysis, and a theoretically driven phase where the output from the first phase was scrutinized through the lenses of MST and JDCS. A conventional approach to qualitative content analysis was used to analyze the data (Elo & Kyngnäs, 2008; Hsieh & Shannon, 2005). Inductive qualitative content analysis was chosen due to the study’s explorative and descriptive nature in the data driven phase (Elo & Kyngnäs, 2008; Vaismoradi et al., 2013). QSR NVivo R1© was used for the qualitative content analysis.

The data driven qualitative content analysis phase was comprised of three steps, with iterative elements in between, allowing the emergent codes to be revised during the process.

The theoretically driven analysis phase was comprised of two steps:

Ethical Considerations

Before data collection started, interview and field observation participants received information about the study and were told that they could withdraw at any time. Each participant also signed an informed consent form. This study received ethical approval by the Swedish Ethics Review Authority (DNR 2019-04653).

Media Used in Three Types of Communication and the Potential Effects on the Work Environment

Tables 2 to 4 present examples of typical interactions involving oral, written, and visual communication between nurses and four common actors within the nurses’ communication web identified in the data: homemaker services, home care nurse colleagues, community health centers and hospitals. These quotes are positioned in the middle of the tables. The tables are read from left to right. To the left, the quotes and media are analyzed from the perspective of the MST framework in terms of synchronicity in accordance with Dennis et al. (2008) (low, medium, high). To the right, we identify how and why the psychosocial work environment of home care nurses was affected by the communication practice from the perspective of the JDCS model (Karasek & Theorell, 1990).

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Table 2.

Examples of Communication Through Oral Media and Their Effects on the Psychosocial Work Environment.

Media and synchronicity levels.MST perspective.	Examples of interactions from observation field notes and interviews	How communication through oral media facilitates demands, control, and support at work.JDCS perspective.
Face-to-face meetings High	Homemaker services Routine morning meeting with the homemaker service group “[The home care nurse] begins the morning meeting with . . . her homemaker service group where . . . [today’s] events and important information about patients [are reviewed]. The home care nurse writes down notes in her calendar of what she needs to pass on to others, such as the [occupational] and physiotherapists, or to [the patient’s] relatives.”—Observation field note Spontaneous meeting with a licensed practical nurse during home visit “[A licensed practical nurse (LPN)] from the morning [meeting] . . . arrives [inside the patient’s home] to drop off [a] prepackaged role of medication . . . She informs the home care nurse that today’s schedule is tough: “I don’t know how they thought about the round today.” The LPN asks the home care nurse if she . . . [could]. . . give the patient the medication instead, which [the nurse agrees to do to help the LPN’s stressful situation].”—Observation field note	The nurse and homemaker service group mutually demand information from each other. They collectively provide mutual instrumental support and thus take control over their future tasks and codependent work situation. The home care nurse perceives a demand to give emotional and instrumental support . In doing so, she acts proactively to lower the risk for negative consequences and loss of control to occur due to the LPN’s strained work situation.
	Home care nurse colleagues Spontaneous meeting with a home care nurse colleague between home visits “[Cycling] on her way to a home visit [where the general practitioner (GP), patient and patient’s daughter will be present], the home care nurse meets . . . [one of her office] colleagues driving a car. The colleague gets . . . out of the car after parking it on the side of the road . . . The two nurses start talking about how [work] is going and how things are with [their] patients. N.N. [informs the colleague that she needs to perform an emergency bandage change after receiving a phone call that one of her] patient’s sores [has] bled through the bandages. [The colleague offers to take over that task for N.N., so she can focus on the upcoming meeting. The nurses negotiate back and forth] . . . The colleague ends up taking on the bandage change task. . . Both nurses agree on this arrangement and . . . go their separate ways.”—Observation field note	The nurse receives instrumental support from her colleague. By redistributing tasks among themselves, the workload is equalized. This lower demands on the nurse while simultaneously restoring her control over her work situation. This also increases the local nursing group’s control over their shared work situation.
	Community Health Center Preparations for routine medical rounds with a general practitioner “I usually keep [errands about enrolling patients into the mobile team and updating coordinated care plans] . . . until the times [when I and the general practitioner (GP)] meet at the community health center once a week. That way there won’t be . . . a lot of faxing and phone calls [back and forth]. . . [T]hen I usually write down [and send, e.g.,] the prepared care plans, follow-ups, and the like [to the GP] so that you take everything together. [Otherwise] it’s likely [things] get lost, you don’t really get feedback that way either.”—Interview Routine medical round with a home care nurse colleague and two general practitioners at community health center “Two general practitioners (GPs) arrive . . . in the meeting room and sit down together with [one home care nurse each] . . . [In pairs, the participants] go through patients. One of the GPs [is stressed due to an ongoing patient visit] and leaves after 5 min. The others [continue] . . . The second GP leaves 2 min later to check up on something. Nine minutes pass, and the second GP returns to talk with the nurses for another 3 min before he finally leaves] . . .”—Observation field note	Demands are put on the nurse to provide/present thorough documentation to the GP before the meeting. Structure is created to enable control over the outcome when the nurse requests instrumental support related to her work. Two home care nurses seek instrumental support from their respective GPs. The nurses have little control over the duration of the meeting and its outcome since the GPs leave on their terms. This increases the demands for the nurses to be well prepared before the meeting and to the point with what they want.
Phone calls Medium*In practice low with community health centers	Homemaker Services About making phone calls to homemaker services during a home visit “. . . And homemaker services if I have any questions [when I’m with] the . . . patient. Perhaps they’ve already been there [earlier], and I . . . don’t understand why they haven’t done [a specific task], or I want to ask [about] something. Then I usually call homemaker services . . .”—Interview	When demands make it necessary for the nurse to get more information, the nurse requests instrumental support from the homemaker service group to gain the information. Thus, the nurse takes the initiative and strives to increase her control over the task.
	Home care nurse colleagues Phone calls with colleagues at or between home visits “It could be that I forgot some materials [at the office]. Then I call my colleagues who . . . I know are nearby and see if they have brought it along . . . Or it could be a patient I’m stuck with, and I’m running out of time for my other tasks . . . If I must be some place at a particular time . . . [Then my colleagues can help me out] . . . Or it could be that I’m simply stuck and need help with a patient [because I cannot handle the situation myself].”—Interview	The nurse seeks instrumental support from her colleagues when demands become too great for her to handle by herself. In doing so, the nurse regains control over her task and work situation with the help from her colleagues.
	Community Health Center Phone call through a triage nurse for allowance to contact physicians “[When I’m to contact the general practitioner (GP)] according to the routine, I must talk to the triage nurse (TN) at the community health center first. If . . . the patient’s [GP] is available for a phone call . . ., then I can call [him] directly myself, but it rarely matches timewise . . . [If it feels] . . . a bit more urgent, then I have to call either the regional mobile care team or [a private physician firm] for a home visit. Then I must talk to the TN at the community health center first before I can call them.”—InterviewPhone call with general practitioner through a triage nurse “[If] I’ve been at a home visit where I feel [a patient is] accumulating [fluid]. . . [Then you might want to] . . . have an assessment [for] heart failure [or] something like that. It’s not urgent, so I’ll take care of it when I’m back [at the office]. Then I call the general practitioner (GP) or . . . we have a VIP number that we call. [Then] I have to talk to the triage nurse (TN) [at the community health center] and ask her to ask the GP to call me.”—Interview	Home care nurses experience needs to seek instrumental support related to their tasks, but they must wait for GPs to get in touch or ask for permission to contact other health care instances. Communication with the TN is synchronous but asynchronous with e.g., GPs. The home care nurses are demanded to ask for permission, wait or even follow up communication if needed. This results in a lack of control as to what they are allowed to do and when they will receive an answer. *The communication synchronicity of phone calls with GPs do not follow MST. The home care nurse-GP interaction is asynchronous, i.e. of low synchronicity. Message passing takes place rather than a direct phone call. The act of communication is pushed to a lower synchronicity level.

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Table 3.

Examples of Communication Through Written Media and Their Effects on the Psychosocial Work Environment.

Media and synchronicity levels. MST perspective.	Examples of interactions from observation field notes and interviews	How communication through written media facilitates demands, control, and support at work.JDCS perspective.
Handwritten notes Low	Homemaker Services Writing a note to the homemaker service group “[The home care nurse] drops off the bag of materials at [the office of] her homemaker service group. The materials include dressing material, bandages [and] anesthetic gel for a catheter. The nurse writes . . . a note, informing the homemaker service personnel [which patient the bag of materials is for] and puts [the note] on top of the bag.”—Observation field note	The home care nurse experiences a demand to provide complementary information to where the materials are intended to be delivered. She provides instrumental support by writing instructions. By leaving the note on top of the bag of materials, the nurse gains control by delegating and instructing where the materials are to be delivered.
	Home care nurse colleagues Reading written instructions during a routine morning meeting with a colleague’s homemaker service group “[The home care nurse] goes . . . to [her colleagues] homemaker service group. [With her] she has two calendars, her own and . . . her colleague’s. [The colleague is off duty, so she covers for her today.] The nurse starts the meeting and goes by what the notes [in her colleague’s calendar] say are important to remember for the day.” – Observation field note Requesting written instructions in the colleague’s calendar “[The home care nurse] converses with her colleague [about] the plans for tomorrow. The colleague will be off work [and the home care nurse will cover for her] . . . so they go through [the planned tasks together], one at a time. The colleague has written some instructions in her calendar . . . for the home care nurse to follow. After reading the instructions, and as they are talking about the tasks, the home care nurse asks her colleague [to] write down extra instructions.”—Observation field note	The situation demands the home care nurse to brief her colleague’s homemaker service group. Instrumental support is received through well-written notes in the colleague’s calendar. This increases the nurse’s control as she successfully can lead the briefing. The nurse requests elaborate instrumental support through written notes from her colleague. This enables increased control for the nurse over tasks for the next day, giving her quick access to more information related to the tasks. Thus, demands for the nurse to look up information decreases.
Texting (SMS) Low	Homemaker services About leaving text messages (SMS) when unavailable “Many times, [homemaker services text] me if I’m busy and don’t answer [the phone]. Like if something needs to be ordered or [if] they want [something].”—Interview About avoiding texting in practice (SMS) “[T]here may arrive . . . texts from the licensed practical nurses (LPNs) in homemaker services. But we try not to have that form of communication . . . It’s easy that you forget to look, you hear the ping, but you are too busy when you hear it . . . and then it’s gone from your mind because it doesn’t ping several times to remind you . . . Then it’s better to call [if you] want something and it’s urgent. If it can wait, then wait until we come back to the office, because you are distracted from your patient every time you are interrupted . . . And if it’s about confidential things, then you must go outside and talk about it, and so on. So, if it’s not urgent we prefer to take things when we get back to the office. Either [that] they leave notes, call us, . . . or just come upstairs and talk to us face-to-face.” – Interview	The home care nurse provides an option for mutual instrumental support if not available. This increases the ability to address tasks fast and gives the nurse more control over when to address and handle tasks. It also decreases demands for availability over the phone right away. This home care nurse wants to limit the number of possible media for communication, that is, to lower her availability. By so doing, the nurse increases her control over where and when to anticipate communication. At the same time, she lowers the risk for communication breakdowns. This also decreases the nurses’ demands to check different media for the same information.
Faxing Low	Community Health Center Having to wait for responses from general practitioners through fax, nr 1 “If [the community health center’s availability] is good, we can get in touch with a general practitioner (GP) and talk to [him] over the phone on the same day, or [even better] at the same time, [that we] call. Otherwise . . . you may have to wait . . . [You can] fax, and then it may take several days before you get an answer.”—Interview Having to wait for responses from general practitioners through fax, nr 2 “We try to contact [the general practitioners (GPs)], but it’s . . . by fax . . . then some get sick, others aren’t there that day, and the [fax forms] start circulating around to other general practitioners.”—Interview	Home care nurses are demanded to communicate via fax with community health centers if tasks are non-urgent. The nurses seek instrumental support from GPs frequently at work. Yet they have little to no control of knowing when an answer will return. In addition, the nurses have no way of knowing if someone handles their request for support or not.
	Hospital Short notice notification via fax of patient discharge “A fax [has arrived from the hospital] . . . during the afternoon. After reading it, the home care nurse hands it over to . . . her colleague. The fax is about . . . [a] patient who is coming home tomorrow [on short notice]. [The notice has taken home care and homemaker services completely off guard. Earlier today, another patient had come home from inpatient care too.] “We don’t want any more.” . . . the colleague exclaims. . . . [The feeling is that] the hospital does not consider the municipality’s [limited preconditions to receive patients with short notice].”—Observation field note	The home care nurses experience no control over the situation, while still being demanded to handle the situation as best they can. The nurses have no possibility to seek instrumental support from the hospital, thus they seek emotional support from each other.
EHR documentation Low	Home care nurse colleagues Reading documentation as a means of communication “Every morning . . . I try to read [the documentation for] what has happened since I previously left my shift. [T]his can be over a weekend, or from yesterday afternoon.”—Interview	Work demands the home care nurse to be updated about the care situation of her patients. By reading documentation on past events, instrumental support is gained, as well as control over coming tasks.
EHR-messaging Low	Homemaker services Initiation of task for coordinator in homemaker services “The home care nurse writes a message through the EHR system [to the homemaker service coordinator] about adding a new entry in the digital medical signing system for redressing a wound on the patient’s nose.” – Observation field note	The home care nurses do not have access to the homemaker services coordination system. Thus, they are demanded to contact the homemaker service coordinator through the EHR system. This nurse reaches for control over the task by requesting instrumental support from the coordinator.
Communication portals Low	Community Health Center Testimony during a scheduled meeting among home care nurse colleagues on complications of messaging general practitioners “Two home care nurses address [the problem to the group] that . . . general practitioners (GPs) do not . . . update/approve new coordinated care plans in the communication portal. One of the nurses shares that she has reminded [one] GP [to] . . . approve [one patient’s] coordinated care plan three times, but . . . nothing has happened. She continues by saying that she has documented this in the local EHR system . . . [and that it] has all resulted in that the patient in question has now been hospitalized.”—Observation field note Absent communication from general practitioner about prescription changes [The home care nurse goes] into the drug prescription service system to look at [a] patient’s medication list. The GP has made changes to the medication list without notifying home care . . .—Observation field note	The home care nurses get little instrumental support from GPs with the completion of the agreed coordinated care plans. Hence, the nurses lose control over their work situation and the demands to follow-up communication and handle consequences increase. Instrumental support from the GP is absent when prescriptions are changed in the drug prescription service system. Home care nurses have little control over if changes have been made, thus they are demanded to continuously check the system and handle changes on short notice.

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Table 4.

Examples of Communication Through Visual Media and Their Effects on the Psychosocial Work Environment.

Media and synchronicity levels.MST perspective.	Examples of interactions from observation field notes and interviews	How communication through visual media facilitates demands, control, and support at work.JDCS perspective.
Picture messaging (MMS) Low	Homemaker services Receiving photographs from licensed practical nurses “It’s mostly the licensed practical nurses (LPNs) in homemaker services who report to us . . . when they discover something, they report it [through photos] so you can tell them directly what to do. [It’s a big help] to them . . . when they’re standing there. Additionally, we don’t have to drive out to have a look. Instead, we may answer straight away, ‘No, but that’s how it looked yesterday too, so there’s no danger’. So sure, it can save us many unplanned home visits.”—Interview	Home care nurses provide instrumental support to homemaker services based on photographs. Demands for the nurse to travel and do unplanned home visits decrease. Control is retained over the nurses’ planned work situation.
	Community Health Center Requesting opinion from general practitioner “At times we can tell the general practitioner (GP) that . . . ‘Well, we have a photo . . . [Can] you look at . . . this rash? What do you think?’ Otherwise, you stand there and have to explain what the rash looks like and such . . .” – Interview Limited infrastructure to communicate with general practitioner “So I take a photo of the wound . . . which I want to give to the triage nurse (TN) [at the community health center], who in turn will give it to the general practitioner (GP) to look at. But where should I send it? It ends up being sent [to] their private phone or something like that. The technology doesn’t sync very well.”—Interview	The home care nurse asks for instrumental support from a GP. The demand to convey information orally decreases. This helps the nurse to gain control over her task. The home care nurse seeks control over her task, but experiences limitations to receive desirable instrumental support . Demands exist to bypass the infrastructural constraints of communication, so the problem is solved by using personal technological belongings instead of technology provided at work.
Photographs in EHR documentation Low	Home care nurse colleagues Referring to a photograph in a EHR message to a colleague “[The home care nurse] writes a message [in the EHR system] to a colleague . . . regarding the redressing of a patient’s foot/heel . . . She asks what the colleague thinks about the healing process [of] the patient’s wound. She uploads a photo [of the wound from her smartphone by sending it to her work e-mail address and then] into the EHR documentation. [In the documentation] there are [earlier] photos [of the wound] as well, making it possible . . . to follow [the wound’s] healing process [over time] . . .”—Observation field note	The home care nurse experiences a demand for a second opinion. The nurse requests instrumental support from one of her colleagues, referring to the series of uploaded photographs. In doing so, the nurses gain better control over their mutual decision-making process.

*

The communication synchronicity of phone calls with GPs do not follow MST. The home care nurse-GP interaction is asynchronous, i.e. of low synchronicity. Message passing takes place rather than a direct phone call. The act of communication is pushed to a lower synchronicity level.

The Communication Web’s Protective Function for the Nurses

Bjornsdottir (2018) describes the idea of home care nurses creating and managing nets of services around each patient to ensure good quality care. The practice of home care nursing is also described as being collective where the boundaries of responsibility and expertise are fluid. This resonates well with the findings of our study where the home care nurses’ behavior of creating and managing the communication webs were at the very heart of their practice (Figure 2). By investigating the web’s functionality from a work environment perspective, this study extends Bjornsdottir (2018) results by finding evidence that the communication web potentially has a protective function for the nurses as well.

The conceptualization of home care nursing as collective work pinpoints the inherent interdependency of work and professionals in this field. This conceptualization showcases the benefits of supporting each other to support oneself (e.g., see Table 2). This resonates well with the results from other studies where nurses find support through well-functioning teamwork in intra- and interprofessional constellations (e.g., San Martín-Rodríguez et al., 2005; Shaw et al., 2016; Tourangeau et al., 2014). Our results indicate that the home care nurses were supportive of one another to safeguard the quality of care provided for their patients. They did this by working proactively to prevent problems from occurring or escalating. Early engagement in communication and collaborative deliberations was highly preferable since catching problems at early stages often required fewer resources. Additionally, this benefited work efficiency.

However, the communication web’s supportive function required work to be maintained. Previous studies show that nurses play an important role in teamwork by holding patient care together (Lee et al., 2019; Sun et al., 2019; Trude Fløystad et al., 2018). This was also the case in our results (see Tables 2 and 3). In a sense, home care nurses took on the role as the driving and coordinating forces within the communication web. From one perspective this is something home care nurses find attractive in their profession (De Groot et al., 2018). But as our results show, it also introduced pressure and demands on the nurses to take on the role of representing the patients’ interests and needs in their interactions with the regional health care system. For the sake of their patients, the home care nurses had to be the driving force of communication to manage the shortcomings of the divided responsibility for care in the Swedish health care system.

Media and Communication Practices Across Organizational Boundaries Better Suit Conveyance Than Convergence

From home care nurses’ perspectives, communication across organizational boundaries, such as with community health centers, was often arranged to support conveyance. Yet, the results showed that communication with high synchronicity, that is, that supported convergence, was preferred by the home care nurses as it provided a means to reduce uncertainty and achieve control over their work, thus reducing stress (Karasek, 1979; Karasek & Theorell, 1990). This also resembles the findings of Bjornsdottir (2018), where formal and informal conversations are described as important for practice.

Synchronous communication best supported convergence and convergence is considered important for creating shared mental models among group members, and for creating shared understandings of goals, tasks and specific roles in relation to collective tasks (Mathieu et al., 2000; McComb & Simpson, 2014). Convergence was important in our study for the sake of the work environment and the needs that professionals experience in home care; it assisted them in reaching understandings of patient care tasks as well as the needs of one another as professional groups.

The results show that home care nurses use a variety of media for communication (see Table 1 and Figure 2). This is not necessarily a bad thing in itself. Dennis et al. (2008) presents the idea that the “best medium” for a given situation may in fact be a combination of media. Combined media can complement or even enhance communication if used correctly. For example, oral media can be combined with written and/or visual media to provide complementary information and to achieve a deeper understanding of what needs to be done. An example of this was the convergence obtained by applying visual communication to better understand the status of wounds (see Table 4). The independent application of visual communication in different municipalities indicated that the nurses found it useful. It enabled them to not only share information of an event but to “experience” it. In one sense, what a picture conveys of a wound was much like the experience of seeing the wound in real life.

Apart from face-to-face meetings, handwritten notes, and physical documents, communication for nurses was found to be highly technologically mediated (see Table 1). This showed how strong the dependency on technology is, and how communication through technology plays an important role in modern Swedish home care work. The utilization of technology-mediated communication indeed enables interactions between professional groups that are normally separated by geographic, time, and organizational boundaries. This enables health care to move outside of traditional institutions and into patient home environments. From a work environment perspective, though, this does not mean that technology-mediated communication is beneficial on its own for the professionals using them. Apart from phone calls, the technological media used by the home care nurses in this study best provided conditions for communication of low synchronicity and conveyance (see Table 1 and Figure 2).

The home care nurses had better means for higher synchronicity in communication with other professionals on the municipal level (see Figure 2). This was due to the lower thresholds to engage in oral communication. Outside the municipality, especially with the regional health care system, communication became more asynchronous. Written communication was the default communication type in this organizational interface. The systematic practice of gatekeeping and message passing here was problematic for the home care nurses (see Tables 2 and 3). For example, communication with community health centers took the form of message passing even when contact was made over the phone. Communication was thus forced to become low in synchronicity even when the medium enabled a higher level of synchronicity.

Control Is Gained by Enabling or Constraining Communication Through Media

Home care nurses value control (Larsson et al., 2022). Previous research has expressed this as an emphasis on autonomy, self-direction, flexibility, and authority (Bjornsdottir, 2018; De Groot et al., 2018; Larsen et al., 2017; Lindblad et al., 2018; Maurits et al., 2017; Tourangeau et al., 2014). As previously stated, control over the work situation was also associated with less stress (Karasek, 1979; Karasek & Theorell, 1990). The home care nurses had some degree of autonomy by which they could tailor their communication practice. Some nurses utilized texting to enable communication with homemaker services (see Table 3). They experienced the option of texting as being advantageous by providing homemaker services the possibility to send short summary notes if necessary. The nurses could later check these notes when convenient. Other nurses chose to actively avoid texting altogether because it could pose the risk of forgetting the message since no reminders were given (see Table 3). By limiting communication to specific media, home care nurses gained a better ability to foresee where to expect communication about certain topics. In other words, the nurses exercised power through their hierarchical status (Thunborg, 1999). Consequently, they gained control and reduced demands for themselves. They took actions that could reduce their own stress levels at the cost of others.

However, if a physician would call, home care nurses would answer the phone even if busy. In a similar manner to the home care nurses, though, through gatekeeping via triage nurses and medical secretaries, the general practitioners and other physicians distanced themselves. By putting up gatekeepers towards the home care nurses, the day-to-day communication over the municipal-regional interface was pushed to be asynchronous and almost exclusively enacted through message passing via faxing and phone calls (see Tables 2 and 3). This is a challenge for home care nurses from a work environment perspective due of the hierarchal dependency they have on physicians, especially the general practitioners at community health centers with whom they interact the most (Thunborg, 1999). In this case, the home care nurses were the ones paying the price of lost control and increased demands due to limitations in communication, which could increase their stress levels (Karasek & Theorell, 1990).

In terms of the JDCS model (Karasek & Theorell, 1990), more predictable communication can increase levels of control while decreasing demands to monitor media in parallel. Controlling the possibilities for others to initiate communication may be a way to guard a worker’s time and resources and thus reduce the complexity of work. Distancing yourself from others who depend on you make your own work less demanding and more predictable because you have taken control over the communication. In turn, though, you may cause problems for them. For example, general practitioners at community health centers probably saved time by limiting the home care nurses’ communication initiatives, but they also created significant loss of time and control for the nurses. This strategy to gain control through communication constraints is a type of local optimization, that is, tailoring a practice according to the conditions in a specific work context, but not to the conditions in work as a whole. These constraining activities seemed to favor conveyance (Dennis et al., 2008). Convergence, which is fundamental to establish common ground and intersubjectivity between people, could be harder to achieve across the municipal-regional boundary (Dennis et al., 2008; Gillespie & Cornish, 2010). Thus, constraining communication to gain control may be a beneficial strategy locally in the short-term if work conditions are strained. But when used as a long-term strategy, it will be a potential source of increased stress for professionals’ having a status of dependency in their profession. This may rather trigger conflicting interests that jeopardize possibilities for reaching well-functioning collaboration and teamwork across organizational boundaries.

Communication is important for teamwork and collaboration in health care (Härgestam et al., 2013; Hewitt et al., 2015; Larsson et al., 2022; Lingard et al., 2006; Rydenfält et al., 2017; Suter et al., 2009). This study indicates that the choice of communication media and organization of communication can affect the psychosocial work environment of the nurses. Thus, the results from this study can inform the design of communication practice in home care nursing and contribute, both to improved care quality, and a better work environment for home care nurses.