ORIGINAL ARTICLE Insights gained through Marte Meo counselling: experiences of nurses in dementia specific care units Rigmor Einang Alnes RN, MD PhD Student, Department of Health Sciences, Aalesund University College, Aalesund, Norway Marit Kirkevold RN, ED.D Professor, Department of Nursing and Health Sciences, Oslo University, Oslo, Norway and Professor, School of Public Health, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark Kirsti Skovdahl RN, PhD Assistant Head of Unit, School of Health and Medical Sciences, Örebro University, Örebro, Sweden Submitted for publication: 28 September 2009 Accepted for publication: 21 March 2010 Correspondence: Rigmor Einang Alnes Department of Health Sciences Aalesund University College Postboks 1517 6025 Aalesund Norway Telephone: +47 70161396 E-mail: ra@hials.no A L N E S R . E . , K I R K E V O L D M . & S K O V D A H L K . ( 2 0 1 1 ) Insights gained through Marte Meo counselling: experiences of nurses in dementia specific care units. International Journal of Older People Nursing 6, 123–132 doi: 10.1111/j.1748-3743.2010.00229.x Aim. This study sought to uncover what nurses perceived to have learned, during their participation in video supported counselling, based on Marte Meo principles, in four dementia specific care units. Methods. This was a descriptive qualitative study. Data were collected through 12 individual and four focus group interviews. In addition, supplementary data from two video recordings and one written log were included. Findings emerged through content analysis and re-examination of the text based on the initial analysis. Results. The nurses experienced that they acquired new knowledge about the residents through Marte Meo Counselling (MMC), resulting in improved capability to interpret the residents‘ expressions, and increased awareness of the residents’ competence. New knowledge about themselves as nurses also emerged; they recognised how their actions entailed consequences for the interaction, in turn making them conscious of the usefulness of taking time, pacing their interactions, maintaining eye contact and describing the situation in words when the interaction took place. This appeared to increase the resident’s perception of being able to cope. Conclusions. This study indicates that MMC helped the nurses to gain knowledge about how to improve interactions with residents suffering from dementia. Further research is warranted into the effectiveness of MMC. Key words: counselling, dementia, Marte Meo, nursing home, staff Introduction Dementia is characterised by successive cognitive impairments involving memory, judgment, planning, abstract thinking and emotional and social functioning (ICD-10, 2007). Frequently, behavioural and psychological symptoms in dementia (BPSD), e.g. depression, anxiety, aggression/  2010 Blackwell Publishing Ltd agitation and apathy, also occur. In Norway, 80% of nursing home residents have dementia, and of these 72% have one or more symptoms that can be characterised as BPSD (Selbæk et al., 2007). Cognitive impairment and BPSD causes major problems, both for the persons who experience these problems and for nurses (Hope et al., 1997; Skovdahl et al., 2004). It leads to 123 R.E. Alnes et al. functional impairment and problems related to activities of daily living (ADL) and to increasing difficulties expressing thoughts and feelings. In this way the residents are completely dependent on the nurses’ ability to ‘sense’, interpret and understand the resident’s expressions. Building a relationship and directed attention towards the resident is required to discover the often underlying meaning of verbal and nonverbal expressions (Killick 1999; Killick & Allan 2001). The Swedish Council on Technology Assessment in Health Care (SBU – The Swedish Council on Technology Assessment in Health Care, 2008) points out that caregivers’ understanding of persons with dementia may influence the quality of their interactions, assessments and care, but highlights the paucity of research assessing the effect of interactions between the nurses and persons with dementia. A recent review (Levi-Storms, 2008) indicates that verbal and non-verbal communication techniques can be taught to long-term care staff, leading to improved communication with residents. However, the review observes that generally the research lacks a larger conceptual framework that connects the techniques to improved patient outcomes, and recommends that future research on communication training include real life examples of interpersonal communication between residents and nurses. Marte Meo counselling (MMC) is a method adopted in recent years to support staff recognise and improve their own communication and interaction when working with people with dementia (Munch, 2006). It is based on the assumption that heightened awareness of what comprises effective communication can be helpful in order to facilitate greater contact and mutuality in interpersonal interactions between persons with dementia and their caregivers (Gudex et al., 2008). Aarts (2008) inductively developed the method by scrutinising the small elements in normal, functional dialogues. This led her to describe essential elements that occur in every human dialogue. Aarts claims that various conditions can disturb this communication process, including disease and changes in normal development. She regards the elements as universal although they need to be adapted to different life situations. A list of communication strategies intended to facilitate communication with people with dementia, so called ‘function-supporting elements’ (Hafstad, 2002; Hatløy & Alnes, 2007), has been developed based on Marte Meo (MM) principles (Table 1). MMC involves video filming of real life interactions between resident and nurse, followed by a presentation of selected video scenes for reflection and discussion. MMC is increasingly used in dementia care (Bakke, 2005; Ulma, 2005; Schultz & Schultz, 2008). Despite this fact, 124 Table 1 Function-supporting elements pertaining to people with dementia (Hafstad, 2002; Roug, 2002; Hatløy & Alnes, 2007) • Prepare for a good beginning and a positive atmosphere through tone and eye contact • Locate, confirm and follow the person’s focus • State what is happening, what is going to happen, and what is experienced • Reinforce coping ability by providing help to start and end an activity • Help the resident to be in rhythm in the dialogue by waiting for an answer or supporting the resident’s initiatives • Help or support the resident to respond to new people or situations in the setting • Pay attention to physical contact • Lead in a positive way to bring the resident to the next step in the activity (e.g. ADL) research on this method is very limited. Using Marte Meo as a key word in ISI Web of Knowledge, PubMed and MEDLINE (search performed January 2010) yielded only a few articles focusing on MM applied in dementia care in Scandinavian professional journals (Lunde & Hyldmo, 2002; Hyldmo et al., 2004; Hatløy & Alnes, 2007; Gudex et al., 2008). More knowledge is needed to explore the possible impact of MMC on the staff caring for persons with dementia and the quality of the care provided. Aim This paper explores the staff’s experiences after participation in MMC, with a particular focus on their learning experiences. Method Design This is a descriptive qualitative study, based on individual interviews and focus group interviews with staff who participated in an intervention study assessing the usefulness of MMC for staff in dementia specific units. The MMC-intervention To inform the reader about the program that the respondents participated in and to which their experiences refer, a short description of the intervention is provided. The staff received MMC from a trained MM therapist seven times (1.5-hour sessions each time) during a period of about two months. Each counselling session was based on a short videotape, lasting some five to ten minutes. As a first step, the therapist  2010 Blackwell Publishing Ltd Insights gained through Marte Meo counselling came to the unit and videotaped a morning care situation involving a resident and a caregiver. The situation was selected by the staff and accepted by the resident. Next, the therapist analyzed the video and identified ‘the functionsupporting elements’ (Table 1). Later the same day, counselling was provided to a group of nurses on the unit. In this third step, and through the use of selected clips from the video, the therapist made the staff aware of how different function-supporting elements emerge in interactions between the caregiver and resident. Sample All nurses, including registered nurses (RNs), enrolled nurses (ENs) and nurse aids (NAs), in four dementia specific care units were invited to participate in MMC, totalling about 60 persons, including part-time staff, night shift staff and unit leaders. Of these 26 consented to participate, 24 women and two men. Twelve of the staff (two to four from each unit), were chosen by their supervisors to join the project group, which was given responsibility for organising the MMC on Table 2 Characteristics of the staff 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 their units. All participants attended the MMC intervention on their units. For more details see Tables 2 and 3. Data collection Data consisted of 12 individual interviews and four focus group interviews. All members of the project group, who were most intimately familiar with the intervention, were invited to participate in individual semi-structured interviews one to two weeks after ending MMC in order to record their immediate experiences with MMC. In addition, all staff at the participating units were invited to participate in focus group interviews aimed at discerning their experiences and opinions about MMC over time (Patton, 2002). These interviewed were conducted six months after the intervention ended in three of the units. In the last unit, where the intervention was delayed, the focus group interview was conducted one week after MMC ended due to time constraints. Topics in both the individual and focus group interviews included experiences with participating in MMC, consequences for practical care, comparison with other types Profession Years working in health related care Years working in dementia caring Age EN EN EN EN EN EN EN EN EN EN EN EN EN EN EN EN NA NA NA RN RN RN RN RN RN RN 25 20 18 32 24 12 20 20 30 – 25 18 16 26 8 25 22 – 6 5 30 12 21 33 12 34 13 20 15 27 12 7 3 15 30 6 5 18 4 4 4 3 22 0.5 3 2 6 6 3 9 5 5 56 47 61 56 55 50 43 49 48 – 49 54 64 50 32 48 54 50 46 26 56 36 47 55 49 57 Individual interview X X X X X X Focus group interview Participant in video recording Sex X X X X X X X X X X X X X Yes Yes Yes Yes Yes No Yes Yes No Yes – Yes – – No No No Yes No Yes No Yes Yes No Yes No F F F F F M F F F F F F F F F F F F F F M F F F F F X X X X X X X X X X X X X X X X X EN, Enrolled Nurse; NA, Nurse’s Aid; RN, Registered Nurse.  2010 Blackwell Publishing Ltd 125 R.E. Alnes et al. Table 3 Characteristics of the units Unit Unit Unit Unit 1 2 3 4 Residents Staff* 10 8 25 15 58 11 13 18 15 57 Mean average number of persons present on MMC 8, 2 7 4, 6 4, 7 Persons interviewed individually 4 3 5 12 Persons interviewed in focus group 11 5 4 4 24 *The number of nursing personnel on the ward is somewhat inexact, since extra personnel on call and minor positions are not included here. of counselling, any negative experiences, and whether or not they would recommend MMC to others. To ensure a correct transcription we filmed the focus group interviews. Data analysis A qualitative content analysis was used for this study (Graneheim & Lundman, 2004). Initially the transcribed material was read in its entirety to gain a sense of the whole. Next the text was divided into meaning units. This was followed by condensing the text by organising the meaning units into themes and sub-themes. This first step of the analysis resulted in 12 themes and 57 sub-themes and reflected various aspects of the staff¢s experiences of MMC. Although it provided an initial description of their experiences, this first step gave little precise information about the usefulness of this method. However, it did indicate that the staff’s experiences of usefulness were closely related to learning. In the second step of the analysis, we explored in further detail what the participants stated they had learned during MMC. This was done by comparing and contrasting all meaning units related to learning. This analysis yielded two new themes which highlighted the perceived usefulness of MMC; New knowledge about the residents and new knowledge about themselves. In a third step, further questions about what this knowledge implied were posed to the text in order to discern a deeper understanding of what this knowledge implied. This final analysis generated more specific sub-themes under each main theme, such as taking enough time, and the importance of eye contact. The individual interviews and the focus-group interviews were analyzed separately. One significant theme, increased consciousness, emerged more clearly in the focus group interviews than in the individual interviews. Otherwise, the themes and subthemes corresponded closely. 126 The second and third authors critically reviewed all steps of the analysis. Whenever questions, lack of clarity and inconsistency occurred, the transcripts were revisited in order to clarify issues and work toward a common understanding of the text and the identified themes and sub-themes. Two video sessions recorded during the MMC intervention were selected after completion of the textual analysis in order to exemplify situations that the nurses referred to in the interviews. Data from a written log by one of the MMC therapists provided further descriptions of these situations. Ethical considerations The project was approved by the Regional Ethics Committee (REK) project nr. 4.2006.897 and the Norwegian Social Science Data Services (NSD) project nr.14693. The staff gave informed consent to participate after receiving written and verbal information from one of the researchers and the MM therapist. Participation was voluntary and the participants could withdraw at anytime without consequences. The audio files were transcribed and anonymity secured. Conducting video recordings involving people with limited ability to give informed consent requires great awareness. The issue of consent must be considered throughout the whole process of video recording. The relatives received an information letter about the project from the head of the unit, and were asked if they consented to let their relatives participate in the study. They were informed of their right to withdraw the consent at any time without consequences and were offered verbal information from the MM therapist and researcher. Whenever regarded as appropriate for the resident, the nurse gave adapted information about the video recording and asked the resident if he/she was willing to participate (e.g. NN is together with us today to take a video film of the two of us. This is for us learning to improve communicating and understand each other better. Is this OK for you?). If the resident said no, or showed any signs that could indicate that he or she felt uncomfortable, the video recording was not initiated or stopped immediately. (Further ethical issues of this study will be discussed elsewhere). Findings The major finding across the data was that the nurses experienced MMC to be enlightening. To actually observe oneself or/and a colleague in an interaction with a resident, followed by a reflection and discussion mainly focusing on the residents ‘ expressions, provided a visible and concrete understanding of the kinds of support that were important and useful in their daily practice with their residents. Their  2010 Blackwell Publishing Ltd Insights gained through Marte Meo counselling learning experiences may be categorised under two overall themes; gaining new knowledge about the residents and gaining new knowledge about themselves as nurses. New knowledge about the resident The nurses stressed that the video-supported counselling sessions (MMC) provided them with new knowledge about their residents. In particular, they discovered that residents had more competence than they generally believed. The concept competence is being used to underline that persons with dementia still have abilities to participate in dialogue, to understand and to act in meaningful ways. On the other hand, they realised the fragility of this competence. Increased awareness of the resident’s intensions and competence One of the main findings was that the nurses recognised that the residents could understand and manage more than the nurses had initially thought. Through video freeze-frames and the counsellor’s guidance, they were able to follow how the residents gave and received messages, how they spoke and followed instructions. The ability to express experiences when given sufficient opportunity is illustrated in the case of ‘Emma’, a woman in her eighties with severe dementia. In two of the individual interviews (no.1 and 4), the respondents described their experiences of participation in MMC by reference to this case. In the log from the Marte Meo therapist after one of the counselling sessions, the same situation was described. The situation evolved as follows: enabled the nurses in the counselling group to be attentive to weak signals and simple expressions. In two of the individual interviews, nurses described that the awareness resulting from taking enough time to observe her simple signal and to give her an appropriate response, led to a meaningful interaction that elicited an unexpected reaction from the resident. The nurses received acknowledgement from Emma, a resident they had considered rather distant and difficult to make contact with. This case illustrates how counselling helped the staff to become aware of the residents’ ability to communicate their experiences and thoughts. As one of the nurses stated: ‘It was so unexpected that she would react like this; unexpected that she was so calm and spoke lucidly …’ The nurses found that when they were attentive to the resident’s subtle initiatives and gave them the opportunity to make choices, they could see that the competence to make simple choices was still present. The residents were still persons with abilities and intentions, and there was a reason for their expressions and actions. This insight is illustrated in the following example, transcribed from a video scene in a morning-care situation where Kora and her caregiver Liz are interacting about which clothes to put on: Kora and caregiver Liz (A) are in Kora’s room. Liz opens the door of the wardrobe while Kora stands with her back to Liz: Liz asks: ‘What else would you like to wear then, Kora?’ Kora turns toward the wardrobe, looks inside it, and says: ‘Well, there is a lot here.’ Liz:’Hmm’. Kora:’Lots of nice things’. Kora looks inside the wardrobe and puts her palms together. Liz and Kora look into the wardrobe. Liz remains quiet (waiting) and then says: ‘Will it be trousers, or a skirt?’ Kora lifts her left hand up to her ear, scratches Two nurses come into Emma’s room. Emma lies quietly, crouched in herself a little above her ear, and says softly: ‘There are lots of nice the bed. One of the nurses sits down on the edge of the bed, says things here.’ Liz confirms this and says: ‘Yes, there are, here’. Kora ‘good morning’, and tries to get contact with her. Emma tries to say raises her hands towards her chest (the gesture gives the impression something, but this is difficult to understand. The caregiver waits of some uncertainty), straightens her blouse a little. She is still awhile before she takes a new initiative. The caregiver sees there is a looking into the wardrobe. Liz looks directly at Kora and Kora little movement in Emma’s hand. The caregiver takes her hand, and looks back. Liz: ‘Shall we take trousers?’ Kora: looks at the nurse Emma slowly starts to speak. She says: ‘It is cold.’ The caregiver and says: ‘Yes.’ Liz: continues: ‘..in case you go out or anything?’ confirms this, and asks if she is cold. Emma speaks louder: ‘...You They both look into the wardrobe and Kora says: ‘Yes.., yes’ Liz: have to help me, dig me up.’ Caregiver: ‘Dig you up?’ Emma: ‘Yes.’ ‘Trousers are fine’. Kora takes an initiative herself, approaches the In the interview, the caregiver elaborates on her perception, stating: wardrobe, stretches out her hand to take a sweater and says ‘Oh, ‘She thought she was lying in a snowdrift; this was in the morning. It here, this is nice.’ Liz says ‘yes’ and steps back slightly to make must be a very traumatic experience, to feel that you are lying in a room for Kora while she watches Kora picking out the sweater. snowdrift; and yet she could speak about it.’ The video-recorded Kora moves back slightly. Liz sees that Kora is about to stop interaction ended with Emma saying: ‘You are very nice girls!’ taking the sweater and says: ‘Just take it - Kora’. Kora takes the According to the log from the MM therapist, the theme of this counselling session was to follow the resident’s initiatives and to slow down the pace (see Table 1. Locate, confirm and follow the person’s focus). Video in slow motion, freezeframes and counselling describing how Emma had responded  2010 Blackwell Publishing Ltd sweater out of the wardrobe and unfolds it. Liz:’ Wonderful color for you.’ Kora holds the red sweater against her chest and says ‘And then I take that one there as well?’ Liz looks at her and says: ‘Yes... yes’… Liz closes the wardrobe doors and they walk toward the bathroom. 127 R.E. Alnes et al. Liz, who is an EN, starts the dialog about what to wear with an open question: ‘What would you like to wear?’ She does not receive an answer to this, so she narrows the question: ‘Do you want trousers or In this way the nurses discovered that this fragile competence was closely related to the nurses’ behaviour, which we turn to next. a skirt?’ The question seems difficult for Kora to understand, beyond the range of Kora’s ability to choose. Liz tries with a more limited question: ‘Shall we take the trousers?’ Then the answer is: ‘Yes’. Kora then takes an initiative to find a garment. She recognises a nice sweater. This situation involves uncertainty, because she is close to backing down from this choice, but with the nurse’s support she can still assert that the red sweater is a good choice. During MMC, this competence became evident. All the nurses who received guidance based on this video recording observed that Kora still had the competence to make her own choices. They saw that she needed time and limits for her choice, but she could still make her own decisions. This finding was recurrent in many of the interviews. The staff discovered that the residents still had the ability to communicate, to provide feedback, and in this way to take part in meaningful dialogues and interactions. One of the nurses described this as follows: What I absolutely had not realised [before, but did now] was – seeing this... seeing what kind of response you get if you communicate something, and whether he or she understands what you have said. This is in fact what we actually do (and have done previously as well), but on film we can see very clearly how it works. Fragile competence At the same time, they also recognised how limited the residents’ competence was. After having seen the film of themselves and the resident in a morning care situation, one of the interviewed nurses stated: With this resident, it was very disturbing for her that I just reached out for the facecloth. This made her lose her concentration in terms of what was going on. And in a similar situation, the caretaker recalls that she recognised how small behavioural activity could result in disorder. The resident was no longer able to brush her teeth at the moment the caregiver turned away from her to get her medicine: There was nobody to make ‘small talk’ and give a helping hand. She dropped out when I turned my face away from her. We would not have seen this without being filmed. It became obvious to the nurses that while residents still had competence to understand and take part in a dialogue, many residents had very limited powers of concentration, and trivial disturbances could make the situation difficult and destroy a coping experience. 128 New knowledge about themselves as nurses The MMC helped the nurses realise that their contributions as nurses were worth observing. It became obvious that their actions, through speech and movements, had significant consequences for the resident’s behaviour and led to emotional reactions in the resident. As the next quote indicates, the video recordings also revealed residents’ feeling of being vulnerable: You can experience along with her that she feels she is vulnerable [in situations where she does not cope] and that it is a very painful feeling, and that she loses control, because we have seen that on film, when she loses control and then becomes very sad. We can understand that, because we become sad as well. Through viewing the video scenes and through counselling, the staff recognised how extremely dependent the residents were on them. The nurses saw how the residents in a caring situation followed them with their eyes. After seeing the videos and reflecting on the situation in the counselling session, one of the staff described how they already do a great deal to adapt communication in their job: ‘ .., but now I recognised in a different way how incredibly useful we are in their lives’. In this way they recognised how their behaviour and their attention made a difference for the residents’ well-being, as is further elaborated below. Knowledge about communication and interaction skills A main focus in MMC was to recognise what happens in successful interactions. Through freeze-frames and slow motion video recordings, nurses were given the opportunity to see and reflect on how small elements in an interaction between nurses and resident affected the situation at hand. In the interviews the participants stressed that although they were familiar with many of these communication adjustments before the MMC, the significance of them became clearer during the intervention. A central theme in all the interviews was the need to take time in the caring situation: The most important thing I have learned from this [MMC] is time; time is what we have to give our patients. The participants emphasised the close connection between enough time and success, for instance in the morning care routine, although they also remarked on how difficult this was to achieve: ‘I learned something I am not able to use, because I cannot give the resident the time I should.’ A conversation about time led to an engaged discussion in one of the focus group interviews, and a dichotomous  2010 Blackwell Publishing Ltd Insights gained through Marte Meo counselling analysis of the problem ensued. Contrary to the statement quoted above, one of the nurses explained how sufficient time spent in the morning care routines with a resident was equal to time saved, because it was much easier to help her get up when she understood what was going on. The following video recorded interaction between Sara and her nurses highlight these communication and interaction skills: Sara, an elderly woman who had lived in the nursing home for several months. The staff wanted to receive MMC in connection with Sara because they had had problems in helping her up from her bed. The staff interpreted her verbal and nonverbal expression as pain. This ‘pain’ occurred when she moved her body, and in some situations this would also develop into agitation and anger. In the film we see two The above example also illustrates other important elements in communication skills that the nurses talked about in the interviews, as illustrated in the following conversation in a focus group interview: Interviewer: I thought about what you said regarding rewinding [the video] and looking at their faces … What did you see? Nurse 1: You saw that one of us had eye contact and how important this was for her understanding. Nurse 2: In a way, you had an eye opener. Nurse 1: Yes, you do not think about having eye contact when you are in the situation, you know, but when you look at this in the video, then; yes, that’s a given requirement! ENs (Siv and Hanna) helping Sara up from her bed: Nurse 3: So now one thinks about it. Siv stands at the head of Sara’s bed, Hanna stands further down near Nurse 1: Yes because now we know. [Several yeses in the Sara’s leg, and they both look at Sara. Siv bends down towards Sara’s background]. face and says: ‘Now we’re going to help you to get up Sara.’ (short pause). Sara looks at the helpers and says: ‘Yes’ (softly). Siv: ‘Shall we help you up? .. Yes’. Siv puts her arm around Sara’s neck and torso and holds her left arm. Hanna holds her legs. Hanna: ‘So, I take your legs’ Siv: ‘then you take my hand here’. Hanna:’ and then I swing you Later in the same focus group interview, the participants also focused on the importance of using eye contact together with explaining what was going on, in order to identify the situation: forward to the edge’. Siv and Hanna have eye contact with Sara while Like Sara, I feel very strongly, that you have to have eye contact they swing her forward. Hanna: ‘Now you can just come along, Sara, with her, explain what is going to happen and get her involved then you take my hand,’ she says while she takes Sara’s hand. They in what is going on. If not, it does not work, you don’t get anywhere swing her to the edge of the bed. Sara smiles. Siv: ‘There, you’re [‘yes’,‘mm’ from some others in the group]. sitting on the edge of the bed’ (short pause). Hanna straightens Sara’s shirt slightly. Hanna: ‘That went well, didn’t it?’ (short pause). Both the nurses are facing Sara. Siv: ‘Hmm? Yes...’ (short pause). Siv: ‘Would you like to sit and gather your thoughts for a moment?’ (short pause). The nurse bends down and moves Sara’s leg a little. ‘See, now I have placed your legs on the floor like this.’ The nurses hold her by the arm on each side. Siv stands for a little while without doing anything. Sara looks up at Hanna and Hanna looks at Sara while she says: ‘Hold on to us firmly, and we’ll go to the bathroom’ (short pause). Sara: ‘Yes.’ Siv looks at Sara and asks: ‘Are you ready?’ Sara moves her body as though she wants to stand up. Sara gets up and they go toward the bathroom. The nurses experienced that through MMC they were able to recognise that Sara was still able to comprehend what was happening as long as they slowed down the pace and took enough time. This situation was adjusted to suit Sara and her ability to recognise what was happening by giving her short pauses enabling her to understand what the nurses were trying to tell her and what was going on. In the interview, the nurses expressed that they thought these tiny pauses made a difference in Sara’s ability to feel comfortable and calm in the situation.  2010 Blackwell Publishing Ltd In various ways, they also mentioned a new consciousness about how to speak, i.e. the importance of using fewer and simpler words, short sentences and of speaking in the present tense. The nurses said that they had gained insight into this, because now they had not only heard or read about it, but they had seen the effect in the situation and experienced that their own way of doing things had worked. A small minority of the nurses questioned the significance of MMC and the usefulness of the method. A few of these wanted greater challenges and more direct advice on how to interact with the resident. A few thought MMC was too banal, elementary and something they already knew, but these people did comment that new nurses with limited experience could benefit from it. Discussion The purpose of this paper was to explore the staff’s perceptions after participating in MMC, focusing in particular on their learning experiences during the intervention. The major findings indicate that the participants experienced that, through MMC, they gained new knowledge about the 129 R.E. Alnes et al. residents and new knowledge about themselves as nurses. Through the MMC, it became clear to them that this knowledge was important, as it made visible the implicit, yet effective factors that support communication and functioning in interactions with persons with dementia. The staff experienced that taking time to interpret facial expressions contributed to their becoming more familiar with the older person. The fact that persons with dementia had the ability to initiate and to respond in their interaction became clear to the staff as they studied and reflected on video recording of micro-situations focusing on the importance of ‘functionsupporting elements’, such as ‘locating, confirming and following the person’s focus’ and ‘waiting for an answer’ (see Table 1). They discovered that subtle responses from the residents became visible and that the expressions of the residents were meaningful. Through this process of concentrated and directed sensing (Martinsen, 2005), communication blocks, such as weak signals and impairment in cognitive functioning, became easier to perceive. Through this they gained an increased awareness of the residents’ oftentimes concealed personhood (Kitwood, 1997; Normann et al., 2002; Dewing, 2008; Edvardsson et al., 2008). Discovering communication blocks is essential to be able to adjust the situation to the abilities of the person with dementia, thereby conveying respect and dignity, reduce stress, improve the capacity to participate in meaningful ways and promote well-being (SBU, 2008; Ward et al., 2008). Elements that support functioning, such as describing what is happening in words, are linguistically comparable to communicating with small children (Sørensen, 2002). This seemed to be an elementary skill, as some of the respondents maintained. However, the significance of these elements places them in the context of professional knowledge where precisely the use of the ‘simple’ elements represents the professional skills involved in interacting effectively with persons suffering from dementia. Learning these communication skills requires both cognitive and emotional presence. Bjork and Kirkevold (2000) described the complexity involved in learning seemingly simple practical nursing skills, and underscore that necessary attention must be devoted to learning such skills. They emphasised that learning practical skills entails learning the substance and sequence of the skill, learning to perform the skill with accuracy and fluency and learning to integrate the different aspects into a functional whole. In addition, performing the skill in a caring manner, i.e. incorporating it into the caring situation in a way that works well for the individual patient, is essential. Taking all these aspects into account, seemingly simple skills may be challenging to learn and to accomplish successfully in clinical situations (Bjork & Kirkevold, 2000; Lomborg & Kirkevold, 130 2005). This is similarly the case with regard to communicating effectively and in a caring manner with persons with dementia, as highlighted in this study. Many practical nursing skills are learned from scratch, without any prior experience. By contrast, communication skills learned through MMC are based on common skills already acquired through experience. Through watching themselves and their colleagues in microsituations, MMC contributed to increased awareness of their own and their colleagues’ ability (Skovdahl et al., 2004). They already possessed this competence, in their natural way of being, but they needed help to realise how important and effective these skills were when used consciously. They became aware of how important this knowledge was and that what may appear simple and insignificant at first sight through MMC emerged as complex situations. Watching themselves on the video recordings made them realise both what to do (substance – ‘know what’) and how to do it (integration – ‘know-how’) (Bjork & Kirkevold, 2000). In this way a link was created between the practical activity and the general principles expressed in the function-supporting elements. This finding aligns well with Levi-Storms’s (2008) recommendation that communication training should be connected to real life situations. Levi-Storm (2008) observes that communication training research generally lacks conceptual frameworks that may facilitate understanding of how communication techniques may impact on interactions and on staff and patient outcomes. This critique applies to the MMC method and to this study as well, although the function-supporting elements provide a rudimentary structure for connecting specific communication techniques to effective and dignifying interactions. The MM elements are closely aligned with the communication behaviors that Levi-Storm identified across some of the studies she reviewed. Some authors have tried to connect the MM principles to interactions theories (Hedenbro & Wirtberg, 2002), but this has not been done within the area of dementia care. We support Levi-Storm’s assertion that this would strengthen future research. Methodological considerations The predominantly positive experiences reported offer initial support of the contribution of MMC in fostering communication skills among long-term care staff. The findings from the individual interviews were confirmed by the focus group interviews. A majority of the staff receiving MMC participated in the interviews, and both positive and negative experiences were expressed. The findings may not be generalised, however, as the sample is limited and not necessarily representative.  2010 Blackwell Publishing Ltd Insights gained through Marte Meo counselling Since MMC can be seen as a collective activity, it matches the focus group method (Kitzinger 1994). When several people talk together in a group, new themes and new nuances often emerge (Carey, 1994). The size of the groups ranged from four to 11 persons, which differs from a typical focus group (Patton, 2002). This variation was a result of an open invitation to participate directed to all staff at the units. Despite differing size, enriching reflections emerged in all of the groups, and all participants were involved in the dialog, even in the largest group. This paper reports on what nurses say they have learned from MMC. Whether participating in MMC influences practice, needs to be explored in further studies. Conclusion Nurses participating in MMC expressed increased awareness and appreciation of the complexity of interacting with residents suffering from dementia and the importance of consciously incorporating function supporting elements when communicating with these residents. Further research is warranted into the effectiveness of MMC. 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