Communication in nursing care for elderly people

Journal of Advanced Nursing, 1997, 25, 915–933

The role of communication in nursing care forelderly people: a review of the literature

Wilma M.C.M. Caris-Verhallen MSc RN

Research Fellow

Ada Kerkstra PhD

Co-ordinator, Department of Nursing and Caring Research, Netherlands Institute ofPrimary Health Care, Utrecht

and Jozien M. Bensing PhDProfessor and Director, Netherlands Institute of Primary Health Care, Utrecht andDepartment of Clinical and Health Psychology, University of Utrecht, Utrecht, TheNetherlands

Accepted for publication 8 May 1996

CARIS-VERHALLEN, W.M.C.M., KERKSTRA A. & BENSING J.M. (1997) Journal ofAdvanced Nursing 25, 915–933The role of communication in nursing care for elderly people a review of theliteratureCommunication in nursing care is an important topic assessing the specificneeds of elderly patients and providing nursing care that is tailored to theindividual patient’s needs. In this review of the literature, we describe the roleattributed to communication in theoretical nursing models and we report howresearch in communication in nursing elderly patients has taken place over thelast ten years. It appears that since the eighties there has been an increase inobservation studies into nurse-patient communication. There still is, however, alack of observation instruments to do justice to the interactive nature of nurse-patient communication. Special attention should be paid to reliability andvalidity.

this time of their lives people have fewer prospects.INTRODUCTION

Nursing care for elderly people, who are faced with theseproblems requires communicative abilities, empathy andWestern countries are being confronted with a steady

increase of the percentage of the elderly in their popu- concern. Apart from that, the elderly population is a veryheterogenous group. In addition to the characteristics oflations (OECD 1994). The increase in dependency and dis-

ability with age means that increasing numbers of elderly diverse cultures and backgrounds, there is variety withrespect to age, limitations, and views on aging.people require for care (OECD 1994, Scenariocommissie

1992). The elderly group is confronted with various prob- Some elderly people camouflage the effects of agingwhile others stereotype themselves and take on the charac-lems, such as physical and psychological deterioration

necessitating adjustments in life patterns; losses due to teristics they believe to be typical of the aging group (Giles& Coupland 1991). Some view aging negatively as aretirement; loneliness caused by children living away from

home and by partners and friends dying (Wright 1988). At decline, while others associate it with development whichis a functional part of the living system (King et al. 1986).These different views and backgrounds lead to differentCorrespondence: Dr W.M.C.M. Caris-Verhallen, Netherlands Institute ofcoping styles, standards and values, and therefore toPrimary Health Care (NIVEL), PO Box 1568, 3500 BN Utrecht, The

Netherlands. E-mail [email protected]. different needs, which nursing professionals have to deal

915© 1997 Blackwell Science Ltd

W.M.C.M. Caris-Verhallen et al.

with. They have to support the elderly in coping with prob- patients have emotional needs, such as reassurance, con-cern and understanding, which are affective in nature. Inlems related to their stage of life and to recognize and

assess their demands, so that they can offer nursing care this connection, Bottorff and Morse (1994) categorize fourdifferent behaviours in four contexts of care:that is tailored to the individual needs. Communication is

an essential prerequisite in this process.1. ‘Doing tasks’, focused on tasks excluding the patient.

The object of these tasks is to get the job done. ThereNURSE-PATIENT COMMUNICATION is rarely any communication with the patient or very

brief task related communication.Communication is a concept used in many ways. In this

2. ‘Doing with’, these tasks are focused equally on patientarticle communication is defined as ‘the exchange of infor-

and the task. The object is to involve the patient andmation for some purposes’ (Cherry 1978). This broad defi-

there is a two-way discussion about care, patient needsnition encompasses enormous diversity with respect to

and instruction.participants, settings and type of exchanges. The scope of

3. ‘Doing for’ refers to tasks focused on the patient, wherethis article is the communicative behaviour in the nurse-

the patient is given the opportunity to direct his/herelderly patient relationship. Within the concept of com-

own care. There is communication about care ormunication, a distinction can be made between verbal and

social talk.nonverbal communication. Verbal communication is all

4. ‘Doing more’ refers to establishing a relation and isbehaviour conveying messages with language. Nonverbal

focused on the patient as a person. The nurse wants tocommunication refers to all behaviour which conveys

understand patient experience of illness and treatment.messages without the use of verbal language. Within the

The dialogue is intensive, with emotionally supportivelatter kind of communication there is a distinction in vocal

statements by the nurse.nonverbal communication (such as pitch, intonation,speech rate and fluency) and nonvocal nonverbal com- This categorization shows aspects of instrumental and

affective behaviour. ‘Doing tasks’ and ‘doing with’ exclus-munication (facial expressions, eye contact, posture, ges-ture, physical appearance and touch) (LeMay & Redfern ively comprises elements of instrumental behaviour; while

‘doing more’ is restricted to aspects of affective behaviour.1987). A major goal of effective communication is inter-preting the messages and responding in an appropriate ‘Doing for’ contains a mixture of both.manner (Pagano & Ragan 1992).

As mentioned before, nurses have to communicate withCommunication with elderly patients

a variety of people. Furthermore, nurses have differentcommunication goals, such as building up a good personal In providing nursing care tailored to the individual needs

of people, effective communication is an essential prere-relationship, assessing the nature of the perceived prob-lem, negotiating and decision making about nursing goals, quisite (Grypdonck 1993, Armstrong-Esther et al. 1989).

This is especially the case in communicating with elderlyexchanging information, giving explanations, providingphysical care, showing empathy etc. These different patients because this kind of communication has some

specific characteristics. Firstly, there may be barriers togoals require different communicative behaviour.Communicative behaviour in health care has instrumental communication due to sensory deficits (Greene et al..

1994). Secondly, elderly patients and nurses may haveand affective aspects. This distinction is often made in theliterature on doctor-patient communication (Bensing different agendas. The patient who is deprived of social

contact, wants to continue the interaction with social talk,1991). Instrumental or task-related behaviour refers tothose aspects necessary in assessing and solving problems. while the nurse wants to hurry up because she has work

to do. Thirdly, the generation gap makes effective com-This kind of behaviour is mainly verbal in nature. Affectiveor socio-emotional behaviour refers to those aspects that munication between them difficult, for elderly people have

different values and different expectations from the youngare needed to establish a good relationship with thepatient, such as showing respect, giving comfort and trust. (LeMay & Redfern 1987). The elderly are, for instance, less

likely to challenge the authority of health care providers,This kind of behaviour is transferred both verbally andnonverbally (Strecher 1983). In nurse-patient communi- become involved in decision making and discuss psycho-

social issues (Greene et al. 1994). These factors may allcation, a comparable distinction can be made; although tosome authors this distinction is artificial because, in nurs- influence communication dynamics in nursing the older

patients, which demands particular communication skills.ing practice, caring has a central role (Kitson 1987, Benner1984). But, even in caring there are instrumental andaffective aspects. In their need for care, patients have two

THE STUDYdistinct goals (Engel 1988). Firstly, patients want infor-mation, clarification and physical care — all instrumental The recognition of the central role of communication in

nursing practice has led to an increase in research intoin nature — for health-related problems. In addition,

916 © 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 915–933

Communication in nursing care

interaction between nurses and patients (May 1990). The three articles describing 21 studies met the inclusioncriteria.aim of this article is to give an overview of the research

into nurse-patient communication. The point of departureis theories on nursing. Since nursing is growing as a pro-

RESULTSfession many theoretical models have been developed. Inthis article, a selective review is made of these models and

The role of communication in nursing theoriesthe role attributed to communication in them. A review ofthe research on nurse-patient communication follows with As nursing grew into a profession in the twentieth century,

theoretical models were developed. Theories were bor-special attention to elderly patients. The object is to out-line communication research in this field and to highlight rowed from other disciplines to develop these models and

they were adapted to suit the nursing context. In this waythe areas in which more research is needed.More specifically, this review seeks to address the a great diversity of theories and models originated, which

can be categorized as interaction, need-oriented, system-following questions:oriented, simultaneity and developmental theories(Kiikkala & Munnukka 1994). Communication is a central1. What is the role attributed to communication in various

theories of nursing? aspect in the so called interaction theories. Examples ofthis kind of theories are from Peplau (1952), Orlando2. How do nurses communicate with elderly patients, i.e.

what kind of verbal and nonverbal strategies are used (1961) and King (1981).in communicating with the elderly?

3. What are the determinants of the quality or quantity of Peplau’s theory of interpersonal relationsPeplau can be considered as a pioneer. In the beginningnurse-patient communication?of the fifties, she paid attention to the types of process innursing and the characteristics of nurse-patient inter-

Methodaction. Before that time, the view of Florence Nightingalewas predominant, in which attention was directed at opti-In order to obtain the international literature, a search was

made of three databases: Medline (1986–1995), Nursing mizing patient condition and environment, so that naturecould take its course (Evers 1991). Peplau (1952) con-and Allied Health Literature (1986–1995) and the

Catalogue of the Netherlands Institute of Primary Health structed a theoretical model of nursing as a developingtherapeutic relationship, in which she described severalCare (up to and including 1995). The key words used in

these searches were: nursing theories, patient-nurse phases:relationship, patient-nurse communication and patient-nurse interaction. A combination of keywords was also 1. Orientation: a working relationship is established.

2. Identification: the nurse helps the patient to identifyused: nursing care-communication, communication-elderly, nursing theories-communication, nursing care- his needs.

3. Exploitation: the patient makes use of the interpersonalcommunication skills, nursing care-observation study.Because of overlap with medline, in nursing and allied relationship with the nurse to derive full value from

what is offered, while at the same time identifying andhealth fewer keywords were used: communication skills,observation study and a combination of keywords: com- working towards new goals.

4. Resolution: old goals are reached and new goals aremunication-elderly.Furthermore, the bibliographies of the selected articles adopted. The patient becomes independent of the

nurse.revealed some relevant literature. A total of 289 articleswere sampled in this way. 46 articles described obser-vation studies. The following inclusion criteria were used These phases can be recognized during the nursing pro-

cess, but are also reflected in each interaction betweenfor the reviewnurse and patient. During these phases the nurse fulfilsseveral roles: stranger, resource person, teacher, leader,— the study was directed at the interaction of nurses and

elderly patients surrogate and counsellor. The nurse’s communication willbe more instrumental or more affective in nature,— the study used observation techniques

— the study was published in English or Dutch depending on the role it reflects.There are also authors (Rhiel & Roy 1980), who describe

Peplau’s theory as developmental, arguing that PeplauIn the survey of observation studies, all those which metthese criteria were included, regardless of their quality considers human growth and development essential in

nursing. Although Peplau’s operational definitions are(reliability and validity) and sample size. Studies assessingcommunicative behaviours using indirect methods such considered as empirically precise (Marriner 1986), little

empirical research has been directed at the theoretical test-as questionnaires or interviews were excluded. Twenty

917© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 915–933


ing of the concept of the nurse-client relationship (Forchuk King’s theory is useful to guide research(Hanucharurnkul 1989). Most studies are not directed at& Brown 1989).communication per se but test hypotheses on the theoryof goal attainment (Parse 1987).Orlando’s interaction theory

Orlando’s (1961) theory is more or less based on Peplau’swork and, in her view, nursing means assisting patients Recently developed nursing theories

The recently developed nursing theories tend to focus onin meeting their needs ‘through a process of deliberativeinteraction in which the nurse recognizes the verbal and the individual rather than on the dyadic relationship.

Orem’s (1991) Self-Care theory, for instance, is annonverbal behaviour indicative of unmet needs, validatesthose needs with the patient, and acts to meet the patient’s example of a need oriented theory. Orem distinguishes

six nursing methods: acting or doing for, advising, givingneeds’. To achieve these goals it is required that:physical support, providing psychological support, cre-

1. What the nurse says to the individual must match (beating an environment to promote personal growth and

consistent with) any or all of the items contained in theinstruction or education (Evers 1991). In all six methods

immediate reaction.communication has a more or less implicit role.

2. What the nurse does nonverbally must be verballyNevertheless there is no explication of this concept. Orem

expressed and the expression must match one or all ofonly gives a prescription ‘to communicate’ which is inter-

the items contained in the immediate reaction.preted as making information — the intangible — the

3. The nurse must clearly communicate to the individualcommon property of all involved (Orem 1991). The

that the item being expressed comes from herself.theory of Orem is widely used in practice and education

4. The nurse must ask the individual about the itemof nurses (Fawcett 1995, Evers 1991, Berbiglia 1991). This

expressed in order to obtain correction or verificationtheory has also been used a great deal in research

(Meleis 1985).(Grypdonck 1990).

Neuman’s (1990) system theory represents the systemIn these requirements the concept of communication ispivotal. Although not explicitly elaborated, nursing in this oriented theories, in which man is viewed as an open

system interacting with internal and external factors fromview asks for both instrumental and affective behaviour.The nurse needs instrumental skills to find out and to meet the environment. Nursing aims ‘to facilitate optimal ‘well-

ness’ for the client through retention, attainment or main-the patient’s need for help. Affective behaviour is a prere-quisite for establishing a good relationship with the tenance of client system stability’ (Neuman 1989). Neuman

describes a nursing process, that is made up of three steps:patient, so that the patient can be fully involved in allaspects of the nursing process. nursing diagnosis, nursing goals and nursing outcomes.

Although the model is based on interacting systems, theconcept of communication is not elaborated. ResearchKing’s interacting systems framework

The roots of King’s theory appear to be in the work of based on the Neuman System Model is rapidly increasing(Fawcett 1995).Peplau and Orlando (Parse 1987). The model contains four

concepts: social systems, perceptions, interpersonalrelations and health. King defines nursing as a process of

Research into nurse-patient communicationhuman interaction between nurse and patient, wherebyeach perceives the other in the situation and, through com- Macleod Clark (1985) presented an overview of research

into nurse-patient communication. The earliest studies,munication, they set goals and explore means to achievethese goals (King 1981). In this view communication is though not specifically directed at nurse-patient communi-

cation reveal data about the subject. For instance, in thesignificant for mutual goal setting and in turn, mutual goalsetting contributes to goal attainment. King defines com- 1960s, survey research of patients’ satisfaction with hospi-

tal care showed that patients were frequently more criticalmunication as: ‘a process whereby information is givenfrom one person to another, either directly in face-to-face about communication with staff than about any other

aspects of hospital care. The dissatisfaction with the com-meetings or indirectly through telephone, television or thewritten word. Communication is the information element munication was generally directed at nursing staff. From

the seventies onwards, researchers have moved towardsin the interaction’ (King 1981). The opinion that nursingis a goal-oriented process, implies communication that is more specific studies of nurse-patient interaction. With

new technology like video recorders and wire-free tapeinstrumental in nature, including aspects such as gatheringinformation, making a nursing diagnosis, listing goals and recorders, more sophisticated data collection became poss-

ible and a growing number of observation studies was car-planning (King 1981). Mutual goal setting and shareddecisions on the means of achieving these goals, requires ried out in a variety of nursing settings. The emphasis

in this review is upon nurse-patient communication incommunication that is both instrumental and affectivein nature. nursing care for the elderly, from 1985 onwards.



Verbal communication in the nursing process students and psychology students, rated the video-vignettes with the three different interaction strategies andOver the last 10 years, several studies have been under-

taken which examine verbal communication in geriatric their combinations.All these strategies were perceived as somewhat patron-nursing. Table 1 gives an overview.

The first part of the table shows five studies which izing, but the elderly rated them significantly less patroniz-ing than the nursing and psychology students. Thefocused on the patients’ interaction level, but also rep-

resented findings about the amount and frequency of interaction with the combined strategy of ‘that’s a goodgirl’ and altered pitch was rated as the most patronizingnurse-initiated communication. (Armstrong-Esther &

Browne 1986, Armstrong-Esther et al. 1989, 1994, Allen & of all, but in addition, the elderly also rated it as respectfuland non-dominant. As no natural communication wasTurner 1991, Nolan et al. 1995). The main conclusion of

these studies was that interaction between nurses and studied in this research its validity was questioned.In the next five studies (Gibb & O’Brien 1990, Daviespatients is low. Yet nurses reported that interacting with

patients was an important and enjoyable aspect in their 1992, Salmon 1993, Waters 1994, Thomas 1994) nurseswere the focus of the observation. Both instrumental andwork (Armstrong-Esther et al. 1989, 1994; Nolan et al.

1995). In the studies of Allen and Turner (1991) and Nolan affective variables were measured. Gibb and O’Brien(1990) used a qualitative method, by which they defined(1995), the samples were rather small. In the three studies

(Armstrong-Esther & Browne 1986, Armstrong-Esther et al. 42 speech act categories, in which a distinction can bemade in instrumental communication, such as expla-1989, 1994) sample sizes were bigger but these concerned

the respondents filling out a questionnaire on nursing atti- nation, instruction, checking out, and affective communi-cation such as encouragement and reassurance. Thetudes. It is unclear how much nurses were involved in the

observation study. Only one study (Allen & Turner 1991) speech style of nurses seemed to vary in relation to theway morning care procedures were carried out. During thegave figures on inter-observer reliability (>0·95).

The next two studies highlight the ways that speakers so called ‘journey’ in which a fixed sequence of activitiesfrom getting up, toiletting, showering, dressing, groomingmodify their speech in communicating with elderly

people. De Wilde and De Bot (1989) studied the use of was carried out, more affective behaviour was observed.During the ‘dissection’ in which parts of care were inter-simplified speech, more specifically ‘secondary babytalk’,

which is defined as a set of accommodations including rupted and the accent was on efficient use of time, a moretask-related communication style was observed. Thesimplification and high and variable pitch, usually

addressed to children, but also used in talking with elderly sample size in this study was rather small; nor were figuresabout reliability or validity reported. In other studies it(Coupland et al. 1991). In this research, the speech of

auxiliary nurses was analyzed on six characteristics of was also found that the way a ward organized nursinglabour could be related to the amount and quality ofbabytalk: length, complexity, imperatives, question-

sentences, repetition and substitutions of pronouns communication.Salmon (1993) reported that arrangement of formal inter-(Ashburn & Gordon 1981). The results showed that auxili-

ary nurses used features of babytalk in communication action periods increased the amount of social nurse-patient interaction. Thomas (1994) concluded that thewith geriatric patients. When asked the nurses reported

that expressive motives were determinants for their way influence of ward organization was clearer than staff grade.Regardless of staff grade, nurses on wards practising pri-of communicating. Still using babytalk may be perceived

as patronizing and is likely to have negative side effects mary nursing used more affective communication, thannurses practising team or functional nursing. They offeredsuch as a decrease in well-being and a decline of physical

and psychological functioning (De Wilde & De Bot 1989, patients more choice and spent more time seeking verbalfeedback. As regards instrumental communication, nursesRyan et al. 1986). Although only six auxiliary nurses par-

ticipated in this study the results were comparable with on primary wards gave more information about the careprovided. The Thomas study reported a rather largethe findings of other research (Ashburn & Gordon 1981).

The Edwards and Noller (1993) study also focused on sample (72 nurses) and a high inter-observer agreement(>0.95) on the observations.speech modifications in communicating with elderly

people. (In this study both verbal and nonverbal character- Davies (1992) examined whether trained and untrainedstaff used different communication strategies. She ident-istics are investigated, but as the nonverbal aspects were

related to speech, this research is discussed in this sec- ified 15 verbal behaviour categories, which included task-related categories like orienting to reality, explanationstion.) Edwards and Noller used a quasi-experimental

design. Special video-vignettes were developed on which and more affective categories, such as personal recognitionand reassurance. It was found that trained and untrainedinteractions between a nurse and an elderly woman, in

which three strategies of over accommodation were used: staff used broadly the same range of verbal strategies, butthat registered and enrolled nurses used proportionatelyaltered pitch, touch and a verbal expression: ‘that’s a good

girl’. Three respondent groups, elderly women, nursing more of those strategies which were in harmony with the



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professions’ recognized philosophy of promoting dignity,self respect, choice and independence, than nursing auxili-aries did. In this way, a division of labour in which nursingauxiliaries provided most of the direct patient care, couldhave effects on the quality of nurse-patient communi-cation. The sample size in this study was small and theinter-observer reliability was 0·90.

Waters (1994) reported the findings of an investigationinto styles of nurse-patient interaction during morningroutines and the effects on elderly patients in rehabili-tation care. This research only concerned instrumentalcommunication. It was found that about 60% of the work-styles used during morning care routine were, to a greateror lesser degree, inappropriate. Often there was too littlenurse-patient communication. The patients were left to goon with morning care, while they were unable to do so. Inother cases, the style of interaction was wholly compensa-tory or dependency-creating. The inter-rater reliability inthis study was high 0·95 and 0·92 for interaction categoriesand verbal communication respectively.

The next two studies (Liukkonen 1992, Kihlgren et al..1993) focus on communication with patients sufferingfrom dementia. Liukkonen (1992) found that nurses con-centrated more on obligatory daily activities than on theindividual needs of the patients or the special character-istics of dementia. They paid less attention to voluntaryactivities such as going outside the ward, going to the can-teen, touching and playful teasing. Interaction was there-fore rather superficial, which made the days for patientsin the institution rather boring and monotonous.Liukkonen used a qualitative method. The observationaldata were completed with interviews about nurses’ obser-vations to achieve better validity and reliability. Basicallythe results were consistent. Kihlgren et al. (1993) describedhow caregivers behaved towards patients with dementiaduring morning care before and after a training programmeof integrity-promoting care. They used an experimentalcontrol group design. A specially developed 93-itemcoding scheme was applied, which noted whether anaction occurred or not. After the training, the nursesoffered patients more opportunities to co-operate and therewas an increase in verbal contact.

Finally, Table 1 describes Hewison’s (1995) study intopower in the nurse-patient communication. He followedthe principles of the grounded theory (Glaser & Strauss1967). The findings confirmed much previous research thatmost of nurse behaviour is instrumental, routinized andsuperficial. It was found that nurses exert a lot of controlover interactions and the language they use is a major factorin it. The use of power is considered a normal situation andis generally accepted by both patients and nursing staff.

Nonverbal communication in the nursing processTable 2 summarizes research into nonverbal communi-

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concerns interaction during mealtimes. (This study con- priate cues to elicit functional feeding behaviour in theresidents; neither did they react appropriately to patient’ssiders both verbal and nonverbal characteristics. Because

the emphasis is on nonverbal aspects it is discussed in signals, because they did not recognize them.this section).

Hollinger (1986) investigated the relationship between Determinants of the quality or quantity ofnurse–patient communicationnurses’ use of touch and the frequency and duration of

verbal responses by elderly hospitalized people. She used Three groups of variables arise from the literature, thatseem to determine the quality or quantity of nurse-patientan experimental design with five treatment conditions,

varying from no touch and touch at different time intervals. communication. Variables related to nurses (that will bereferred to in this article as provider variables), variablesFindings showed that nurses’ touch increased the duration

of verbal responses in the patients during the time period related to patients and variables related to the situation,particularly ward characteristics (Table 3).when touch was applied.

LeMay and Redfern (1987), Oliver and Redfern (1991) Provider variables that were shown to be related wereattitude, education, job satisfaction and gender. Nursesand McCann and McKenna (1993) used an observation

schedule developed by Porter et al. (1986). In all three with a favourable attitude towards elderly people thoughtit more important to have social interaction with patientsinvestigations, following Watson (1975), a distinction was

made between instrumental and expressive touch. than to provide hygienic care (Armstrong-Esther et al.1989). On the other hand, Salmon (1993) could not demon-Instrumental touch is defined as deliberative physical con-

tact necessary to perform a task. Expressive touch is rela- strate a relation between nurses’ attitude towards the eld-erly and their communicative behaviour. Actually, hetively spontaneous and affective, and not necessary for the

completion of a task. The Observation Schedule from found that establishing formal interaction periods, lead toa greater increase of interactions than targeting nurses’ atti-Porter et al. (1986) was in 1987 refined and tested by

LeMay and Redfern (1987); to improve the reliability. After tudes. A positive factor relating to communication mightbe the amount of job satisfaction. Kramer & Kerkstra (1991)another refinement (Oliver & Redfern 1991) the reliability

of this instrument was acceptable, still validity is ques- showed that nurses with high levels of job satisfactionwere more sensitive to patients’ needs than nurses withtioned. All three studies reveal that touch in the nurse-

patient interaction is predominantly instrumental. lower levels. With regard to training and education, Davies(1992) found that although trained and untrained staffExpressive touch, on the contrary, is scarcely used.

McCann and McKenna report that the nurse’s gender and used broadly the same range of verbal strategies, trainedstaff used proportionately more of those strategies whichthe part of the body being touched determined how touch

was perceived. Instrumental touching of the arm and promoted dignity, self-respect, choice and independence.These results compete with the conclusions from studiesshoulder by a female nurse is perceived as comfortable by

all respondents. in other fields of nursing care. Macleod Clark (1985) forinstance did not find a difference in frequency of com-In 1995 another study in touch was carried out by Moore

and Gilbert (1995). They investigated whether affection munication between trained and untrained staff.Wilkinson (1991) found that nurses in cancer care, whoand immediacy could be communicated to elderly nursing

home residents by means of touch, using a quasi- had a post basic training in communication skills, wereno more effective in communicating than nurses who hadexperimental design. For that purpose, video-taped inter-

actions were developed, in which four nurses utilized not. On the contrary nurses who had completed anoncology course showed more facilitative communication,comforting touch or not. The residents rated the tapes on

a 30-item scale, developed by Burgoon & Hale (1987). than nurses who had not. It might therefore be concludedthat training should not only focus on communicationElderly patients appeared to perceive greater immediacy

and affection from nurse’s use of comforting touch. skills, but also on knowledge of the specific area in whichnursing is carried out. (The studies from Macleod ClarkAlthough the reliability of the rating scale was acceptable,

validity in this study was questioned, because the sample (1985) and Wilkinson (1991) are not included in Table 3because they are not directed at communication with eld-might not be representive and the video tapes did not

reflect natural communication. erly patients.)Patient characteristics that seem to be related to nurse-Finally, Van Ort and Philips (1992) identified and cate-

gorized nursing behaviours that elicit or sustain functional patient communication are level of mental alertness andlevel of physical ability. Armstrong-Esther et al. (1986,behaviour in Alzheimer patients or decrease non func-

tional behaviour, during eating activities. Using videotape 1989) showed that nurses interact significantly less withconfused patients than those who are. De Wilde and Derecordings and a systematic observation of the events, they

noted that the environment in which the eating activities Bot (1989) showed that nurses used more babytalk whenthe elderly were more dependent. Referring to Armstrong-took place were rather chaotic and not arranged to support

self-feeding attempts. Further, nurses did not give appro- Esther and Browne (1986), Allen and Turner (1991) sug-



gested that nurses would also be less likely to interact with theory or test hypotheses derived from a developed theory.None of the studies reviewed however, modified or testedphysically dependent patients as compared with those

who were more physically able. In investigating the effect existing nursing theories. This is consistent with the find-ings of Jaarsma and Dassen (1993) who concluded thatof an intervention programme to enhance patients’ quality

of life, no effect of the intervention was found, which could nursing theories were scarcely used in research to test atheory, although sometimes a research problem was fittedbe attributed to the difference of the physical ability level

in the pre- and post-intervention group. into a theory, retrospectively. Grypdonck (1990) made thesame conclusion in analysis of research in relation toFinally, an important role was attributed to ward charac-

teristics. Time pressure seems to be a variable of influence. Orem’s theory: a theory is often used as a frame of refer-ence, which contributes little to the research itself.Gibb and O’Brien (1990) showed that nurses who were

responsible for the ward (so they could be interrupted by Although none of the studies in this review used a nursingtheory, some studies did have an identifiable linkquestions from other patients or staff, during the provision

of morning care), were brief and task-related in interaction with theory from allied fields such as linguistics,communication science and social psychology.with their patients. The arrangement of special activity

programmes seemed to have a positive influence on theamount of nurse-patient interaction (Turner 1993, Salmon

Observed quality of nurse-patient communication1993). Thomas (1994) compared the differential contri-bution to patient care made by qualified nurses and auxili- In theories as well as in practice, it is widely accepted that

communication is essential in nurse-patient interaction.aries on wards practising primary nursing, team andfunctional nursing. In practising primary nursing, nurses Nurses view their relationships with patients as an import-

ant aspect of nursing care. (May 1990, Sundeen et al. 1989,showed more patient centred communication than nurseson wards with functional or team nursing, regardless of Kitson 1987, Macleod Clark 1983, Hockey 1976).

Nevertheless, social interaction is scarce in nursing.staff grade.(Nolan et al.. 1995, Salmon 1993, Armstrong-Esther et al.1993, 1989, Macleod Clark 1983). Further, the quality of

DISCUSSIONnurse-patient interaction is questioned. Waters (1994)showed that two thirds of the workstyles observed inThis review of the literature has dealt with communication

in nurse-patient interaction, with special reference to the morning care were inappropriate and dependency cre-ating. Wilkinson (1991) reported that nurses had overall acommunication of nurses with elderly people. Firstly,

attention was drawn to the role of communication in theor- poor level of communication. They used more blockingthan facilitating communication. Hewison’s (1995) studyetical nursing models. Secondly, a review of the research

on nurse-patient communication was given. showed that nurses exerted power in communication withtheir patients.

It seems that although research on nurse-patient com-Relations between nursing theories and research

munication is increasing, only little change has occurredin practice. Further, patient surveys show that dissatis-The importance of communication is emphasized particu-

larly in theories which have nurse-patient interaction as faction, if it exists, is usually directed at poor communi-cation. (Davis & Fallowfield 1991, Macleod Clark 1985).the dominant theme (Peplau 1952, Orlando 1961, King

1981). The early theorists Peplau and Orlando and more Hence, nurse-patient communication still deservesattention.recently King describe nursing as a process of interaction,

in which communication is a central concept. None of thetheories described distinguishes explicitly between instru-

Limitations and methodological shortcomings ofmental and affective behaviour, although they do pay

research into nurse-patient communicationattention to building up a relationship and to task-relatedbehaviour. As mentioned above, research in nurse-patient communi-

cation can contribute to knowledge and theory in nursing.When Peplau and Orlando developed their theories,there was little research on nurse-patient communication. Apart of that, research findings can be used in curricula

for nursing students and continuing nursing education. InOver the past 10 years, many more studies have been pub-lished, nevertheless we have found that in the recently this way research can contribute to effective communi-

cation in nursing care. Good research is needed to achievedeveloped and commonly used theoretical models(Neuman 1990, Orem 1980) the role of communication these goals. But, though observation research is growing,

there are serious gaps and limitations, which will betends to be implicit. This gives rise to the question of therelationship between theory and research. discussed in this section.

All the observation studies presented here, were carriedTheories give directions to research (Fawcett 1995) andin this way research can generate or modify an existing out in institutional care. In none of the studies was atten-



Tabl

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tion paid to the nurse-patient communication in home care relation in nurse–patient interaction. Although littleresearch was found investigating patient outcomes, theor the possible generalizations to primary care settings. In

addition, generalization is questioned because of the small relationship between nurse-patient communication andpatient outcomes has been mentioned in the literature.sample sizes that were used in several studies. Besides,

some studies revealed no figures about observer reliability Fosbinder (1994) states for instance that nurse-patientinteraction is critical in determining the quality of careand the validity was questioned in nearly all studies.

These findings make the quality of several of the studies from the patient’s point of view. LeMay and Redfern (1987)and Copstead (1980) concluded that touch can enhance adoubtful.

A second limitation is that in several studies patient- patient’s self esteem and reduce anxiety. If we believe thatthe patient will benefit from more effective communicationfocused observation was used. Those studies revealed data

about the amount of patient interaction but did not provide we should focus on research into patient outcomes, suchas patient satisfaction, psychosocial adjustment, com-specific information about the communication process.

Other studies recorded the amount of communication, and pliance, patient autonomy and well-being, and quality oflife.studied individual aspects of communication, such as the

length of the interaction, who initiated it, whether it was All in all, the following conclusions can be drawn.Future research will require efforts to develop observationtask-related or social interaction. Studies doing justice to

the interactive nature of communication are scarce and, instruments and analysis systems which do justice tonurse-patient communication as an interactive activity,no instruments are available using systematic obser-

vations. Although there is a lot of research literature about taking place in a variety of settings. Special attentionshould be paid to reliability and validity. Future researchnurse-patient interaction, only few studies focus on the

development of observation instruments. The most com- should also take patients’ contributions into account andfocus on patient outcomes.monly applied instruments count frequencies of various

types of communicative behaviours. No instrument wasfound that investigated interaction patterns or paidattention to sequences of behaviour. References

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gramme on interactions on a continuing care ward for olderobservation studies were patient-focused, these studies

people. Journal of Advanced Nursing 16, 1172–1177.did not show how patients contributed to interactions. Armstrong-Esther C.A. & Browne K.D. (1986) The influence ofJarrett and Payne (1995) in their review article concluded elderly patients’ mental impairment on nurse-patient inter-that the contribution of the patients had been neglected. action. Journal of Advanced Nursing 11, 379–387.Frequently, it is indicated in research that nurses deal with Armstrong-Esther C.A., Browne K.D. & McAfee J.G. (1994) Elderly

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Communication in nursing care for elderly people

Education

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