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Student nurse–older person communication
Article
Student nurse–older person communication Dympna Tuohy
There is an increasing ageing population in western countries. Most nurses will be involved in caring for older people in the future. Over the last number of years much has been written about the benefits of effective nurse–patient communication. However, research findings indicate that the quality of nurse–older person communication has been and continues to be poor. The purpose of this mini ethnography was to ascertain how student nurses communicate with older people. This is relevant as today’s students are tomorrow’s registered nurses and the manner in which they currently communicate with older person may indicate how they will interact with this population in the future. Data were collected using both participant observation and semi-structured interviews. Data were analysed using latent thematic analysis. Four major themes were identified from the findings. These were: types of communication, modes of communication, factors that either hinder or enhance effective communication and student nurses’ approach to communicating with older people. There are a number of recommendations from this study. These include, promoting a personcentred approach to care of the older person, ensuring appropriate clinical supervision of student nurse–older person communication by preceptors, increasing theoretical input in relation to interpersonal skills and communication theory, facilitating reflective practice whilst students are on clinical placement and regular auditing of clinical placements as suitable learning environments. c 2002 Elsevier Science Ltd. All rights reserved.
Introduction
Dympna Tuohy RGN, RNT, BNS, MSc (Nursing), Nurse Tutor in Limerick School of Nursing, Limerick School of Nursing, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland. Tel.: +353-061482675 (Requests for offprints to DT) Manuscript accepted: 30 July 2002
There is an increasing ageing population in western countries. Nursing care of the older person is and will be provided in a variety of health care settings, e.g., residential care, community and acute hospitals. It is likely that all nurses will be involved in the care of the older person with a few notable exceptions, i.e., those working in paediatric and obstetric units. Over the last number of years, nurse–patient communication has been extensively researched and discussed. Strong criticism has been levelled at the quality of nurse–patient communication (Crotty 1985; Jarett & Payne 1995; Caris-Verhallen et al. 1997; Kacperek 1997). In response to this, there has been increased emphasis on interpersonal and communication skills training at both pre and post registration level education (Morrison &
0260-6917/02/$ - see front matter c 2002 Elsevier Science Ltd. All rights reserved doi:10.1016/S0260-6917(02)00160-0
Burnard 1997). The benefits of effective nurse–patient communication can be enormous, ranging from reducing patient anxiety and fears to quicker recovery times (Hayward 1975; Fielding & Llewelyn 1987). However, findings from studies on nurse–older person communication indicate that there has been little improvement in practice (Armstrong-Esther et al. 1994; Caris-Verhallen et al. 1997). There have been relatively few studies undertaken which specifically explore how student nurses communicate with older people. Thus, the purpose of this study was to ascertain how student nurses communicate with older people. This is relevant as today’s students are the future’s registered nurses. Therefore, the manner in which they currently communicate with older people may indicate how they will communicate with this population in the future.
Nurse Education Today (2003) 23, 19–26 19
Student nurse–older person communication
Literature review A review of the literature indicates that there are four main issues relevant to this study. These include an ageing population, effective communication, communication and the older person, and factors influencing student nurse–older person communication. In western countries, the proportion of older people (people aged 65 years and over) is rising. Suggested reasons for this are decreased infant mortality, decreased birth rates, better nutrition and improved health care (Kenny 1995). An ageing population has implications for the provision of nursing care both now and in the future. Older people are more likely to require health care than younger populations for a number of reasons, such as physiological and psychological problems associated with the ageing process. Furthermore, increased morbidity in the older person population is a significant factor for the provision of nursing care for this group. Almost half of the older person population suffer from major health care problems such as cardiovascular, respiratory and cancer related diseases (National Council on Ageing & Older People & Department of Health & Children 1998). ‘Communication needs to be effective so that care can be planned on the basis of the patient’s authentic problems rather than on what we think his problems are’ (Faulkner 1996, p. 2). There are a number of issues associated with effective communication. These include, understanding the components of interpersonal effectiveness in communicating with patients (Quinn 1988), identifying barriers to effective communication and being aware of the benefits of effective communication for patients. In recent years, much has been written about the importance of effective nurse–older person communication. However, the literature indicated that the quality of this interaction has been and continues to be poor. These studies have addressed issues such as the use of power, institutional rules, routinised care, interactions with both alert and confused patients and the use of non-verbal behaviour, especially touch (Le May & Redfern 1987; McCann & McKenna 1993; Salmon 1993;
20 Nurse Education Today (2003) 23, 19–26
Armstrong-Esther et al. 1994; Hewison 1995; Nolan et al 1995). It is recognised that these factors also influence student nurse–older person communication. The nurse population sampled in many of the studies have been registered nurses, enrolled nurses and auxiliary staff. There have been relatively few that have specifically investigated student nurse–older person communication. There are a number of factors which could influence how student nurses communicate with older people. These include student nurse education in relation to communication and care of the older person; attitudes of student towards older people and factors affecting the clinical learning environment, i.e., the student’s role, the influence of the ward sister and the qualified staff, and the type of nursing practised in the care of the older person ward (Ashworth & Morrison 1989; Ogier 1989; Slevin 1991; Treharne 1990; Stevens & Crouch 1992).
Research design The research design chosen for this study was ethnography, as this methodology is useful for studying the culture and social organisation of groups (Kaufmann 1995). There are a number of advantages to using ethnography in nursing research. According to Baillie (1995) and Laughrane (1995), the core strength of ethnography is that it occurs within a natural setting and is neither artificial nor controlled. Furthermore, ethnography enables culturally specific care to be identified (Baillie 1995). Laughrane (1995) considers one of the main advantages of this methodology is that the cultural environment of the research site can be described from the participants’ points of view. Student nurses’ knowledge of effective communication skills, their attitudes towards older people and their perceptions about their ability to communicate are likely to affect their behaviour. Nurse–patient interaction does not occur in isolation or ignorance of the ward environment, but must occur within the social culture of the ward. Thus, cultural influences may affect student nurse–older person communication. The methods of data collection were participant observation and semi-structured
c 2002 Elsevier Science Ltd. All rights reserved
Student nurse–older person communication
interviews. These are useful in studying what the participants actually do in practice and ascertaining their knowledge, beliefs and attitudes about the research question. Data were analysed using latent thematic analysis. According to Morse and Field (1996) latent thematic analysis refers to reviewing sections within the context of the entire interview and observation process, in order to identify and code important themes within the sections. The aim in using this approach for this study was to understand how student nurses communicate with older people, by identifying and linking categories in order to develop themes and concepts about student nurses’ verbal and non-verbal behaviour from raw data. A pilot study (sample of two students) was undertaken in order to trial the research method so as to ensure its feasibility. A number of issues were highlighted and taken into consideration for the actual study. These included observing students’ interactions with patients on respite care as well as long term residents; participating on a couple of occasions in direct patient care with students, in order to maintain patient safety; realising that it was not feasible to write up all verbal interactions as this would have interfered with the observation process. The final issues dealt with (a) extending the semi-structured interviews from 30 to at least 45 min and (b) making the decision that if a student became emotionally upset that the interview would be temporarily suspended. The study’s sample population was a purposive sample of 8 second year diploma pre-registration students, who had completed modules on communication and care of the older person and who were on clinical placement in the continuing care unit. A purposive sample refers to sampling participants who have information relevant to the topic being studied (Gijbels & Burnard 1995). Baillie (1995) states that the notion of targeting key informants is integral to obtaining quality data in ethnography. By its nature, small selective sampling is used in ethnography. Thus, the sample size used for this study was appropriate. Access to the research site was gained through obtaining permission and holding meetings to discuss potential concerns with relevant personnel,
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e.g., ward sister, participants, ethics committee, directors of nursing and the older people. One of the main issues of concern highlighted at the ethics committee was that the researcher was also the students’ tutor. This is acknowledged as a limitation of the study and the manner in which this concern was addressed is discussed further on in this section. The research site was a continuing care unit, which accommodates both residential and respite patients (32 and 8, respectively). Issues of trustworthiness were addressed in a number of ways. These included keeping records of data collection and analysis, and obtaining verification of interview transcripts from the participants. Furthermore, the opinions of two nursing colleagues were sought with regard to data analysis, and a clear audit trail of the data collection and analysis was presented. Ethical issues, e.g., protection of participants’ rights and identifying the researcher’s responsibilities to the participants, the institutions and the body of nursing knowledge were examined (Schrock 1991). Participants’ rights were ensured by obtaining informed consent, assuring anonymity, confidentiality and giving freedom to withdraw from the study at any time (Schrock 1991). Some limitations of the study are acknowledged. As the researcher was also the participants’ tutor, they may have felt obliged to participate, although a number of steps were taken to avoid the potential adverse effects of this relationship. These included considering the participants’ rights as outlined above, as well as providing assurance that their participation was voluntary, being reminded that they could withdraw from the study at any time and being assured that their decision to participate or not would in no way affect their course work. A second limitation was, that the presence of and note-taking by the researcher might have influenced student nurse–older person interactions. A third limitation was that, it was impossible to note all of the interactions during participant observation, so only the main elements were written up as field notes. A final limitation was the length of time for data collections
Nurse Education Today (2003) 23, 19–26 21
Student nurse–older person communication
(38 h), had the study been extended it is possible that more data would have been elicited.
The findings Four themes were identified from the data. These are: • Types of communication; • Modes of communication; • Factors which hinder or enhance student nurse–older person communication; • The student nurses’ approaches to communicating with the older person. Theme 1: Types of communication This has two main categories, namely ‘task’ and ‘non-task’ related student nurse–older person communication. These include both verbal and non-verbal modes of communication. To a certain degree, the manner in which nursing care was organised in this unit determined the type of communication. In general much of the communication in the mornings was task related (e.g., assisting the patients with their meals and personal hygiene) with some non-task related communication occurring whilst the students attended to nursing care activities. One student stated We talked to them but you wouldn’t have time to sit down on the bed and have a conversation, you’d be doing something at the same time, like putting them to bed. . . you’d be talking away. . . did you watch this last night or did you sleep ok, but then when you’ve finished your task you have to go and do the next room. . .. However, in the afternoon, there was a change of emphasis in relation to nursing care activities and the students were engaged in more non-task related communication with the patients. Topics such as the patients’ hobbies, likes, dislikes, families and favourite TV programmes were also discussed. As one student said Once you have the. . . initial morning stuff done. . . you sit down and . . . they’d start
22 Nurse Education Today (2003) 23, 19–26
to tell you about what happened and about the family and like, problems like that. . .
Theme 2: Modes of communication This can be divided into two categories, verbal and non-verbal. However, neither was used independently of the other. Effective communication as defined by one of the students, has both verbal and non-verbal components, I suppose it’s a combination, balancing it out between actually talking, verbal communication, listening communication, touch communication. . . Students identified understanding and being understood as being important. One student stated: You might have to talk louder. . . and it would have to be clearer as well ‘cause. . . if you’re talking too fast. . . they mightn’t understand. . . Many of the verbal skills used were questioning, listening, encouraging, praising and instructing with some less effective skills such as leading and blocking as well. Important non-verbal skills identified were: being at eye level, eye contact, facial expressions and the use of appropriate touch to both physically and psychologically support the older person. One student stated Touch can be good. . . just let them know you’re there and supportive of their problems. . .
Theme 3: Factors which either hinder or enhance student nurse–older person communication The factors which hindered communication included physical and psychological difficulties associated with ageing, ward routine (including lack of time), misunderstandings, distractions, lack of knowledge and certain subject matters such as death. The quality of the older person’s memory especially if they were confused posed
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Student nurse–older person communication
some difficulties with regard to effective communication, as the following incident illustrates She has absolutely no concept of where she is or the time or who we are. . . that’s very, very difficult and I find it hard to communicate with her. . . I try to smile and keep everything positive. Certain factors associated with the ward routine were clearly identified by the students as hindering effective communication, e.g., getting the job done, being busy, a ‘heavy’ ward and lack of time. One student felt there was no time to provide extra attention or care for the older person. There was only time to attend to essential nursing care, this the student referred to as no French polishing. Factors, which were identified as enhancing communication included the use of communication aids, spending time and developing a relationship with the older person, using games to motivate, encouraging, persevering, having a laugh and how communicative the older person was. There was more time in the afternoon for students to communicate with the older people. The following statement illustrates this In the afternoon you had a nice bit of time. . . just to chat away. The more communicative an older person was, the more likely the students were to engage in conversation, as the following statements demonstrate I suppose in a way you would talk to the chatty people more. It’s easier to communicate with people that are going to talk back to you. Although, interestingly some of the students also suggested that the level of dependence of the older person determined the length of time and likelihood of communicating with them. Students were more likely to spend time with the more dependent older person, attending to their physical needs. This presented opportunities for the student to engage in conversation
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Anyone who couldn’t feed themselves or couldn’t wash themselves. . . you’d be talking to them more because you’d be with them more. However, this communication was likely to be task related if the student was attending to the older person’s physical needs.
Theme 4: Student nurses’ approach to communication with the older person This theme has four sub-categories. The first sub-category, student assumptions about how one should communicate with the older person, included having respect, being honest and caring, showing interest, motivating, encouraging, having a rapport and building upon this rapport. Quite a number of the students felt that one should have respect for older people regardless of their level of physical and/or psychological dependence. This is illustrated in the following statements Even though. . . they’re confused and you might be doing everything for them. . . they’re still adults. . . and you have to respect them because they’re older than you. The second sub-category, student assumptions about older people, in part, influence their approach to communication. These assumptions ranged from believing that older people love to talk, were lonely, demotivated, lacked autonomy and the notion that older people could be demanding and manipulative. Some of the students felt that older people had no control over their lives and that this affected their desire and/or ability to communicate, e.g., They’ve lost their self control. . . they’ve lost choice. Vast institutionalisation. . . they just adapt to everything being done for them. Although, in contrast, a number of the students felt that older people could be attention seeking and manipulative, as the following statements illustrate
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Student nurse–older person communication
They do take advantage when you’re a student. A lot of them are cute. . . they know if I’m going to get away with this I will. The third sub-category, student assumptions about the registered staff nurses included the notions that most were caring, did the best they could but were too busy to talk to the older people and that for some the routine nature of the care provided, adversely affected their ability to communicate effectively with the older people. The manner in which many of the students communicated with the older people was both negatively and positively influenced by their observation of the RGNs’ behaviour towards and communication with the older person. The following statements illustrate this influence By watching them and how they communicated. . . I definitely learnt from it. . . she’d always be very caring. . . I just learnt a lot from her. . . The staff are there. . . quite a while. . . they get into that routine and they don’t see. . . extra things to be done. . . so used to doing things you forget to. . . explain something to the patient. . . The fourth sub-category, student views on how one should protect one’s self, included the notion that one needed to protect one’s self-emotionally, e.g., You come to work and you leave your personal life outside. . . you have to distance yourself. . . I don’t think I would have lasted this long otherwise. Furthermore, students sometimes used blocking techniques when older people began discussing perceived difficult topics such as death and dying.
Discussion This section discusses the study’s findings and links the identified themes with relevant literature. A number of issues are discussed, namely the meaning of communication, communicating with cognitively impaired older adults, intergenerational issues and
24 Nurse Education Today (2003) 23, 19–26
learning to communicate with older people in the clinical area. It is suggested that the routinised and task-orientated approach to patient care within the continuing care unit adversely affected student nurse–older person communication. Communication was not seen as a priority. Issues such as student autonomy and empowerment, providing older people with choice in relation to their care and the predominance of the curative model in continuing care units warrant attention within the context of care provision (Nolan & Grant 1993). In recent years, the notion of person centred care has become increasingly popular (McCormack & Wright 1999). Therefore, a change in the philosophy and culture of the continuing care unit may have benefits for patient care and this change in focus may promote effective nurse–older person communication. However, there are a number of challenges to changing the philosophy and practices of a routine, task-orientated approach to patient care. These include recognition and a desire by staff for such a change and identification of ways in which such change could be realised. The development of a therapeutic nurse–patient relationship is considered essential to the provision of effective nursing care (Johns 1995; Barber 1997). Kitson (1991, p. 69) states that ‘therapeutic action comprises both emotional and personal interaction as well as the use of knowledge and skills’. The study’s findings indicate that the students understood communication to be a means of providing emotional support, developing a rapport and building a relationship with the older people. Therefore, it is suggested that attempts were made by the students to develop therapeutic relationships with the older people. According to Fulmer and Abraham (1998) cognitive impairment can range from mild confusion to profound dementia. The study’s findings indicate that various factors influenced the amount and type of communication that the students had with cognitively impaired older people. While a number of difficulties were highlighted, many of the students felt that it was important for the older person’s well being to have respect and ‘be there’ for them regardless of their cognitive
c 2002 Elsevier Science Ltd. All rights reserved
Student nurse–older person communication
impairment. It is suggested that a change to person centred approach to care of the older person would be of particular benefit to cognitively impaired older people as this approach to patient care recognises that all people (regardless of cognitive ability) have rights (Dewing 1999). The study’s findings highlight how intergenerational issues may be a barrier to effective nurse–older person communication. The students had a number of assumptions about older people. This highlights the dangers of ageism, stereotyping and viewing older people as a homogenous group. However, overall the students seemed to have positive attitudes to older people and in general valued them. Integral to this study’s findings is how student nurses learn to communicate with older people. It is suggested that role modelling by Registered General Nurses is central to student learning within the clinical area. According to Davies (1993, p. 628) clinical role modelling can be seen ‘as a primary source of learning from experience, it may enable students to discover knowledge in clinical practice’. The students had a number of assumptions about Registered General Nurses and their views and behaviour toward older people. These had both positive and negative influences on student nurses’ approach to communicating with older people. This highlights the relevance and importance of issues such as clinical role modelling, clinical supervision, preceptorship, reflective practice and auditing of clinical placements.
Conclusion The purpose of this study is to ascertain how student nurses communicate with older people. There are relatively few studies undertaken which specifically explore this area. In view of current and future nursing care needs of an ageing population and the benefits of effective communication for patient well-being, this study’s findings are relevant. It is acknowledged that this is a small study and it may be suggested that its findings cannot be generalised. Nonetheless, through discussion of the findings in conjunction with current literature, a number of recommendations for
c 2002 Elsevier Science Ltd. All rights reserved
improving student nurse–older person communication are proposed. These are: • Practice development within the continuing care unit, to facilitate change to a person centred approach to patient care. • Increased theoretical education on interpersonal skills, to occur in the second year of the diploma programme. • The need for preceptors who will facilitate student learning in the clinical area and who will provide clinical supervision of student nurse–older person communication. • Regular auditing of the clinical placement as a suitable learning environment, to be a collaborative approach with representatives from both clinical and education services. • Increased facilitation of reflective practice, whilst the students are on clinical placement.
References Armstrong-Esther CA, Browne KD, McAfee JG 1994 Elderly patients: still clean and sitting quietly. Journal of Advanced Nursing 19(2): 264–271 Ashworth P, Morrison P 1989 Some ambiguities of the student’s role in undergraduate nurse training. Journal of Advanced Nursing 14(2): 1009–1015 Baillie L 1995 Ethnography and nursing research: a critical appraisal. Nurse Researcher 3(2): 5–21 Barber P 1997 Caring – the nature of a therapeutic relationship. In: Perry A (ed). Nursing, A Knowledge Base for Practice. Arnold, London, pp. 171–211 Caris-Verhallen WMCM, Kerkstra A, Bensing JM 1997 The role of communication in nursing care for elderly people: a review of the literature. Journal of Advanced Nursing 25(5): 915–933 Crotty M 1985 Communication between nurses and their patients. Nurse Education Today 5(3): 130–134 Davies P 1993 Clinical role modelling: uncovering hidden knowledge. Journal of Advanced Nursing 18(4): 627–636 Dewing J 1999 Dementia, part 1: person centred care. Professional Nurse 14(8): 585–588 Faulkner A 1996 Effective Interaction with Patients. Churchill Livingstone, London Fielding RG, Llewelyn SP 1987 Communication training in your nursing may damage your health and enthusiasm: some warnings. Journal of Advanced Nursing 12(13): 281–290 Fulmer T, Abraham IL 1998 Rethinking geriatric nursing. Nursing Clinics of North America 33(3): 387–394 Gijbels H, Burnard P 1995 Exploring the Skills of Mental Health Nurses. Ashgate, Aldershot Hayward J, 1975. Information, A Prescription Against Pain. Royal College of Nursing, London Hewison A 1995 Nurses’ power in interactions with patients. Journal of Advanced Nursing 21(1): 75–82
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Jarett N, Payne S 1995 A selective review of the literature on nurse–patient communication: has the patient’s contribution being neglected. Journal of Advanced Nursing 22(1): 72–78 Johns C 1995 Achieving effective work as a professional activity. In: Schober JE, Hinchcliff (eds). Towards Advanced Nursing Practice. Arnold, London, pp. 202–280 Kacperek L 1997 Non-verbal communication: the importance of listening. British Journal of Nursing 6(5): 275–279 Kaufman KS 1995 Center as haven: findings of an urban ethnography. Nursing Research 44(4): 231–236 Kenny G 1995 Take Good Care of Yourself, Growing Older in Ireland. Gill and Macmillan, Dublin Kitson A, 1991. Therapeutic Nursing and the Hospitalised Elderly. Scutari Press, Harrow Laughrane C 1995 Ethnography: research method or philosophy. Nurse Researcher 3(2): 45–54 Le May AC, Redfern SJ 1987 A study of non-verbal communication between nurses and elderly people. In: Fielding P (ed). Research into Nursing Care of Elderly People. Wiley, Chichester, pp. 171–189 McCann K, McKenna HP 1993 An examination of touch between nurses and elderly patients in a continuing care unit in Northern Ireland. Journal of Advanced Nursing 18(5): 838–846 McCormack B, Wright J 1999 Achieving dignified care for older people through practice development: a systematic approach. Nursing Times Research 4(5): 340–352 Morrison P, Burnard P 1997 Caring and Communicating. Macmillan, London Morse JM, Field P 1996 Nursing Research. Chapman & Hall, London
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National Council on Ageing and Older People and Department of Health and Children 1998 Adding years to life, adding life to years... a health promotion strategy for older people. Hawkins’ House, Dublin Nolan M, Grant G 1993 Rust out and therapeutic reciprocity: concepts to advance the nursing care of older people. Journal of Advanced Nursing 18(8): 1305–1314 Nolan M, Grant G, Nolan J 1995 Busy doing nothing: activity and interaction levels amongst differing populations of elderly patients. Journal of Advanced Nursing 22(3): 528–538 Ogier ME 1989 Working and Learning. Scutari Press, Middlesex Quinn F 1988 The Principles and Practice of Nurse Education. Chapman & Hall, London Salmon P 1993 Interactions of nurses with elderly patients: relationship to nurses’ attitudes and formal activity periods. Journal of Advanced Nursing 18(1): 14–19 Schrock R 1991 Moral issues in nursing research. In: Cormack DFS (ed). The Research Process in Nursing. Blackwell Science, Oxford, pp. 30–39 Slevin ODA 1991 Ageist attitudes among young adults: implications for a caring profession. Journal of Advanced Nursing 16(10): 1197–1205 Stevens JA, Crouch M 1992 Working with the elderly: Do students care for it? The Australian Journal of Advanced Nursing 9(3): 12–17 Treharne G 1990 Ageist attitudes towards the care of elderly people: Are they getting better? Journal of Advanced Nursing 15(7): 777–781
c 2002 Elsevier Science Ltd. All rights reserved
Student nurse–older person communication Dympna Tuohy
There is an increasing ageing population in western countries. Most nurses will be involved in caring for older people in the future. Over the last number of years much has been written about the benefits of effective nurse–patient communication. However, research findings indicate that the quality of nurse–older person communication has been and continues to be poor. The purpose of this mini ethnography was to ascertain how student nurses communicate with older people. This is relevant as today’s students are tomorrow’s registered nurses and the manner in which they currently communicate with older person may indicate how they will interact with this population in the future. Data were collected using both participant observation and semi-structured interviews. Data were analysed using latent thematic analysis. Four major themes were identified from the findings. These were: types of communication, modes of communication, factors that either hinder or enhance effective communication and student nurses’ approach to communicating with older people. There are a number of recommendations from this study. These include, promoting a personcentred approach to care of the older person, ensuring appropriate clinical supervision of student nurse–older person communication by preceptors, increasing theoretical input in relation to interpersonal skills and communication theory, facilitating reflective practice whilst students are on clinical placement and regular auditing of clinical placements as suitable learning environments. c 2002 Elsevier Science Ltd. All rights reserved.
Introduction
Dympna Tuohy RGN, RNT, BNS, MSc (Nursing), Nurse Tutor in Limerick School of Nursing, Limerick School of Nursing, Mid-Western Regional Hospital, Dooradoyle, Limerick, Ireland. Tel.: +353-061482675 (Requests for offprints to DT) Manuscript accepted: 30 July 2002
There is an increasing ageing population in western countries. Nursing care of the older person is and will be provided in a variety of health care settings, e.g., residential care, community and acute hospitals. It is likely that all nurses will be involved in the care of the older person with a few notable exceptions, i.e., those working in paediatric and obstetric units. Over the last number of years, nurse–patient communication has been extensively researched and discussed. Strong criticism has been levelled at the quality of nurse–patient communication (Crotty 1985; Jarett & Payne 1995; Caris-Verhallen et al. 1997; Kacperek 1997). In response to this, there has been increased emphasis on interpersonal and communication skills training at both pre and post registration level education (Morrison &
0260-6917/02/$ - see front matter c 2002 Elsevier Science Ltd. All rights reserved doi:10.1016/S0260-6917(02)00160-0
Burnard 1997). The benefits of effective nurse–patient communication can be enormous, ranging from reducing patient anxiety and fears to quicker recovery times (Hayward 1975; Fielding & Llewelyn 1987). However, findings from studies on nurse–older person communication indicate that there has been little improvement in practice (Armstrong-Esther et al. 1994; Caris-Verhallen et al. 1997). There have been relatively few studies undertaken which specifically explore how student nurses communicate with older people. Thus, the purpose of this study was to ascertain how student nurses communicate with older people. This is relevant as today’s students are the future’s registered nurses. Therefore, the manner in which they currently communicate with older people may indicate how they will communicate with this population in the future.
Nurse Education Today (2003) 23, 19–26 19
Student nurse–older person communication
Literature review A review of the literature indicates that there are four main issues relevant to this study. These include an ageing population, effective communication, communication and the older person, and factors influencing student nurse–older person communication. In western countries, the proportion of older people (people aged 65 years and over) is rising. Suggested reasons for this are decreased infant mortality, decreased birth rates, better nutrition and improved health care (Kenny 1995). An ageing population has implications for the provision of nursing care both now and in the future. Older people are more likely to require health care than younger populations for a number of reasons, such as physiological and psychological problems associated with the ageing process. Furthermore, increased morbidity in the older person population is a significant factor for the provision of nursing care for this group. Almost half of the older person population suffer from major health care problems such as cardiovascular, respiratory and cancer related diseases (National Council on Ageing & Older People & Department of Health & Children 1998). ‘Communication needs to be effective so that care can be planned on the basis of the patient’s authentic problems rather than on what we think his problems are’ (Faulkner 1996, p. 2). There are a number of issues associated with effective communication. These include, understanding the components of interpersonal effectiveness in communicating with patients (Quinn 1988), identifying barriers to effective communication and being aware of the benefits of effective communication for patients. In recent years, much has been written about the importance of effective nurse–older person communication. However, the literature indicated that the quality of this interaction has been and continues to be poor. These studies have addressed issues such as the use of power, institutional rules, routinised care, interactions with both alert and confused patients and the use of non-verbal behaviour, especially touch (Le May & Redfern 1987; McCann & McKenna 1993; Salmon 1993;
20 Nurse Education Today (2003) 23, 19–26
Armstrong-Esther et al. 1994; Hewison 1995; Nolan et al 1995). It is recognised that these factors also influence student nurse–older person communication. The nurse population sampled in many of the studies have been registered nurses, enrolled nurses and auxiliary staff. There have been relatively few that have specifically investigated student nurse–older person communication. There are a number of factors which could influence how student nurses communicate with older people. These include student nurse education in relation to communication and care of the older person; attitudes of student towards older people and factors affecting the clinical learning environment, i.e., the student’s role, the influence of the ward sister and the qualified staff, and the type of nursing practised in the care of the older person ward (Ashworth & Morrison 1989; Ogier 1989; Slevin 1991; Treharne 1990; Stevens & Crouch 1992).
Research design The research design chosen for this study was ethnography, as this methodology is useful for studying the culture and social organisation of groups (Kaufmann 1995). There are a number of advantages to using ethnography in nursing research. According to Baillie (1995) and Laughrane (1995), the core strength of ethnography is that it occurs within a natural setting and is neither artificial nor controlled. Furthermore, ethnography enables culturally specific care to be identified (Baillie 1995). Laughrane (1995) considers one of the main advantages of this methodology is that the cultural environment of the research site can be described from the participants’ points of view. Student nurses’ knowledge of effective communication skills, their attitudes towards older people and their perceptions about their ability to communicate are likely to affect their behaviour. Nurse–patient interaction does not occur in isolation or ignorance of the ward environment, but must occur within the social culture of the ward. Thus, cultural influences may affect student nurse–older person communication. The methods of data collection were participant observation and semi-structured
c 2002 Elsevier Science Ltd. All rights reserved
Student nurse–older person communication
interviews. These are useful in studying what the participants actually do in practice and ascertaining their knowledge, beliefs and attitudes about the research question. Data were analysed using latent thematic analysis. According to Morse and Field (1996) latent thematic analysis refers to reviewing sections within the context of the entire interview and observation process, in order to identify and code important themes within the sections. The aim in using this approach for this study was to understand how student nurses communicate with older people, by identifying and linking categories in order to develop themes and concepts about student nurses’ verbal and non-verbal behaviour from raw data. A pilot study (sample of two students) was undertaken in order to trial the research method so as to ensure its feasibility. A number of issues were highlighted and taken into consideration for the actual study. These included observing students’ interactions with patients on respite care as well as long term residents; participating on a couple of occasions in direct patient care with students, in order to maintain patient safety; realising that it was not feasible to write up all verbal interactions as this would have interfered with the observation process. The final issues dealt with (a) extending the semi-structured interviews from 30 to at least 45 min and (b) making the decision that if a student became emotionally upset that the interview would be temporarily suspended. The study’s sample population was a purposive sample of 8 second year diploma pre-registration students, who had completed modules on communication and care of the older person and who were on clinical placement in the continuing care unit. A purposive sample refers to sampling participants who have information relevant to the topic being studied (Gijbels & Burnard 1995). Baillie (1995) states that the notion of targeting key informants is integral to obtaining quality data in ethnography. By its nature, small selective sampling is used in ethnography. Thus, the sample size used for this study was appropriate. Access to the research site was gained through obtaining permission and holding meetings to discuss potential concerns with relevant personnel,
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e.g., ward sister, participants, ethics committee, directors of nursing and the older people. One of the main issues of concern highlighted at the ethics committee was that the researcher was also the students’ tutor. This is acknowledged as a limitation of the study and the manner in which this concern was addressed is discussed further on in this section. The research site was a continuing care unit, which accommodates both residential and respite patients (32 and 8, respectively). Issues of trustworthiness were addressed in a number of ways. These included keeping records of data collection and analysis, and obtaining verification of interview transcripts from the participants. Furthermore, the opinions of two nursing colleagues were sought with regard to data analysis, and a clear audit trail of the data collection and analysis was presented. Ethical issues, e.g., protection of participants’ rights and identifying the researcher’s responsibilities to the participants, the institutions and the body of nursing knowledge were examined (Schrock 1991). Participants’ rights were ensured by obtaining informed consent, assuring anonymity, confidentiality and giving freedom to withdraw from the study at any time (Schrock 1991). Some limitations of the study are acknowledged. As the researcher was also the participants’ tutor, they may have felt obliged to participate, although a number of steps were taken to avoid the potential adverse effects of this relationship. These included considering the participants’ rights as outlined above, as well as providing assurance that their participation was voluntary, being reminded that they could withdraw from the study at any time and being assured that their decision to participate or not would in no way affect their course work. A second limitation was, that the presence of and note-taking by the researcher might have influenced student nurse–older person interactions. A third limitation was that, it was impossible to note all of the interactions during participant observation, so only the main elements were written up as field notes. A final limitation was the length of time for data collections
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(38 h), had the study been extended it is possible that more data would have been elicited.
The findings Four themes were identified from the data. These are: • Types of communication; • Modes of communication; • Factors which hinder or enhance student nurse–older person communication; • The student nurses’ approaches to communicating with the older person. Theme 1: Types of communication This has two main categories, namely ‘task’ and ‘non-task’ related student nurse–older person communication. These include both verbal and non-verbal modes of communication. To a certain degree, the manner in which nursing care was organised in this unit determined the type of communication. In general much of the communication in the mornings was task related (e.g., assisting the patients with their meals and personal hygiene) with some non-task related communication occurring whilst the students attended to nursing care activities. One student stated We talked to them but you wouldn’t have time to sit down on the bed and have a conversation, you’d be doing something at the same time, like putting them to bed. . . you’d be talking away. . . did you watch this last night or did you sleep ok, but then when you’ve finished your task you have to go and do the next room. . .. However, in the afternoon, there was a change of emphasis in relation to nursing care activities and the students were engaged in more non-task related communication with the patients. Topics such as the patients’ hobbies, likes, dislikes, families and favourite TV programmes were also discussed. As one student said Once you have the. . . initial morning stuff done. . . you sit down and . . . they’d start
22 Nurse Education Today (2003) 23, 19–26
to tell you about what happened and about the family and like, problems like that. . .
Theme 2: Modes of communication This can be divided into two categories, verbal and non-verbal. However, neither was used independently of the other. Effective communication as defined by one of the students, has both verbal and non-verbal components, I suppose it’s a combination, balancing it out between actually talking, verbal communication, listening communication, touch communication. . . Students identified understanding and being understood as being important. One student stated: You might have to talk louder. . . and it would have to be clearer as well ‘cause. . . if you’re talking too fast. . . they mightn’t understand. . . Many of the verbal skills used were questioning, listening, encouraging, praising and instructing with some less effective skills such as leading and blocking as well. Important non-verbal skills identified were: being at eye level, eye contact, facial expressions and the use of appropriate touch to both physically and psychologically support the older person. One student stated Touch can be good. . . just let them know you’re there and supportive of their problems. . .
Theme 3: Factors which either hinder or enhance student nurse–older person communication The factors which hindered communication included physical and psychological difficulties associated with ageing, ward routine (including lack of time), misunderstandings, distractions, lack of knowledge and certain subject matters such as death. The quality of the older person’s memory especially if they were confused posed
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Student nurse–older person communication
some difficulties with regard to effective communication, as the following incident illustrates She has absolutely no concept of where she is or the time or who we are. . . that’s very, very difficult and I find it hard to communicate with her. . . I try to smile and keep everything positive. Certain factors associated with the ward routine were clearly identified by the students as hindering effective communication, e.g., getting the job done, being busy, a ‘heavy’ ward and lack of time. One student felt there was no time to provide extra attention or care for the older person. There was only time to attend to essential nursing care, this the student referred to as no French polishing. Factors, which were identified as enhancing communication included the use of communication aids, spending time and developing a relationship with the older person, using games to motivate, encouraging, persevering, having a laugh and how communicative the older person was. There was more time in the afternoon for students to communicate with the older people. The following statement illustrates this In the afternoon you had a nice bit of time. . . just to chat away. The more communicative an older person was, the more likely the students were to engage in conversation, as the following statements demonstrate I suppose in a way you would talk to the chatty people more. It’s easier to communicate with people that are going to talk back to you. Although, interestingly some of the students also suggested that the level of dependence of the older person determined the length of time and likelihood of communicating with them. Students were more likely to spend time with the more dependent older person, attending to their physical needs. This presented opportunities for the student to engage in conversation
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Anyone who couldn’t feed themselves or couldn’t wash themselves. . . you’d be talking to them more because you’d be with them more. However, this communication was likely to be task related if the student was attending to the older person’s physical needs.
Theme 4: Student nurses’ approach to communication with the older person This theme has four sub-categories. The first sub-category, student assumptions about how one should communicate with the older person, included having respect, being honest and caring, showing interest, motivating, encouraging, having a rapport and building upon this rapport. Quite a number of the students felt that one should have respect for older people regardless of their level of physical and/or psychological dependence. This is illustrated in the following statements Even though. . . they’re confused and you might be doing everything for them. . . they’re still adults. . . and you have to respect them because they’re older than you. The second sub-category, student assumptions about older people, in part, influence their approach to communication. These assumptions ranged from believing that older people love to talk, were lonely, demotivated, lacked autonomy and the notion that older people could be demanding and manipulative. Some of the students felt that older people had no control over their lives and that this affected their desire and/or ability to communicate, e.g., They’ve lost their self control. . . they’ve lost choice. Vast institutionalisation. . . they just adapt to everything being done for them. Although, in contrast, a number of the students felt that older people could be attention seeking and manipulative, as the following statements illustrate
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They do take advantage when you’re a student. A lot of them are cute. . . they know if I’m going to get away with this I will. The third sub-category, student assumptions about the registered staff nurses included the notions that most were caring, did the best they could but were too busy to talk to the older people and that for some the routine nature of the care provided, adversely affected their ability to communicate effectively with the older people. The manner in which many of the students communicated with the older people was both negatively and positively influenced by their observation of the RGNs’ behaviour towards and communication with the older person. The following statements illustrate this influence By watching them and how they communicated. . . I definitely learnt from it. . . she’d always be very caring. . . I just learnt a lot from her. . . The staff are there. . . quite a while. . . they get into that routine and they don’t see. . . extra things to be done. . . so used to doing things you forget to. . . explain something to the patient. . . The fourth sub-category, student views on how one should protect one’s self, included the notion that one needed to protect one’s self-emotionally, e.g., You come to work and you leave your personal life outside. . . you have to distance yourself. . . I don’t think I would have lasted this long otherwise. Furthermore, students sometimes used blocking techniques when older people began discussing perceived difficult topics such as death and dying.
Discussion This section discusses the study’s findings and links the identified themes with relevant literature. A number of issues are discussed, namely the meaning of communication, communicating with cognitively impaired older adults, intergenerational issues and
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learning to communicate with older people in the clinical area. It is suggested that the routinised and task-orientated approach to patient care within the continuing care unit adversely affected student nurse–older person communication. Communication was not seen as a priority. Issues such as student autonomy and empowerment, providing older people with choice in relation to their care and the predominance of the curative model in continuing care units warrant attention within the context of care provision (Nolan & Grant 1993). In recent years, the notion of person centred care has become increasingly popular (McCormack & Wright 1999). Therefore, a change in the philosophy and culture of the continuing care unit may have benefits for patient care and this change in focus may promote effective nurse–older person communication. However, there are a number of challenges to changing the philosophy and practices of a routine, task-orientated approach to patient care. These include recognition and a desire by staff for such a change and identification of ways in which such change could be realised. The development of a therapeutic nurse–patient relationship is considered essential to the provision of effective nursing care (Johns 1995; Barber 1997). Kitson (1991, p. 69) states that ‘therapeutic action comprises both emotional and personal interaction as well as the use of knowledge and skills’. The study’s findings indicate that the students understood communication to be a means of providing emotional support, developing a rapport and building a relationship with the older people. Therefore, it is suggested that attempts were made by the students to develop therapeutic relationships with the older people. According to Fulmer and Abraham (1998) cognitive impairment can range from mild confusion to profound dementia. The study’s findings indicate that various factors influenced the amount and type of communication that the students had with cognitively impaired older people. While a number of difficulties were highlighted, many of the students felt that it was important for the older person’s well being to have respect and ‘be there’ for them regardless of their cognitive
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Student nurse–older person communication
impairment. It is suggested that a change to person centred approach to care of the older person would be of particular benefit to cognitively impaired older people as this approach to patient care recognises that all people (regardless of cognitive ability) have rights (Dewing 1999). The study’s findings highlight how intergenerational issues may be a barrier to effective nurse–older person communication. The students had a number of assumptions about older people. This highlights the dangers of ageism, stereotyping and viewing older people as a homogenous group. However, overall the students seemed to have positive attitudes to older people and in general valued them. Integral to this study’s findings is how student nurses learn to communicate with older people. It is suggested that role modelling by Registered General Nurses is central to student learning within the clinical area. According to Davies (1993, p. 628) clinical role modelling can be seen ‘as a primary source of learning from experience, it may enable students to discover knowledge in clinical practice’. The students had a number of assumptions about Registered General Nurses and their views and behaviour toward older people. These had both positive and negative influences on student nurses’ approach to communicating with older people. This highlights the relevance and importance of issues such as clinical role modelling, clinical supervision, preceptorship, reflective practice and auditing of clinical placements.
Conclusion The purpose of this study is to ascertain how student nurses communicate with older people. There are relatively few studies undertaken which specifically explore this area. In view of current and future nursing care needs of an ageing population and the benefits of effective communication for patient well-being, this study’s findings are relevant. It is acknowledged that this is a small study and it may be suggested that its findings cannot be generalised. Nonetheless, through discussion of the findings in conjunction with current literature, a number of recommendations for
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improving student nurse–older person communication are proposed. These are: • Practice development within the continuing care unit, to facilitate change to a person centred approach to patient care. • Increased theoretical education on interpersonal skills, to occur in the second year of the diploma programme. • The need for preceptors who will facilitate student learning in the clinical area and who will provide clinical supervision of student nurse–older person communication. • Regular auditing of the clinical placement as a suitable learning environment, to be a collaborative approach with representatives from both clinical and education services. • Increased facilitation of reflective practice, whilst the students are on clinical placement.
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