Towards a Conversion of the Nursing Communication Paradigm: A View from the Analysis of Actual Nurse-Elderly Interactions

We have conducted a series of studies on communication between nurses and elderly patients in geriatric facilities in Japan. The average speech duration per day for elderly people in nursing homes was roughly 4 minutes. The reason for such a short speech duration was that 76% of the nurses’ communication content was composed of “type I” communication (“task-oriented” communication) and that “type II” communication (“life-worldly” communication) made up for only 24% of the total. We also analyzed the ways in which “type I” communication constrained spontaneous speech by the elderly whereas “type II” communication tended to promote and encourage it. This article, based on the findings obtained from our research, aims to encourage reconsideration and advancement in the research of nursing communication.


Introduction
This paper, based on a brief review of the previous literature on nurse-patient communication, introduces the findings obtained from our research and aims to encourage reconsideration of the research and practice of nursing communication.
One such problem is a lack in the amount of verbal communication at the nursing site [4][5][6]. For example, Armstrong-Esther and Browne [7,8] observed that the amount of verbal communication is very small, except for routine nursing activities: in 52% of nursing encounters with patients, nurses had no interaction with them. Nolan et al. found that while nurses recognized that communication with patients was of utmost priority, the amount of communication in the actual nursing setting was very small [9].
Another problem relates to the quality of nurse-patient communication. Especially with regard to communication between nurses and the elderly, the contents of communication are superficial, elderly utterances are controlled by nurses, one-way (one-sided) conversation is overwhelmingly prevalent, and the use of baby talk (such as how one talks to a child) is frequent [9][10][11][12]. In addition, while the above problems and challenges that nurses face in clinical settings have been reported in previous literature, we have also noted some problems with regard to the ways in which the previous studies have been conducted.
First, many of the previous studies have been done through the observation of specific types of care activities, such as dietary assistance, and thus the full extent of the communication in a wide range of different nursing activities has not necessarily been the focus of the studies.
advancing nursing communication research, three stages of research on the communication between caregivers and elderly residents. First, we started by investigating conversation content and time of day by tape recording and transcribing conversations between elderly and facility nursing care staff [15].
Then, based on the findings revealed by this research, we developed an educational intervention program to improve the communication of nurses, and examined its effectiveness [16]. Third, we examined the influence of educational intervention programs on the language of the staff, and clarified the mechanisms of communication between the care providers and the elderly, from the viewpoint of "interaction" with each other [17,18]. What follow are some details of the stages of our study.
• The aim of the first research stage was to clarify the actual situation concerning verbal communication between caregivers and elderly residents. The subjects were 37 elderly residents in general hospital recuperation wards and 34 elderly residents in public aid nursing homes. The study method involved analysing the types of verbal communication and utterances by caregivers and the elderly, with the duration and frequency of the communication measured. The observation period lasted from 9:00 am to 5:00 pm. Factors affecting caregiver and elderly resident utterances were then evaluated. In this stage of research, the two types of communication between the two parties were identified: type I (instrumental speech/communication related to staff nursing tasks) and type II (life-worldly speech/communication related to elderly life) [15]. • The second stage research was designed and developed as an education intervention (lecture and group discussion) with the aim of making caregivers aware of the need for Type II communication with the elderly, and to discover practical measures for increasing Type II communication after such education intervention. The subjects were the 240 nurses who had the possibility of being assigned to work with any of the 37 elderly people from the 3 general hospital recuperation wards. The educational intervention in this study comprised of a lecture (30 minutes) on the importance of Type II communication, and a group discussion (60 minutes) based on 'Critical Reflection', for a total of 90 minutes conducted once at each surveyed facility. The group discussions focused on the current state of verbal communication by caregivers, the background to the current communication situation, and improvement measures for increasing Type II communication. In order to evaluate the effect of the educational intervention, measurement of the type and quantity of verbal communication was performed for a full day at each facility before the intervention, 1 week after the intervention, and 3 months after the intervention. The observation period lasted from 9:00 am to 5:00 pm. To assess reproducibility, the measurements were repeated three times [16]. • The aim of the third stage of research was to (a) examine the effect of educational intervention on the frequency and duration of all utterances and self-initiated utterances by elderly residents prior to the educational intervention, and (b) to examine the structural mechanisms of Type II speech through comparing the characteristics of Type I and Type II communication. The subjects of the survey were 37 elderly people in the general hospital recuperation wards of 3 facilities, which were the subject of the second survey. In researching, we used statistical analysis to understand the changes in speech content and duration of elderly residents before and after the educational intervention of nurses.
Conversational analysis was used for analyzing the structural mechanisms of communication [17,18].
Details of the results of the three research stages are as follows. The average speech duration of the elderly patients was 247.4 sec (SD 171.06) in one day, or roughly about 4 minutes. Table 1 shows the speech duration broken down by minutes, with the total duration of speech being less than 5 minutes for 70% of individuals. For 18.9% of the individuals, the total duration of speech was less than 1 minutehighlighting the troubling speech situation of elderly residents currently living in geriatric care facilities in Japan, and the situation that we will face when we become older.    As shown in Table 2, when comparing the time that the staff spoke to individuals in different types of facilities, the mean time was 1084 seconds in general hospital recuperation wards and 1391 seconds in public aid nursing homes, with the latter being significantly higher. Thus, the more medically dependent the elderly people were, the less the staff spoke to them.  Types of communication between caregivers and elderly residents were extracted using content analysis. As shown in Table 3, communication between them was categorized into 2 types. The first type of communication, making up to 76% of the total, was task oriented communication, which includes talking based on various nursing or caregiving responsibilities to elicit daily living activities from the elderly, labeled here as "type I" communication. The most common type of type I communication, at 44%, was talking to prompt an action from an elderly person, such as "Okay, open your mouth and swallow, " or "Grab a hold of that. " Next was speech that is always addressed to patients or elderly persons when caregivers are providing some type of care.  This is when the staff tells an elderly person what they intend to do, or when they want the elderly person to understand what they are doing, such as, "I'm going to wipe your back a bit, " or "Okay, I'm going to push the wheelchair. " This type of speech accounted for 23% of the total. The next type is speech attempting to assess or explain the physical status of the elderly person, such as, "You are a little red here, " or "Does this hurt?" Temperature measurement is a good example of this type of speech.
This type of speech made up to 16% of the total. Another type of type I communication, which consisted of up to 10% of the total, is speech to confirm the requests or wishes of the elderly individual, such as, "Are you hungry?" or "Is your room too hot?". Warnings to patients made up 4%such as, "Be careful, the tea is hot, " or "There is a step here". Miscellaneous speech made up to 3%.
The second type of communication, labeled here as "type II", was "life-worldly communication", related to conversations about family, work, or social events that occur normally in social interactions. These made up to 24% of the total. The most common of type II communication, at 30%, was speech related to social events such as newspaper or television news on, for example, elections or sport events. The next most common type II communication, at 29%, was speech for stabilizing the patient's psychological state, such as, "Would you wait a bit for the meal?", and for verifying knowledge, such as "What is this flower?" or "Have you seen this before?". Greetings, such as "Good morning" or "Nice weather, isn't it?" made up 12% of the total, while speech about life experiences were at 8%. These includes conversations about the elderly person's past job or cooking recipes. Miscellaneous speech made up to 21% of the total.
With a view to examining what type of interactions occur in type I and type II communication, we used conversation analysis to analyze the actual interactions that occurred between nurses and patients. Conversation analysis is an analytical method based on ethnomethodology. Garfinkel describes ethnomethodology as the study of "the methods" used when various activities or behaviors are performed routinely and naturally by "people (ethno-)" in society to achieve intersubjectivity or social order [19]. Conversation analysis is an attempt to elucidate linguistic interactions, as well as the order and mechanisms of behavior and activities that we perform through those interactions, by studying detailed transcripts from audio/visual recordings [20]. Table 4 shows examples of type I and type II communication when assisting a patient in taking a bath. The characteristics of the interactions in type I communication, as shown in the left part of Table  4, were analyzed from 3 different aspects: (1) characteristics of speech sequence and order assignment, (2) characteristics of conversation content, and (3) characteristics of speech length. All of the caregiver's speaking turns of speech, for example, in lines 1, 3, 5, and 7 were initiated on her own initiative. In contrast, all the utterances of the resident, in lines 2, 4, and 6 are replies to the caregiver.
In other words, they are all produced as the second-pair parts of adjacency pairs prompted by the caregiver's speech. Thus, self-initiated utterances by the resident are entirely absent. With regard to the characteristics of the content of this conversation, as in, "I'll wipe your back a bit" and "Okay? Can you turn to the side?", the speech from the staff is a prompt to the elderly person so that the caregiver can perform a specific work task, such as wiping the individual's back. In most cases, the elderly person then responds by acknowledging the caregiver's speech (line 2, line 15) and in doing what the caregiver asked.  From the above analysis, the characteristics of type I communication is as follows: The caregiver obtains information from the patient in relation to the caregiver's task, and therefore, the purpose of this communication is to enable the caregiver to perform his or her task. Since the caregiver requests cooperation from the patient by bringing up a conversation topic with the use of closed questions and leads the conversation, the elderly person's speaking is limited to short utterances, and his or her spontaneous speech is not observed.
The right part of Table 4 is an excerpt of type II communication. In this case, the elderly person had been working in agriculture for many years. First, the staff begins the conversation with "The taro roots aren't ready yet?" The elderly person replies, "They're just about ready. " However, in line 4, the staff replies with a "Yeah, " and since the next turn to speak has not been taken, the elderly person spontaneously begins speaking with "I was wondering if they were ready this year. " Then, the elderly person is able to lead the conversation: "Because a lot of rain fell", "my son is now engrossed in picking mushrooms, " and "Going picking mushrooms. " In this way, the staff treats the elderly person as a storyteller by providing a topic related to the life of the elderly person, the topic of taro roots, and by receiving the elderly person's speech with interest by laughing and agreeing, "That's right:: There was a lot of rain, wasn't there::?", and "Ahahahahahaha mushrooms? Haha::".
The characteristics of type II communication are the following: presenting the elderly person with a topic that relates to their own lifeworld can expand the opportunities for the elderly person to speak and, by showing interests and agreement, expand the elderly's speech into an expanded narrative, resulting in prompting the elderly person to speak spontaneously. The results obtained from the conversation analysis were also verified using statistical analysis.
As shown in Figure 2, the relationship between the caregiver's type I speech duration and elderly utterance duration was r=0.44, but the relation between the caregiver's type II speech duration and elderly utterance duration was r=0.58. Therefore, Type II speech is better at encouraging an elderly person to speak. Thus, it was found that type II communication could promote elderly speech more than type 1 communication. To this end, we conducted an educational intervention aimed at increasing type II communication amongst caregivers.  Table 5 shows a comparison of type II communication before and after the intervention to examine its effects. The results showed that the amount of time in type I speech significantly decreased in the 3 months following the intervention compared to the amount of time prior to the intervention. In contrast, the amount of time in type II speech significantly increased 1 week after the intervention to 390.1 seconds, compared to 226.5 seconds prior to the intervention. While type II speech slightly decreased after 3 months, it was still higher than it had been, and therefore we concluded that educating the staff significantly increased type II communication.   [16]]. Table 6 shows the effect of educational interventions on the duration and frequency of elderly utterances. The total amount of time that elderly people spoke increased to a mean of 304.41 seconds from 208.23 seconds, but a significant difference was not observed. However, an approximate 2-fold increase in Type II speech time and production frequency was observed. Therefore, the educational intervention was believed to have been effective in increasing the time the staff spoke to the elderly and in the amount speech from elderly persons.   [17]].
Finally, we examined the reasons behind why Type I communication was the main form of speech in actual nursing practice. Table 7 shows some reasons for this. As a result of the content analysis, 3 such factors were identified. The first is the high burden of work and the unrelenting work environment; the second is the lack of awareness and skills towards Type II communication; and the third is, most importantly in relation to this article, that Type II communication is not taken seriously as an integral and constitutive part of nursing per se. However, we believe that a way of communication that takes into consideration the inherent meaning communication holds for human needs should be explored when examining nursing communication for the elderly, especially for those who have no choice but to live in institutions for a prolonged period and for those in the final stages of life. Figure 4, shows a diagram of Maslow's hierarchy of needs, and is something which all nurses are familiar with [32].
From our research findings, the needs that a nurse emphasizes with type I communication are the physiological and safety needs, while type II communication corresponds to the higher-order needs of belonging, esteem, and self-actualization. The fact that approximately 80% of nursing communication is that of type I may suggest that nurses are not completely responding to the social needs that patients have as human beings, with nurses being unable to depart from the medical treatment model. Person-centered communication and therapeutic communication are believed to be very important for preventing disease and restoring health.
However, for elderly persons, residents of long-term facilities, patients with end-stage disease, and pediatric patients, communication that further enriches an individual's social life as a human being must be taken into serious consideration. A lack of such types of communication can cause a decline in the sense of person as a social being as well as mental and physiological functions, particularly in elderly people. Nursing, therefore, should provide living support based on a broader definition of health and nursing as physical, emotional, and social well-being.
We believe that it is necessary to convert the purpose of communication into health support in a broader sense, as evident from WHO's definition of health ("Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity") [33]. In order to enrich the remaining days of the elderly and of people in the final stage of their life, it is of utmost importance to offer them opportunities to engage in communication that enables these people to lead a normal daily life as a social, autonomous being. In short, communication is important not only as a means of satisfying narrowly conceived nursing needs, but also as a means of satisfying the social needs of patients as human being with dignity.