Communication Behaviors in Nursing Homes in South-East Iran: An Ethnographic Study.

BACKGROUND: Because of the increasing number of the elderly, the need for care in aged nursing homes (NHs) is increasing. As a cultural perspective toward care is new, it is very important to understand the communication behavior of the elderly in various cultures. This study aimed to explore the communication behaviors among the elderly in NHs in Kerman, Iran.
MATERIALS AND METHODS: This ethnographic focused study was conducted on 25 staff members and 8 residents in two NHs in 2015. Data were collected through observation of the participants, field notes, and semi-structured deep interviews in Kerman. Cuba and Lincoln method was used to ensure the trustworthiness of the data. The collected data were analyzed through content analysis.
RESULTS: By analyzing primary codes, 3 categories and 8 subcategories were extracted through content analysis including fluctuation in communication (task-oriented communication, avoidance of communication, and establishment of effective communication), artificial collaboration (fake friendships, jealousy, and its consequences, and cooperation in concealing error), and lack of collaboration among team members (fragmented teamwork, extreme working conditions, and physical burnout among the elderly).
CONCLUSIONS: The results of this study indicate that communication problems between caregivers and the elderly are high. Thus, it is necessary that people who care for elderly indiviuals are trained regarding special communication strategies and skills, and they are not influenced by fatigue and burnout resulting from caring.

Introduction

Improvement of life conditions, longevity, and life expectancy are the leading factors in a phenomenon called aging.[1] At present, over 7 million (9%) of the Iranian population are 65 years of age and over.[12] Although paying attention to the quality of life (QOL) of the aging population is generally considered to be challenging and important, those living in aged nursing homes (NHs) should be prioritized.[34] Tension resulting from presence in an unfamiliar environment, distance from family, NHs rules, reduction in physical activity, increased dependency on others, and lack of love and affection are factors that lead to deprivation of communication with others in the elderly.[5] Useful communication skills can help nurses reduce the tension.[6]

The most important strategy for overcoming such challenges and providing high-quality care is to communicate appropriately.[7] Communication has become more important in recent years and has become an essential part of nursing care.[8] Communication is defined as the process of information transfer through a variety of verbal and non-verbal behaviors among individuals and is the basis of all social relationships.[9] Such values, opinions, and cultures among the elderly differ from other societies and groups of people.[10] Therefore, appropriate communication is the cornerstone of nursing care. Furthermore, in the Islamic culture of Iran, the aging population has a special position. So far, a great deal of research has investigated nurses' communication with older people in various caring settings around the world. Studies conducted in the US and Sweden showed that caregivers had poor verbal communication with the elderly living in NHs. If appropriate communication is not established, or the elderly's needs are not met, their social services processes will be disturbed, and thus, they will become unwilling to cooperate.[11]

Chan et al., in their study, reported that nurses at NHs are more concerned about their routines than talking to the elderly.[12] In another study, poor communication skills of nurses such as talking fast, lack of eye contact, and lack of communication knowledge and information, which lead to the incapability of answering the elderly's questions, are barriers to appropriate communication.[10] In Iran, however, little research has been done on communication with the residents of NHs.[13] Elderly care is a burdensome task, and caregivers face many problems in establishing appropriate communication with the elderly in a way to maintain respect and their dignity. Moreover, misconduct and unsuitable communication methods in the NHs are prevented. Therefore, it is important to study and identify the problems of the elderly in the field of communication. Few studies have been performed on the communication problems of Iranian elderly individuals.[13] Therefore, the aim of the present study was to explore the communication behavior of caregivers with elderly individuals living in NHs.

Materials and Methods

This study was based on focused ethnography, which is a qualitative research approach. Focus ethnography is appropriate for studying unidentified areas. It reveals the inner attitudes of people and reflects professional behaviors in the culture, beliefs, norms, and perceptions of groups.[14] Ethnography provides the means to determine cultural sensitivities among nurses.[15] An ethnographer attempts to create a detailed understanding of the conditions of people under study.[16] The participants of this study consisted of 25 personnel and 18 elderly individuals (10 men and 8 women) without cognitive diseases (about 70% of residents under long-term care). The 25 personnel included two female administrators (a female social worker, a female psychologist) and 21 caregivers [three female nurses and 18 nursing assistants (nine men and nine women)], with an average work experience of 6 to 7 years. Furthermore, the elderly participants had been living in two semi-private male and female wards of NHs in Kerman, southern Iran, for 2 months to 7 years. Each NH had 100 beds and about 43 elderly residents (a total about of 86 individuals). The demographic characteristics of participants included in this study are shown in Table 1.

Table 1

Demographic characteristics of the participant

Participants’ role	Participant’s age range (year)	Gender	Work experience (year)	Education level
Administrators (n=2)	35-42	Females	3-5	Master’s degree
Nurses (n=3)	25-62	Females		Bachelor’s degree
Nursing assistants (n=18)	22-42	Females (n=9) Males (n=9)	6-7	Elementary education (n=10), High school diploma (n=7), and Master’s degree (n=1)
Social workers (n=1)	32	Female	5	Master’s degree
Psychologist (n=1)	30	Female	5	Master’s degree
Elderly individuals (n=18)	65-85	Females (n=10) Males (n=8)		Illiterate-Elementary Reading and writing ability

Data were collected through participant observation, semi-structured interviews, and field notes from April to August 2015. The study lasted 18 months. First, the researcher met the administrators of the two NHs, and after explaining the aims of the study, invited the caregivers to participate in the study. Informed written consent was obtained from all the participants. In the present study, according to the different situations and conditions experienced by the researcher, the four methods of complete observer, partial participant, observer as participant, and complete participant were used. The researcher used a variety of observation methods. Observations were performed directly by the first author who followed and observed the staff of the two studied wards. On the basis of the Spradley's approach (1980), three types of observations were made in this study: descriptive, focused, and selective observations. Combinations of these three kinds of observations helped the researcher find rich and accurate data. Before the observations, descriptive, structural, and contrast questions were considered, and participative observations were conducted accordingly. First, descriptive questions (general questions) were asked, and descriptive observation was shown accordingly. The goal of this type of observation was to collect general data concerning the culture of communication behaviors among the caregivers and elderly individuals in the studied NHs.[16] The research followed the activities of the staff regarding their communication caring behaviors such as the emotional expressions of respondents such as laughter, silence, and tone. The emic and etic approaches were implemented for data collection. The main researcher of this study did not work as a staff member in a NH. She entered the study as an outsider, and she was not well-informed about the research setting of the NHs. The observations lasted from 15 to 40 min and took 720 h a year. Observations were carried out during 1 year in the morning, afternoon, and evening shifts. To resolve bias, the researcher first recorded all the observations without any changes. Then, she controlled all the results through the confirmation of the participants. Interviews were conducted to complete the data collected from the observations. The managers and caregivers of the NHs were interviewed as key participants. The semi-structured interviews conducted in NHs took between 30 and 60 min. First, interviews were conducted informally to gain the participants' trust, and then, were formally proceeded during the participant observations. The interviews were began with general questions about the participants' experiences regarding their communication with the elderly. Some of these questions were as follows:

The question asked from staff: What are your experiences and attitudes regarding communication with older people?

The question asked from elderly participants: How do the personnel behave toward you? Could you please give me an example?

Data were analyzed using the MAXQDA software (VERBI GmbH, Berlin, Germany). The qualitative data were explained by conventional qualitative content analysis and on the basis of Graneheim and Lundman's approach (2004). Content analysis can be performed with various degrees of interpretation. The ethnographic content analysis is used to document and understand the communication of meaning, as well as to verify theoretical relation-ships.[17] The researchers adopted a qualitative content analysis method to extract and summarize the real meaning of participants' experiences of the experiential concept of communication with the elderly.

They stated that in each text, there are manifest messages versus latent messages; however, both messages require interpretations that may vary in depth and level of abstraction.[18] First, the text was read several times to understand the core content. Then, it was divided into meaning units. The participants' experiences, interviews and observations, and explicit and implicit concepts were specified in the form of words, and then, compressed. The compressed meaning units were labeled with codes at a low level of abstraction, and finally, the removed codes were categorized depending on their differences or similarities. The data reduction continued until all the categories and themes were developed. In this study, data saturation was achieved after interviewing and long-term observations of all the participants. An example of the process of analysis is shown in Table 2.

Table 2

Example of qualitative content analysis process

Category	Subcategory	Codes	Condensed meaning unit	Meaning unit
Fluctuation in communication	Task-oriented communication	Communication within the framework of daily tasks; communication during nursing practices; the attention of caregivers to routine care; inadequate communication because of the multiple responsibilities; busy; lack of communication in caring according to the job description, non-educational behavior communication of staffs, staff’s lack of response to the elderly’s requests	Communication only within the framework of daily job description	Staff’s communication based on their routine duty
			Insufficient communication because of the multiple responsibilities	Caregivers’ lack of ongoing communication with the elderly because of their multiple responsibilities

The validity and reliability of the results were ensured through the determination of credibility, confirmability, dependability, and transferability.[19] To increase the credibility of the study, data were peer checked and member checked by three participants. Furthermore, they were externally checked by a specialist in qualitative studies to ensure the accuracy of coding. The method of time integration was used to ensure the validity of data collection and comparative data prolonged for 2 years. Thus, sampling was performed three times a day in the morning, afternoon, and evening. Dependability was ensured through field notes collection. Transferability was ensured through interviews with different participants.

Ethical consideration

This study was approved by the Ethics Committee of Kerman University of Medical Sciences, Iran (No.IR. Kmu.REC.1395.561). Informed written consent, confidentiality, and anonymity forms were filled out by the participants. In addition, the participants were given the right of withdrawal at any time. Before observation and interview, the purpose of the study was explained to all the participants. Written and oral informed consent was obtained from all elderly participants. They consented to the observation and recording of their behavior.

Results

The age of study participants ranged from 22 to 85 years. The participants consisted of two administrators, three nurses, one social worker, one psychologist (woman), 18 nursing assistants (nine women and nine men), and 18 elderly individuals (ten men and eight women). The main findings of this study illustrated three types of communication behaviors including fluctuation in communication, artificial collaboration, and lack of unity among team members. These three categories and eight subcategories are presented in Table 3. The three categories and eight subcategories are explained in the following sections.

Table 3

Results of data analysis: [A main class (communication behaviors in NHs), three categories, and eight subcategories form communication behaviors in NHs]

Category	Subcategory
Fluctuation in communication	Task-oriented communication
	Avoidance of communication
	Somewhat effective communication
Artificial collaboration	Fake friendship, jealousy, and its consequences
	Cooperation in concealing error
Lack of unity among team members	Fragmented teamwork
	Extreme working conditions
	Physical burnout among the elderly

Fluctuation in communication

Because inconsistency was observed in the communication among nurses, caregivers, and rehabilitation team members, and among the personnel and elderly individuals, three themes including fluctuation in communication, inter-personnel behavior pattern, and communication barriers were formed in this study.

Task-oriented communication

In this kind of communication, nurses communicate with the elderly when they are performing routine tasks and nursing cares. This kind of communication seems to be poor and formal and is only established while the caregivers perform their responsibilities. The present study observations and interviews highlighted the fact that most staff members performed this behavior according to formal task. This is a missed opportunity because effective communication is associated with a higher QOL.

“…Our communication with the elderly is within the framework of our job. We are so busy with multiple affairs and responsibilities that we do not have an ongoing relationship with them” (NA 5).

“As this group of elderly individuals suffer from severe Alzheimer's or do not have any communication with others, we can do nothing for them (the psychologist).”

Old caregivers treat the elderly better and with more respect than younger caregivers.

“…An old man was walking with a stick in the lounge. A young NA bumped into him while passing him quickly and the old man fell down. While helping the man to stand up, an old caregiver warned the new caregiver of his behavior, expecting him to apologize to the old man. But he did not care about what he had done and left the scene just looking at them. The old caregiver said: “the young generation seems to view the elderly as statues in a showcase." He left without an apology…!” (Observation).

Avoidance of communication

One reason that makes the staff avoid communication with elderly individuals is their repetitive and boring questions.

“At first, caregivers answered their questions kindly and calmly, but after repeating the same questions a couple of times they were unwilling to reply (observation).”

“Due to their limited ability to communicate, the elderly were often isolated. The personnel were willing to communicate with those who were good at verbal communication. Loud conversations in the NH were very common, as though they were used to them, and therefore, it made others protest (observation).”

However, speaking loudly, especially to the elderly, is not considered respectful in our culture. “…I would like to talk to the nurses, but they do not listen to me (Elderly no. 3).”

Establishing effective communication

All participants emphasized that communicating with the elderly is an inevitable aspect of greeted them when they enter NH, and this is the first indication of communication in the Iranian Islamic culture. “We try to accept whatever they request for. If an elderly is talking, let him finish what he is saying… (Nurse 2).”

Moreover, participants emphasized hugging, embracing, and kissing for those of the same gender because, in the Iranian culture, it is not common for people of opposite gender to touch each other to show love or friendship.

In the female NH, the facial hair of elderly woman was threaded by women monthly. “They talked with older women, even older people with Alzheimer's laughed with them (observation).”

Artificial collaboration

The relationship among personnel can be a significant factor in meeting the mental and physical needs of older people. In this study, according to the participants' statements in their interviews, the following two types of relationships were obtained.

Fake friendship, jealousy, and the consequences

Despite false claims by some personnel, insincere friendships were reported by a group of participants. Despite the cooperation and friendship that helped advance things, participants often had hidden layers. “Once I forgot to give an elderly individual medicine because there were a large number of them. One of the caregivers, who claimed to be a close friend, reported it to the person in charge of the center. They are very jealous of people who do a lot of work (N 6).”

Cooperation in concealing error

Unlike the previously mentioned aspect of relationship, sometimes personnel cover each other's faults and mistakes, which lead to some unfavorable results for the elderly. Here, there are two examples of such conduct.

“They do not receive a good salary, so if there is negligence in their care, I will tell themselves, rather than the center director. Thus, the same errors are continued and it just gets worse for us … (Social worker).”

“In spite of camera surveillance, some personnel do not take full responsibility, or at times speak angrily with the elderly. However, we ignore their behavior because they have been working here for a long time … (Administrator 1).”

Lack of unity among team members

A correct form of communication between the staff and elderly, particularly those with dementia, was not always easy because of the stereotypes regarding these residents. The care team members did not cooperate with one another in tasks that required teamwork and assessed the elderly independently; none of them performed their function accurately. According to the staff's point of view, lack of unity among team members includes fragmented teamwork, extreme working conditions, and physical burnout of older people.

Fragmented teamwork

There was no unity and consistency among caregivers, which resulted in insufficient information exchange. This was because nurses, caregivers, and the doctor of the center assessed the residents' situation separately, and nurses were often absent during the examination.

“The doctor prescribes the medicines in his/her room, and then, we check them. I wish “we, nurses, along with the doctor and caregivers could follow the care and treatment procedure together (nurse 3).”

Extreme working conditions

The barriers to effective communication reported by nurses include busy workplace, heavy workload, and lack of motivation to communicate. “There are 6 elderly individuals in a 4-bed room… Due to the imbalance between the number of personnel and elderly, we do not have enough time to communicate with them… (NA 12).”

“If you are not patient enough, you cannot stay here for even 2 months because you might be easily irritated due to problems such as the nonstop shouting of the elderly with Alzheimer's disease (Nurse 1).”

Regarding beneficial communication, an elderly participant stated: “One of the nurses showed good behavior toward us. he talked to use with a happy attitude. he looked at us with a smile on his face. Above all, he called us with our surnames or the word Mr.”

Physical burnout among the elderly

In the present study, caregivers believed that factors such as forgetfulness and memory loss, hearing impairment and hearing aid use, inability to speak and visual impairment, social isolation, and medication side effects affecting the speech of elderly patients also lead to the disruption of communication. “… An elderly resident came to me, and began to speak through sign language; I did not understand what he was speaking about. He has been talking through sign language for many years, I have never understood him. I wish we had a speech-language pathologist so that we could understand his speech (Nurse 3).”

Discussion

The results revealed that one of the evident manifestations of communication between the staff and elderly individuals was a task-based relationship. The results of a study conducted in Norway showed that most nurses, who provide physical care, are only in contact with elderly patients during the treatment period and avoid talking to them about themselves. This is in contradiction with values such as working together, convincing the personnel to interact with the elderly, and a positive relationship between nurses and elderly patients.[20] Another study reported that after entering the NHs, because of the caregivers' unwillingness to communicate, some of the elderly residents were not able to make important decisions for their life, which led to hopelessness and frustration as well as poor well-being.[21] One reason for some caregivers utilization of a task-based relationship as a protective and defensive mechanism versus an emotional mechanism is that the caregivers felt that they did not receive the support necessary to motivate them to communicate and interact with the elderly.[22] Factors such as daily routines, lack of time, and a sense of a need to maintain a gap between themselves and their elderly patients are considered as barriers to effective communication between nurses and the elderly.[23] Williams and Bower found that patient-nurse interactions are superficial and are according to the routines and duty.[7]

In most cases, the only opportunity that a nurse and a patient have to communicate or interact is when the nurse is performing his/her duty. Consequently, they cannot improve their relationship.[22] It should be noted that at the beginning of being admitted to a NH, all elderly individuals experience such lack of communication especially the newly admitted individuals.[23] Unfortunately, nurses and caregivers only take a 3-day training course before starting their duty at NHs, which does not seem sufficient. It necessitates teaching communication skills to personnel regarding how to treat newcomers. Need-oriented educational intervention is an efficient, harmless, inexpensive, and low-cost method for improving the general health of the elderly living in NHs.[24] In another study, the researchers remarked: “More attention should be paid to improve health communication through shifting toward student-centered approaches in nursing curriculum."[25]

The most frequently mentioned problem by caregivers was related to understanding the elderly's requests. As the elderly who were deaf or had hearing impairment could not buy hearing aids, they were not able to communicate well with nurses or caregivers, and as a result, nurses could not understand what they wanted to say.

Yektatalab et al. reported that inappropriate communication or insufficient interaction is likely to affect care in NHs.[26] The findings of this study described the establishing of effective communication. Furthermore, it was observed that such behaviors are shaped by communication between caregivers and the elderly. A study in Iran showed that nurses used emotional behaviors such as non-verbal communication and verbal communication.[3] Accordingly, the relationships among the personnel had a positive or negative effect on communication behavior with the elderly residents of NHs. Personal and demographic characteristics of NH personnel are determinant factors of communication with the elderly.[27] Cleary et al. stated that there is a negative relationship between jealousy and group cohesion/consistency.[28] The present study revealed that the patterns of communication in the care culture in NHs were the disruption of teamwork. Despite the importance of teamwork, this study found that the position of teamwork in caring for the elderly in NHs is weak. Understanding the improvement of interprofessional teamwork is a useful first step in care. In a study that investigated teamwork in NHs in Sweden, trust was the basis for decision-making about the quality of care provided for the elderly.[29]

An ethnographic study investigated teamwork in two NHs in the US, one NH showed that positive teamwork and high team spirit, regarding the elderly's rights and trust, had a positive effect on the care process. However, in the other NH, because of the teamwork disruption, the elderly could not be cared for effectively, leading to their confusion and inconsistency in the care process.[30] Furthermore, it was revealed that lack of caregivers and insufficient time affected the care process. The high workload of nurses and their subsequent fatigue, directly or indirectly affected the relationship and level of communication with the elderly.[31] The present ethnographic study is introduced as a unique study regarding communication behaviors, methodology, and its results. It seems that it has been able to reveal the hidden and observable cultural components of care in NHs.

The present study had some limitations, for example, the application of the results of this research is limited to the culture of communication in non-private Iranian NHs. We did not allocate our study to private NHs (for-profit NHs) because of the different structure and styles of management. However, our sampling from among the elderly residents of non-private NHs helped us further explore this phenomenon.

Conclusion

Regarding the research findings and the physical and mental vulnerability of the elderly, the existence of communication problems in the care of the elderly leads to deficiency of teamwork and reduction in the quality of care and causes various problems such as negligence of caregivers toward the elderly. Although respect and communication with the elderly are emphasized in the Iranian culture, it is recommended that other studies be conducted to find specific and effective strategies for communication with this group of elderly individuals so that they may benefit from the results of planning and education for caregivers. Moreover, communication strategies of the elderly can also be used by caregivers. The study revealed that communication behaviors used in the work environment are the major factors in providing holistic care. However, the findings revealed that this factor is not appropriate enough in NHs in Iran to lead to holistic care, and Iranian NH personnel tends to carry out their routine tasks. The present study may encourage the development of new communication behaviors in NHs in Iran.

Financial support and sponsorship

Kerman University of Medical Sciences

Conflicts of interest

Nothing to declare.