Communication in Elderly Care

Cross-Cultural Perspectives

Peter Backhaus

• Publisher: Continuum
• Year: 2011
• ISBN:
  9780826433985
• Edition: 1
• Topic: Languages & Linguistics
• Subtopic: Linguistic Semantics
• Index: Languages & Linguistics

The topic of communication in elderly care is becoming ever more pressing, with an aging world population and burgeoning numbers of people needing care. This book looks at this critical but underanalyzed area. It examines the way people talk to each other in eldercare settings from an interdisciplinary and globally cross-cultural perspective. The small body of available research points to eldercare communication taking place with its own specific conditions and contexts. Often, there is the presence of various mental/physical ailments on the part of the care receivers, scarcity of time, resources and/or flexibility on the part of the care givers, and a mutual necessity of providing/receiving assistance with intimate personal activities. The book combines theory and practice, with linguistically informed analysis of real-life interaction in eldercare settings across the world. Each chapter closes with a "Practical Recommendations" section that contains suggestions on how communication in eldercare can be improved. This book is an important and timely publication that will appeal to researchers and carers alike.

Chapter 1

Elderspeak in Institutional Care for Older Adults

Kristine N. Williams

Introduction

Communication is of critical importance to residents of elder care institutions, such as nursing homes, as a means to maintain both a connection with other persons and a sense of self (Buron 2008). The importance of social relationships is described in Maslow’s hierarchy of needs which places the human need for affiliation second only to survival and safety (Maslow 1954). “Successful aging” is defined not only as physical and functional health, but also as high cognitive functioning and involvement with society (Rowe and Kahn 1997). Active engagement with others through productive activity and interpersonal relationships is necessary to realize functional capacities and achieve successful aging.

Nursing home (NH) communication has long been characterized as insufficient in both quantity and quality by residents and social scientists alike (Buron 2008; Grau et al. 1995; Lubinski 1995; Nussbaum 1991). Research has demonstrated that limited staff-resident communication focuses on care tasks instead of personal concerns, is controlling, and ultimately encourages dependency (Baltes and Wahl 1996; Carpiac-Claver and Levy-Storms 2007; Grainger 1995; Iwasiw and Olson 1995; Levy-Storms 2008; Williams et al. 2005). Correspondingly, NH residents who engage in interpersonal communication and relationships with staff tend to live longer (Kiely et al. 2000), and residents themselves report that communication with staff is an aspect of care that is highly valued (Grau et al. 1995).

Research has established that communication training for NH staff improves institutional communication (Levy-Storms 2008; Williams et al. 2003; Williams 2006). McGilton and colleagues (2003) report that such training increases positive interactions and results in relationship-promoting communication during care, whereas Burgio and colleagues (2002) have documented increased positive statements from certified nursing assistants after training as well as reductions in ineffective communication. NH residents themselves have reported improved staff nonverbal communication and increased personal (versus task-focused) messages after the staff underwent communication training (Medvene et al. 2006; van Weert et al. 2005).

Quality of care, it has been shown, also increases after NH staff communication training (Levy-Storms 2008). Other studies report that NH residents even experienced reduced anxiety and increased satisfaction with care after staff training and that staff stress was also reduced (Finnema et al. 2005; Grosch et al. 2008). Furthermore, staff use of individualized communication care plans succeeded not only in increasing resident engagement in sustained and meaningful conversations with staff (Acton et al. 2007), the training has also reduced agitation and other problem behaviors in residents with dementia (Burgio et al. 2002; McCallion et al. 1999; Roth et al. 2002).

One prevalent and problematic speech style used by NH staff is called elderspeak. Elderspeak is a common intergenerational speech style used by younger persons in communication with older adults in a variety of community and health care settings. Based on negative stereotypes of older adults as less competent communicators, younger speakers (in this case NH staff) modify their communication with NH residents by simplifying the vocabulary and grammar and by adding clarifications such as repetitions and altered prosody, resulting in changes in affective messages within dimensions of care, respect, and control. Intended to show a caring attitude and improve communication, staff elderspeak communication actually sounds like baby-talk and may lead to negative outcomes. This paper provides an overview of the current knowledge of elderspeak, its characteristics and prevalence across institutional care settings in the United States, and the negative outcomes associated with elderspeak use by NH staff. It starts with a brief general overview of institutional care for older adults in the United States and will demonstrate why staff training to overcome elderspeak is an effective means to improve the quality of NH care.

Institutional Care for Older Adults in the United States

The population of older adults continues to grow in the United States and reflects the expansion of the aging population in other developed countries and around the world. The number of persons over 65 years of age increased by 13% from 1998 to 2008, growing by 4.5 million to reach 38.9 million. Currently, one in eight U.S. citizens is 65 years of age or older. As life expectancy continues to increase, the older adult population is projected to increase from 40 million in 2010 to 55 million by 2020, a 36% increase (Administration on Aging 2010).

In 2008, approximately 1.6 million (4.1%) of older Americans lived in institutional care settings where they needed support in performing activities of daily living (ADLs): bathing, using the toilet, dressing, eating, etc. The majority (1.4 million) of these individuals resided in NH facilities. The typical resident of a NH in the United States requires assistance with 3.75 ADLs (Lawton and Brody 1969; NCAL 2001). Alternative residential care facilities developed more recently include assisted living that serves older adults who need lower levels of support. Assisted living currently serves approximately 1 million older adults, a population expected to double in the next decade (Mollica and Johnson-Lemarche 2005; NCAL 2007). Other senior citizen housing options include congregate senior apartments that serve approximately 2.4% of older adults and provide at least one supportive service such as meals (Administration on Aging 2010).

Care for older adults in NHs and other facilities is institutionally regimented and results in a loss of control and autonomy when making everyday decisions (Gubrium 1975; Hayley et al. 1996). In addition, traditional health care provider-patient relationships reflect an imbalance of power in which older adults assume the sick role. Most NH residents are primarily cared for by certified nursing assistants. These paraprofessionals have limited education and training in elderly care, especially in meeting psychosocial needs. Many come from educational and socio-economic backgrounds that are different from those of nursing home residents. Staffing shortages and high turnover rates make work in a NH physically and emotionally demanding and stressful (Cohen-Mansfield 1995). Changes in federal and state licensure regulations have been enacted to improve the quality of NH care prompting a culture change that has been adopted to make NH care more resident-centered and less task-oriented and institutional (White et al. 2008). Training staff to reduce elderspeak is one approach to improve staff-resident communication.

Elderspeak

Elderspeak is a speech style commonly used by younger adults interacting with older adults and occurs across societies and cultures (Backhaus 2009; de Bot and Makoni 2005; Grainger 1993; Kihlgren et al. 1994). Elderspeak, or “secondary baby talk,” was first characterized by Caporael (1981), who found that it made up 20% of staff-resident interactions in NHs. She identified the slower speaking rate, exaggerated intonation, elevated pitch and volume, greater repetition, simpler vocabulary, and reduced grammatical complexity as being typical of elderspeak. Another aspect of intergenerational speech common to institutions is overly directive or overbearing talk, frequently referred to as patronizing speech (Ryan et al. 1991). Both overly directive and overly nurturing communication occur frequently as forms of elderspeak and may negatively influence the lives of older adults residing in NHs. Characteristic features of elderspeak include over-simplification and clarification strategies and alterations in emotional tone, and they all imply incompetence on the part of the listener (Ryan, Hummert and Boich 1995). Simplification of syntax includes reductions in the length of sentences, number of embedded verb clauses, and grammatical complexity and is reflected in both the vocabulary used by a younger person or care staff member and the density of the ideas communicated to an older adult. Repetitions and altered prosody are attempts to clarify speech. This includes paraphrasing or word-for-word repetition of communication content as well as the high pitch and intonation characteristics of “ ‘baby talk.” Other characteristic features of elderspeak include the use of diminutives, tag questions, and collective pronouns. Diminutives include terms of endearment such as “good girl,” “honey,” and “dear” and imply parent-child dynamics. The use of collective pronouns when the singular form is grammatically correct implies that the older adult cannot act alone. For example, “Do we want to go back to our room now?” Tag questions, such as “You want to get dressed now, don’t you?” appear to offer a choice to the listener. However, the implication is that the speaker had to guide the listener to select the appropriate response. These characteristic features of elderspeak all imply indirectly that the listener is incompetent and dependent.

Other significant characteristics of elderspeak are modifications in nonverbal communication such as prosody, gaze, facial expression, proximity, and gestures (Ryan et al.1994). They too significantly alter the underlying emotional or affective messages in communication within dimensions of care, respect, and control. In fact, nursing staff may add diminutives (terms of endearment) and other verbal and nonverbal features of elderspeak to soften the underlying messages of control typical in institutional care; the message itself varies depending on the words (and voice tone and other nonverbal behaviors). For example, the controlling message “You need to get in your room [pointing]” may be softened by elderspeak as follows: “Come on honey [diminutive], we’ll [collective versus individual pronoun] find our [collective pronoun] room down by the potty [childish reference].” The overly caring tone overcomes the message of control. However, this results in an overly nurturing, infantilizing message.

Alteration in emotional tone is a qualitative aspect of elderspeak that reflects an imbalance of care and control (Hummert and Ryan 1996). Normal adult speech exemplifies affirming emotional tone, indicating that the older adult is competent to comprehend the message and act independently. In contrast, elderspeak implies a lack of competence on behalf of the listener, requiring the speaker to assist or direct the conversational partner. Patronizing messages can be classified as overly nurturing, reflecting high care and low control, or directive, reflecting a high degree of control and little caring (Hummert et al. 1998).

The following is a transcript of a typical conversation illustrating the modified communication of elderspeak. It was recorded during a research study in which a NH certified nurse assistant speaks with a resident during morning care (Williams 2001). This example includes simplified vocabulary and childish reference to the resident:

Jenny . . . Where’s your legs? . . . Hangin’ off the bed girl . . .

hanging off the bed . . . Hey Jenny . . . You’re zonked this

morning aren’t ya girlie? . . . . . . Sound asleep.

The Communication Predicament of Aging

Communication Accommodation Theory (Giles et al. 1991) describes how conversational partners modify speech during social interactions. Participants in conversation universally accommodate, or modify, their speech and language in order to match or minimize differences with the person with whom they are communicating. Accommodation has been observed in a variety of populations including persons of differing native tongues as well as intergenerational dyads. Over- and under-accommodation occur when one person misunderstands the needs of the communication partner or alters communication purposefully for therapeutic goals. For older adults, consequences of positive accommodation are important in achieving social support and in receiving information that they can comprehend from medical practitioners. However, over-accommodation may encourage dependent behavior and the assumption of the role of a patient.

The Communication Predicament of Aging Model (Ryan et al. 1986) applies Communication Accommodation Theory specifically to the world of older adults. In this model, the younger communication partner recognizes visual or other clues as to the advanced age of the conversational partner. This triggers stereotypical ideas about older adults as a group being less competent communicators (Hummert et al. 1994). In addition, older adults are perceived to have sharply declining abilities, dependency needs, and a desire to disengage. Because of these stereotypes, of which the younger adult may not be aware, younger partners alter their speech to meet the assumed needs of the older person. Alterations may include limiting content to safe topics, speaking louder and in shorter sentences, using simplistic vocabulary, as well as emphasizing and repeating key words.

The older adult receiving this message may recognize these changes and may adopt a self-concept consistent with his or her own negative stereotype of older adults, thus enacting a self-fulfilling prophecy of being old and feeling old. In order to avoid further reminders of this negative identity, older adults may avoid interacting with younger adults who provide these messages. Repeated exposure to elderspeak may contribute to decreased self-esteem and depression, withdrawal from further social encounters, and the assumption of behaviors consistent with negative stereotypes of aging (Rodin and Langer 1980). This predicament is part of a negative feedback loop that affects future communication encounters. Persons with obvious physical or cognitive disabilities frequently receive patronizing talk (Hummert 1994; Kemper et al. 1998), and those in environments suggesting dependency, such as in institutions, trigger more speech accommodations than older adults in community settings (Hummert et al. 1998). If persons outside the communication dyad observe a patronizing interaction, they may assume that the older adult benefits from the accommodations. In their future interactions with that older person, they may accordingly employ elderspeak. In effect, elderspeak is thus reinforced, and the recipient of elderspeak may, in the worst cases, even be blamed for its occurrence.

From an interpersonal perspective, elderspeak fails to acknowledge the older adult as an independent actor and indicates that he or she is not a worthy communication partner. Specifically, the metamessage may reflect: (i) “indifference”—that is, denying the existence of the partner; (ii) “imperviousness”—that is, denying the validity of the partner’s experiences; or (iii) “disqualification”—that is, denying the significance of the other (Cissna and Siebert 1981). The relational message in elderspeak may insult the self-concept of the older adult.

The communication enhancement model (Ryan, Meredith, et al. 1995) provides a guide for appropriate communication that modifies speech as needed while avoiding over-accommodations. Prior to employing speech modifications, an individual assessment is made of the older adults’ communication abilities and limitations. Only accommodations determined necessary to achieve successful staff-resident communication are employed and abilities of the individual older adult are reinforced. For example, limiting complex and abstract sentences may be needed to overcome language and cognitive changes in per...

Table of contents

• Cover
• Title
• 1 Elderspeak in Institutional Care for Older Adults
• 2 Dementia Care Communication in Residential Facilities: Intersections of Training and Research
• 3 Creating a Positive Communication Environment in Long-Term Care
• 4 Care of People with Alzheimer’s Disease in New Zealand: Supporting the Telling of Life Stories
• 5 From Home to Institution: Roles, Relations, and the Loss of Autonomy in the Care of Old People in Denmark
• 6 Cake or Meat?—A Case Study on Dinner Conversations in a Migrant-in-the-Family Household in Germany
• 7 “Me Nurse, You Resident”: Institutional Role-Play in a Japanese Caring Facility
• 8 Reframing to Regain Identity with Humor: What Conversations with Friends Suggest for Communication in Elderly Care
• 9 At the Intersection of Art, Alzheimer’s Disease, and Discourse: Talk in the Surround of Paintings
• 10 Using Narrative Arts to Foster Personhood in Dementia
• Notes on Contributors
• Index