Issues and innovations in nursing practice
Non-verbal behaviour in nursing care
which interfere with developing social contact. Because of declining physical function, a lower income and a de- creasing social network, elderly people may have little social contact. For people depending on care, a situation may develop in which the elderly person is mainly reliant on nurses who deliver nursing care (Nesbitt-Blondis & Jackson 1978, Arnold & Boggs 1995, Staab & Hodges 1996). This means that, apart from the fact that nurses need good communication skills to assess the patients' needs and to provide care that is tailored to the individual, there is also a need for communication to create good interpersonal relationships in which there is room for socializing, affection and empathy. These communication aspects can be expressed verbally or non-verbally. However, most authors agree that non-verbal behaviour is an essential method to convey warmth, love and support (Bensing There are numerous aspects of non-verbal communica- tion. In this study we are interested in non-verbal behav- iour that is important for the establishment of the nurse patient relationship. Heintzman et al. (1993) describe ve non-verbal behaviours which were found to be essential in a person's attempt to build rapport with another person: eyegaze, af rmative head nodding, smiling, body posi- tioning and touch. Eyegaze behaviour Eyegaze takes a special place in non-verbal communica- tion. In western cultures, gaze is a positive value in communication between people: listeners are expected to look at the speaker, and speakers look at the listeners to check whether the information is understood (Collier 1985). Eibl-Eibesfeldt (1972, 1971) and Von Cranach (1971) consider eyegaze to be a signal for readiness to initiate interaction with others. Maintaining moderate to high levels of direct eye contact conveys a sense of interest in the person with whom one is communicating. Con- versely, averting one's eyes while talking with someone can damage the rapport-building because it is interpreted as expressing disinterest, detachment and dislike (Heintz- man et al. 1993). To express warmth and empathy the nurse needs to make eye contact with the patient. Apart from that, the amount of patient-directed gaze in uences the patient's share of talking. Bensing et al. (1995) showed that the duration of the general practitioner's gaze was related to the duration of patient speaking time about psycho-social health problems. Moreover, eye contact at appropriate levels has been shown to contribute positively to another's perceptions of an individual's competence and credibility (Heintzman et al. 1993, Burgoon 1994). et al. 1995, Mehrabian 1981, Strecher 1983, Roter & Hall 1992). Mehrabian (1981) even states that non-verbal com- munication is the pre-eminent mode to build rapport with other people. Non-verbal communication includes all forms of com- munication that do not involve the spoken word (Greene et al. 1994). Perception of non-verbal communication involves all the senses, including hearing used on the verbal level to detect vocal characteristics of the spoken word (Sundeen et al. 1989). Non-verbal communication becomes important when elderly people develop hearing problems that affect their verbal communication ability. Touch is increasingly important in visually impaired people. Most research into nurses' interaction with elderly patients is still directed towards verbal communication. When attention is paid to non-verbal behaviour, most of the time the study is con ned to one non-verbal aspect such as, for instance, touch. As a part of a larger study of nurse patient communication (Caris-Verhallen et al. 1997a, b), this paper investigates how nurses use a number of non-verbal behaviours in interaction with elderly people. The relationship of non-verbal to verbal commu- nication was also studied. Af rmative head nodding Af rmative head nods do have an obvious social function. Schabracq (1987) distinguishes three functions in af rma- tive head nods: (1) regulation of the interaction, especially changing turns in speaking; (2) support of spoken lan- guage; and (3) comment upon the interaction concerning the rapport and the content of the communication. For instance, nodding to af rm what was said and nodding while listening, to convey interest (Anderson 1985, Me- hrabian 1972). The nurse's head nods encourage the client to tell their story (Caris 1997) In addition, people who use af rmative head nods frequently are considered as more friendly and more concerned (Heintzman et al. 1993). The role of non-verbal communication in the nursing process Human communication, especially face-to-face communi- cation, is largely non-verbal. Gross (1990) stated that the non-verbal component of communication comprises 55 97% of the message communicated. Non-verbal communication has different functions. Smiling Argyle (1972) contends that non-verbal communica- tion: Smiling may be one of the most important characteristics of a nurse who wishes to establish good rapport with patients (Schabracq 1987; Heintzman et al. 1993). Smiling is positively judged by other people and is considered as a sign of good humour, warmth and immediacy (Mehrabian 1972, Reece & Whitman 1962). _ conveys interpersonal attitudes and emotional states; _ supports or contradicts the verbal communication; and _ functions as a substitute for language, if speech is impossible. 809 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 W.M.C.M. Caris-Verhallen et al. Body positioning 3 Are the non-verbal behaviours related to the setting (home nursing vs. home for the elderly) and the type of care provided? A person's body positioning may indicate if he is listen- ing, attending and involved (Von Cranach 1971, Gross 1990). Leaning forward is a way of showing awareness and immediacy. During the interaction with another person it clearly suggests interest in that person (Heintzman et al. 1993, Schabracq 1987). Forward leaning is also a sign of attention (Rosenfeld 1978). In earlier research Reece & Whitman (1962) showed that leaning forward conveys warmth and friendliness. Forward leaning combined with smiling, eye contact and verbal attentiveness (`hm-hm') communicates an attitude of involvement. This behaviour stimulates the other person to continue talking (Reece & Whitman 1962, Caris 1997). To answer these questions, observations were made of videotaped nurse patient communication. Based on one of the functions of non-verbal behaviour, the support of verbal communication, it is expected that affective verbal communication and the affective non-verbal communica- tion categories will be related to each other. As the two care settings differ in character and their patients' age, gender and level of independence (Caris- Verhallen et al. 1997b), one could assume differences in nurses non-verbal behaviour. In the home for the elderly, the residents, although living in separate rooms, make up part of a ward on which nursing care continues through- out the day. Nurse patient communication patterns re ect a daily routine in nursing (Nystro m & Segesten 1996). Apart from communication related to the delivered care, there is more time for socializing than in the community where the elderly live independently and each nursing visit has an explicit start and nish. Touch Touch is a very important aspect in building rapport and establishing a relationship. Touch has also the potential to convey affection, care and comfort (McCann & McKenna 1993, De Wever 1977). Following Watson (1975), in research into the effect of touch in the nurse patient interaction touch is divided into two categories, `instru- mental touch' and `affective' or `expressive' touch. Instru- mental touch is de ned as deliberate physical contact necessary to perform a task, e.g. to dress a wound or to take a pulse. Expressive touch is relatively spontaneous and affective, and is not necessary for the completion of a task (Le May & Redfern 1987, Oliver & Redfern 1991, McCann & McKenna 1993). In nursing, the latter type of touch is used seldom compared with instrumental touch (Routasalo 1996, Le May & Redfern 1987, McCann & McKenna 1993). Moore & Gilbert (1995) showed that residents of a home for the elderly experienced more immediacy and affection from nurses who used expressive touch than from nurses who did not. Hollinger (1986) found a relationship between nurses' touch and the verbal responses of the hospitalized elderly during the nurse patient interactions. Furthermore, there is some evidence that the relation- ship between nurse and elderly patient in institutional care is different from the nurse patient relationship in home care. Some researchers describe this relationship in institutional care as strongly reciprocal, intimate and even mimicking a family bond (Sumaya-Smith 1995, Nystro m & Segesten 1996). Based on this literature, one might expect that nurses would display a great deal of non-verbal behaviour, which is an essential mode for conveying affection, love and support (Strecher 1983, Mehrabian 1972). Although, in the community, nurse patient rela- tionships can be also very intimate and reciprocal, the major objective of a home visit in the community is to deliver nursing care. Earlier research into verbal behav- iour in these settings (Caris-Verhallen et al. 1997b) showed that the interactions in home nursing are less familiar than in institutional care. This could be connect- ed with a low level of non-verbal behaviour. THE STUDY As regards the different types of nursing care, it is expected that nurses will display more non-verbal behav- iour during psycho-social care than during personal hygiene and technical nursing care. Psycho-social care requires empathy and concern, which are conveyed par- ticularly by non-verbal communication. Aim of the study and research questions The aim of the current study was to investigate non-verbal communication in nursing care for the elderly. The study used a descriptive design and has been carried out in the community and in a home for the elderly in The Netherlands. More speci cally, three research questions guided this study: MATERIALS AND METHODS Data collection 1 To what extent do nurses display non-verbal commu- nication, in particular eyegaze direction, af rmative head nodding, smiling, forward leaning and touch? In order to meet the research objectives real nurse patient interactions were videotaped, during the delivery of nursing care. Each encounter was videotaped entirely using a manned camera, focusing on the nurse and the 2 How are non-verbal behaviours related to the verbal communication of nurses? 810 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 Issues and innovations in nursing practice Non-verbal behaviour in nursing care patient, except in the case of nursing activities where the patient was undressed. In such cases the video camera was focused on the nurse only, or when that was impos- sible only verbal communication was recorded. A few days prior to the data collection, nurses informed their patients about the research, and asked them to give informed written consent to participate. Very sick pa- tients, patients suffering from dementia and terminally ill patients were excluded from participation. In the com- munity very few patients refused consent. In the home for the elderly, half the 60 residents who were asked to participate agreed. Nurses did not systematically inform us about those patients who did not want to co-operate, but they reported that there was no clear difference between participant and non-participant residents. received nursing care for a long period (mean 37 months). Twenty-eight patients were residents in a home for the elderly. These patients were older than the patients in the community. Their mean age was 86 7 years. On average, they lived about 5 5 years in the home for the elderly. These two groups of patients can be considered repre- sentative samples of the populations of patients in the community and in homes for the elderly, with regard to age and gender (CBS 1995, Delnoij et al. 1996). The two groups differed from each other in respect of age, gender and mean duration of nursing care received (see Table 2). Observation scheme The observation scheme is directed at non-verbal and verbal communication. Nurses Table 2 Distribution of age, sex and duration of receiving nursing care of patients who took part in the study (n = 109) Forty-seven nurses of different grades took part in this study. The nurses were not a random sample, but nurses who were going to participate in a training in communi- cation skills. Twenty-four nurses worked in an organiza- tion for home nursing and provided nursing care in the community. Twenty-three nurses provided care in a home for the elderly. Each nurse was followed during part of the day in which, on average, four encounters with patients were recorded. The two groups did not differ signi cantly with respect to age, gender, education and years of experience (see Table 1). Patients in the community Patients in the home for elderly Patients' characteristics Mean SD Mean SD Gender Women 65% 89% Men 35% 11% Mean age 77 5 (8 7)** 86 7 (4 4) Subjective health 2 0 (0 4)** 2 3 (0 4) Mean duration Patients of received Nursing care in 37 (43 6)* 70 (77 2) One hundred and nine patients agreed to participate in the study. Together they participated in 181 recorded nursing encounters. Eighty-one patients lived in the community; mean age 77 5 years. Most of the patientsin the community months * Signi cance level of P 0 05. ** Signi cance level of P 0 01. Table 1 Distribution of different characteristics of nurses participating in the study (n = 47) Nurses in the community (n = 24) Nurses in a home for the elderly (n = 23) Provider variables Mean SD Mean SD Genderb Women 100% 91% Men 9% 37 4 (9 3) 40 9 (8 7) Mean agea Educational level1b Nurses 46% 35% Auxiliary nurses 54% 65% Years of employmenta 16 5 (8 8) 15 9 (7 2) 1 Nurses = Dutch higher professional education level, HBO or 3 5 years of in-service training. Auxiliary nurses = Dutch secondary professional education level, MBO or 2 5 years of in-service training. a Differences in age and amount of experience were tested by means of t-tests and were not signi cant. b Differences in gender and education level were tested by means of a chi-square tests and were not signi cant. 811 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 W.M.C.M. Caris-Verhallen et al. Non-verbal communication _ Affective communication, which provides information about the extent to which the nurse shows verbal attentiveness, concern, empathy and sympathy with the patient. The observation scheme contains six non-verbal catego- ries: patient-directed gaze, af rmative head nods, smiling, forward leaning and instrumental and affective touch. In fact, instrumental touch does not play a role in building rapport, but because this kind of touch is inherent in nursing it has to be observed to distinguish it from affective touch. _ Communication that structures the encounter, involves utterances that indicate guidance and direction such as orientating and instructing, requests for clari cation, asking for understanding and asking for opinion. _ Communication about nursing and health, which con- _ Patient-directed gaze is de ned as the nurse looking at tains all items with respect to nursing, medical or therapeutic topics. the face of the patient. _ Head nods are de ned as nodding one or more times as _ Communication about lifestyle and feeling, which a sign of attentiveness in conversation or as reinforcing the spoken word (Mehrabian 1972, Anderson 1985). contains all verbal expressions with respect to lifestyle issues and emotional topics. _ Smiling in this context is de ned as an utterance of friendliness. Laughing out loud, on the other hand, in response to a joke is not considered as non-verbal communication; it is coded in the verbal part of the observation scheme. Reliability of the observations The video recordings were observed systematically by two observers using the CAMERA computer system (Iec Pro- GAMMA 1994), which is especially designed for coding behavioural interactions from video recordings. _ Forward leaning is de ned as posture which involves bending towards or sitting closer to the patient when this is not necessary to carry out the nursing tasks. This position conveys involvement and a concentrated focus on the interaction partner (Heintzman et al. 1993). With respect to the non-verbal behaviours, both dura- tion and frequencies of the variables were recorded. In this study duration was used. Ten of the contacts were coded by each of the two observers in order to calculate the inter- rater reliability of the non-verbal behaviours. Pearson's R _ Affective touch is relatively spontaneous and affective, and not necessary for the completion of a task (Le May & Redfern 1987). An example is a nurse who puts an arm around the shoulder of a distressed patient. proved to be between 0 70 and 0 98. Cohen's Kappa was used to calculate the inter-observer reliability of the ve verbal communication categories. This statistical procedure corrects for agreement based on chance and is particularly suitable for observations coded in exclusive categories (Hollenbeck 1978). A kappa coef cient can range from A1 to +1 and a value of _ Instrumental touch is deliberate physical contact, which is necessary in performing the nursing task. An example is touch while dressing a wound. The duration of all six non-verbal categories was recorded. The type of nursing care was also coded, using Kerkstra & Vorst-Thijssen (1991), as a point of departure. We discerned three types of encounters: encounters dom- inated by personal hygiene care, encounters principally involving technical nursing procedures and encounters which were dominated by psycho-social care. 0 60 indicates an acceptable level of reliability (Cichetti 1984). Cohen's Kappa in our study varied between 0 74 and 0 81. Following Henbest & Fehrsen (1992), who noted that scoring only a part of a consultation could be as reliable as scoring an entire consultation, preliminary observations with observation periods of 5 min, 10 min and the total length were carried out during 48 encounters. As 10-min observation periods proved to be very reliable compared with the observation of the total length (non-verbal com- munication between 0 61 and 0 92 and verbal communi- cation between 0 80 and 0 93, Pearson's R), observation time was standardized and the rst 10 min were observed of each of the 181 nursing encounters. Verbal communication In order to observe the verbal communication of the nurses, an adapted version of Roter's Interaction Analysis System (RIAS) was used (Roter 1989). Using this system all utterances in patient and nurse dialogue are coded in separate and non-overlapping scoring categories. RIAS discerns socio-emotional and instrumental communica- tion. Within these two categories we de ned in an earlier study ve clusters, based on Correspondence Analysis (Caris-Verhallen et al. 1997b): Analyses In order to answer the rst research question, we specify the amount of nurses' non-verbal communication during the nursing encounters. Proportional scores were used. The recorded time spans of `eyegaze direction', `forward leaning', `affective touch' and `instrumental touch' were _ Social communication, which provides information about the degree to which the nurse uses social conversation that has no particular function in nursing activities, such as personal statements, banter, jokes and small talk. 812 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818
Non-verbal behaviour in nursing care
which interfere with developing social contact. Because of declining physical function, a lower income and a de- creasing social network, elderly people may have little social contact. For people depending on care, a situation may develop in which the elderly person is mainly reliant on nurses who deliver nursing care (Nesbitt-Blondis & Jackson 1978, Arnold & Boggs 1995, Staab & Hodges 1996). This means that, apart from the fact that nurses need good communication skills to assess the patients' needs and to provide care that is tailored to the individual, there is also a need for communication to create good interpersonal relationships in which there is room for socializing, affection and empathy. These communication aspects can be expressed verbally or non-verbally. However, most authors agree that non-verbal behaviour is an essential method to convey warmth, love and support (Bensing There are numerous aspects of non-verbal communica- tion. In this study we are interested in non-verbal behav- iour that is important for the establishment of the nurse patient relationship. Heintzman et al. (1993) describe ve non-verbal behaviours which were found to be essential in a person's attempt to build rapport with another person: eyegaze, af rmative head nodding, smiling, body posi- tioning and touch. Eyegaze behaviour Eyegaze takes a special place in non-verbal communica- tion. In western cultures, gaze is a positive value in communication between people: listeners are expected to look at the speaker, and speakers look at the listeners to check whether the information is understood (Collier 1985). Eibl-Eibesfeldt (1972, 1971) and Von Cranach (1971) consider eyegaze to be a signal for readiness to initiate interaction with others. Maintaining moderate to high levels of direct eye contact conveys a sense of interest in the person with whom one is communicating. Con- versely, averting one's eyes while talking with someone can damage the rapport-building because it is interpreted as expressing disinterest, detachment and dislike (Heintz- man et al. 1993). To express warmth and empathy the nurse needs to make eye contact with the patient. Apart from that, the amount of patient-directed gaze in uences the patient's share of talking. Bensing et al. (1995) showed that the duration of the general practitioner's gaze was related to the duration of patient speaking time about psycho-social health problems. Moreover, eye contact at appropriate levels has been shown to contribute positively to another's perceptions of an individual's competence and credibility (Heintzman et al. 1993, Burgoon 1994). et al. 1995, Mehrabian 1981, Strecher 1983, Roter & Hall 1992). Mehrabian (1981) even states that non-verbal com- munication is the pre-eminent mode to build rapport with other people. Non-verbal communication includes all forms of com- munication that do not involve the spoken word (Greene et al. 1994). Perception of non-verbal communication involves all the senses, including hearing used on the verbal level to detect vocal characteristics of the spoken word (Sundeen et al. 1989). Non-verbal communication becomes important when elderly people develop hearing problems that affect their verbal communication ability. Touch is increasingly important in visually impaired people. Most research into nurses' interaction with elderly patients is still directed towards verbal communication. When attention is paid to non-verbal behaviour, most of the time the study is con ned to one non-verbal aspect such as, for instance, touch. As a part of a larger study of nurse patient communication (Caris-Verhallen et al. 1997a, b), this paper investigates how nurses use a number of non-verbal behaviours in interaction with elderly people. The relationship of non-verbal to verbal commu- nication was also studied. Af rmative head nodding Af rmative head nods do have an obvious social function. Schabracq (1987) distinguishes three functions in af rma- tive head nods: (1) regulation of the interaction, especially changing turns in speaking; (2) support of spoken lan- guage; and (3) comment upon the interaction concerning the rapport and the content of the communication. For instance, nodding to af rm what was said and nodding while listening, to convey interest (Anderson 1985, Me- hrabian 1972). The nurse's head nods encourage the client to tell their story (Caris 1997) In addition, people who use af rmative head nods frequently are considered as more friendly and more concerned (Heintzman et al. 1993). The role of non-verbal communication in the nursing process Human communication, especially face-to-face communi- cation, is largely non-verbal. Gross (1990) stated that the non-verbal component of communication comprises 55 97% of the message communicated. Non-verbal communication has different functions. Smiling Argyle (1972) contends that non-verbal communica- tion: Smiling may be one of the most important characteristics of a nurse who wishes to establish good rapport with patients (Schabracq 1987; Heintzman et al. 1993). Smiling is positively judged by other people and is considered as a sign of good humour, warmth and immediacy (Mehrabian 1972, Reece & Whitman 1962). _ conveys interpersonal attitudes and emotional states; _ supports or contradicts the verbal communication; and _ functions as a substitute for language, if speech is impossible. 809 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 W.M.C.M. Caris-Verhallen et al. Body positioning 3 Are the non-verbal behaviours related to the setting (home nursing vs. home for the elderly) and the type of care provided? A person's body positioning may indicate if he is listen- ing, attending and involved (Von Cranach 1971, Gross 1990). Leaning forward is a way of showing awareness and immediacy. During the interaction with another person it clearly suggests interest in that person (Heintzman et al. 1993, Schabracq 1987). Forward leaning is also a sign of attention (Rosenfeld 1978). In earlier research Reece & Whitman (1962) showed that leaning forward conveys warmth and friendliness. Forward leaning combined with smiling, eye contact and verbal attentiveness (`hm-hm') communicates an attitude of involvement. This behaviour stimulates the other person to continue talking (Reece & Whitman 1962, Caris 1997). To answer these questions, observations were made of videotaped nurse patient communication. Based on one of the functions of non-verbal behaviour, the support of verbal communication, it is expected that affective verbal communication and the affective non-verbal communica- tion categories will be related to each other. As the two care settings differ in character and their patients' age, gender and level of independence (Caris- Verhallen et al. 1997b), one could assume differences in nurses non-verbal behaviour. In the home for the elderly, the residents, although living in separate rooms, make up part of a ward on which nursing care continues through- out the day. Nurse patient communication patterns re ect a daily routine in nursing (Nystro m & Segesten 1996). Apart from communication related to the delivered care, there is more time for socializing than in the community where the elderly live independently and each nursing visit has an explicit start and nish. Touch Touch is a very important aspect in building rapport and establishing a relationship. Touch has also the potential to convey affection, care and comfort (McCann & McKenna 1993, De Wever 1977). Following Watson (1975), in research into the effect of touch in the nurse patient interaction touch is divided into two categories, `instru- mental touch' and `affective' or `expressive' touch. Instru- mental touch is de ned as deliberate physical contact necessary to perform a task, e.g. to dress a wound or to take a pulse. Expressive touch is relatively spontaneous and affective, and is not necessary for the completion of a task (Le May & Redfern 1987, Oliver & Redfern 1991, McCann & McKenna 1993). In nursing, the latter type of touch is used seldom compared with instrumental touch (Routasalo 1996, Le May & Redfern 1987, McCann & McKenna 1993). Moore & Gilbert (1995) showed that residents of a home for the elderly experienced more immediacy and affection from nurses who used expressive touch than from nurses who did not. Hollinger (1986) found a relationship between nurses' touch and the verbal responses of the hospitalized elderly during the nurse patient interactions. Furthermore, there is some evidence that the relation- ship between nurse and elderly patient in institutional care is different from the nurse patient relationship in home care. Some researchers describe this relationship in institutional care as strongly reciprocal, intimate and even mimicking a family bond (Sumaya-Smith 1995, Nystro m & Segesten 1996). Based on this literature, one might expect that nurses would display a great deal of non-verbal behaviour, which is an essential mode for conveying affection, love and support (Strecher 1983, Mehrabian 1972). Although, in the community, nurse patient rela- tionships can be also very intimate and reciprocal, the major objective of a home visit in the community is to deliver nursing care. Earlier research into verbal behav- iour in these settings (Caris-Verhallen et al. 1997b) showed that the interactions in home nursing are less familiar than in institutional care. This could be connect- ed with a low level of non-verbal behaviour. THE STUDY As regards the different types of nursing care, it is expected that nurses will display more non-verbal behav- iour during psycho-social care than during personal hygiene and technical nursing care. Psycho-social care requires empathy and concern, which are conveyed par- ticularly by non-verbal communication. Aim of the study and research questions The aim of the current study was to investigate non-verbal communication in nursing care for the elderly. The study used a descriptive design and has been carried out in the community and in a home for the elderly in The Netherlands. More speci cally, three research questions guided this study: MATERIALS AND METHODS Data collection 1 To what extent do nurses display non-verbal commu- nication, in particular eyegaze direction, af rmative head nodding, smiling, forward leaning and touch? In order to meet the research objectives real nurse patient interactions were videotaped, during the delivery of nursing care. Each encounter was videotaped entirely using a manned camera, focusing on the nurse and the 2 How are non-verbal behaviours related to the verbal communication of nurses? 810 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 Issues and innovations in nursing practice Non-verbal behaviour in nursing care patient, except in the case of nursing activities where the patient was undressed. In such cases the video camera was focused on the nurse only, or when that was impos- sible only verbal communication was recorded. A few days prior to the data collection, nurses informed their patients about the research, and asked them to give informed written consent to participate. Very sick pa- tients, patients suffering from dementia and terminally ill patients were excluded from participation. In the com- munity very few patients refused consent. In the home for the elderly, half the 60 residents who were asked to participate agreed. Nurses did not systematically inform us about those patients who did not want to co-operate, but they reported that there was no clear difference between participant and non-participant residents. received nursing care for a long period (mean 37 months). Twenty-eight patients were residents in a home for the elderly. These patients were older than the patients in the community. Their mean age was 86 7 years. On average, they lived about 5 5 years in the home for the elderly. These two groups of patients can be considered repre- sentative samples of the populations of patients in the community and in homes for the elderly, with regard to age and gender (CBS 1995, Delnoij et al. 1996). The two groups differed from each other in respect of age, gender and mean duration of nursing care received (see Table 2). Observation scheme The observation scheme is directed at non-verbal and verbal communication. Nurses Table 2 Distribution of age, sex and duration of receiving nursing care of patients who took part in the study (n = 109) Forty-seven nurses of different grades took part in this study. The nurses were not a random sample, but nurses who were going to participate in a training in communi- cation skills. Twenty-four nurses worked in an organiza- tion for home nursing and provided nursing care in the community. Twenty-three nurses provided care in a home for the elderly. Each nurse was followed during part of the day in which, on average, four encounters with patients were recorded. The two groups did not differ signi cantly with respect to age, gender, education and years of experience (see Table 1). Patients in the community Patients in the home for elderly Patients' characteristics Mean SD Mean SD Gender Women 65% 89% Men 35% 11% Mean age 77 5 (8 7)** 86 7 (4 4) Subjective health 2 0 (0 4)** 2 3 (0 4) Mean duration Patients of received Nursing care in 37 (43 6)* 70 (77 2) One hundred and nine patients agreed to participate in the study. Together they participated in 181 recorded nursing encounters. Eighty-one patients lived in the community; mean age 77 5 years. Most of the patientsin the community months * Signi cance level of P 0 05. ** Signi cance level of P 0 01. Table 1 Distribution of different characteristics of nurses participating in the study (n = 47) Nurses in the community (n = 24) Nurses in a home for the elderly (n = 23) Provider variables Mean SD Mean SD Genderb Women 100% 91% Men 9% 37 4 (9 3) 40 9 (8 7) Mean agea Educational level1b Nurses 46% 35% Auxiliary nurses 54% 65% Years of employmenta 16 5 (8 8) 15 9 (7 2) 1 Nurses = Dutch higher professional education level, HBO or 3 5 years of in-service training. Auxiliary nurses = Dutch secondary professional education level, MBO or 2 5 years of in-service training. a Differences in age and amount of experience were tested by means of t-tests and were not signi cant. b Differences in gender and education level were tested by means of a chi-square tests and were not signi cant. 811 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818 W.M.C.M. Caris-Verhallen et al. Non-verbal communication _ Affective communication, which provides information about the extent to which the nurse shows verbal attentiveness, concern, empathy and sympathy with the patient. The observation scheme contains six non-verbal catego- ries: patient-directed gaze, af rmative head nods, smiling, forward leaning and instrumental and affective touch. In fact, instrumental touch does not play a role in building rapport, but because this kind of touch is inherent in nursing it has to be observed to distinguish it from affective touch. _ Communication that structures the encounter, involves utterances that indicate guidance and direction such as orientating and instructing, requests for clari cation, asking for understanding and asking for opinion. _ Communication about nursing and health, which con- _ Patient-directed gaze is de ned as the nurse looking at tains all items with respect to nursing, medical or therapeutic topics. the face of the patient. _ Head nods are de ned as nodding one or more times as _ Communication about lifestyle and feeling, which a sign of attentiveness in conversation or as reinforcing the spoken word (Mehrabian 1972, Anderson 1985). contains all verbal expressions with respect to lifestyle issues and emotional topics. _ Smiling in this context is de ned as an utterance of friendliness. Laughing out loud, on the other hand, in response to a joke is not considered as non-verbal communication; it is coded in the verbal part of the observation scheme. Reliability of the observations The video recordings were observed systematically by two observers using the CAMERA computer system (Iec Pro- GAMMA 1994), which is especially designed for coding behavioural interactions from video recordings. _ Forward leaning is de ned as posture which involves bending towards or sitting closer to the patient when this is not necessary to carry out the nursing tasks. This position conveys involvement and a concentrated focus on the interaction partner (Heintzman et al. 1993). With respect to the non-verbal behaviours, both dura- tion and frequencies of the variables were recorded. In this study duration was used. Ten of the contacts were coded by each of the two observers in order to calculate the inter- rater reliability of the non-verbal behaviours. Pearson's R _ Affective touch is relatively spontaneous and affective, and not necessary for the completion of a task (Le May & Redfern 1987). An example is a nurse who puts an arm around the shoulder of a distressed patient. proved to be between 0 70 and 0 98. Cohen's Kappa was used to calculate the inter-observer reliability of the ve verbal communication categories. This statistical procedure corrects for agreement based on chance and is particularly suitable for observations coded in exclusive categories (Hollenbeck 1978). A kappa coef cient can range from A1 to +1 and a value of _ Instrumental touch is deliberate physical contact, which is necessary in performing the nursing task. An example is touch while dressing a wound. The duration of all six non-verbal categories was recorded. The type of nursing care was also coded, using Kerkstra & Vorst-Thijssen (1991), as a point of departure. We discerned three types of encounters: encounters dom- inated by personal hygiene care, encounters principally involving technical nursing procedures and encounters which were dominated by psycho-social care. 0 60 indicates an acceptable level of reliability (Cichetti 1984). Cohen's Kappa in our study varied between 0 74 and 0 81. Following Henbest & Fehrsen (1992), who noted that scoring only a part of a consultation could be as reliable as scoring an entire consultation, preliminary observations with observation periods of 5 min, 10 min and the total length were carried out during 48 encounters. As 10-min observation periods proved to be very reliable compared with the observation of the total length (non-verbal com- munication between 0 61 and 0 92 and verbal communi- cation between 0 80 and 0 93, Pearson's R), observation time was standardized and the rst 10 min were observed of each of the 181 nursing encounters. Verbal communication In order to observe the verbal communication of the nurses, an adapted version of Roter's Interaction Analysis System (RIAS) was used (Roter 1989). Using this system all utterances in patient and nurse dialogue are coded in separate and non-overlapping scoring categories. RIAS discerns socio-emotional and instrumental communica- tion. Within these two categories we de ned in an earlier study ve clusters, based on Correspondence Analysis (Caris-Verhallen et al. 1997b): Analyses In order to answer the rst research question, we specify the amount of nurses' non-verbal communication during the nursing encounters. Proportional scores were used. The recorded time spans of `eyegaze direction', `forward leaning', `affective touch' and `instrumental touch' were _ Social communication, which provides information about the degree to which the nurse uses social conversation that has no particular function in nursing activities, such as personal statements, banter, jokes and small talk. 812 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 808 818
ความคิดเห็น
แสดงความคิดเห็น