Effective communication with clients and/or their families or caretakers is essential in a nursing system. It is the basis for establishing the nurse-client relationship, which is of vital importance whether the need is to provide physical care, guidance, support, education, or a therapeutic environment.1 This nurse-client relationship is perhaps more important to the elderly institutionalized client than to those in other situations. The elderly institutionalized client is dependent on the nurse not. only for physical care but also for the satisfaction of such needs as socialization, affection, information, and security against feelings of being lost and abandoned,2 A supportive environment is essential in preventing hazards to the clients' well-being that may result from a failure to provide for these needs, and as a result of failure to provide adequate sensory stimulation.
The elderly confused client maybe unable to make the decisions or carry out the actions needed in self care. Guiding becomes an especially important nursing action, not only in assisting clients to make choices but also in giving direction and/or supervision in self care. According to Orem,1 this mediod of assisting requires that nurse and client be in communication with one another. Interferences with communication often have been observed with this population. Important factors contributing to interferences may include absence of adequate or appropriate stimulation, withdrawal from familiar communication networks, functional disorders, or organic decline of the instruments of communication.3 Developing the most effective methods of communicating with elderly confused clients is an especially important challenge to nurses.
Touch often has been advocated by nurses as an important means of communicating caring, support, and empathy, and of establishing rapport, as well as being necessary in giving physical care. Burnside5 and Burton and Heller6 have stated that the elderly clients' need to touch is greater than the need to verbalize, and offers reinforcement on a level more coincident with deficit status. Communication theorists also have stressed that communication consists of not only the content of the message, but also relational factors that are conveyed mainly by nonverbal cues used along with the message.7
Several non-nursing stuthes have indicated that the use of two sensory stimuli in communication is more effective man one alone, either in increased detection of signals or increased compliance to requests.8'9'10 These findings may have implications for improving communication when there are impairments; however, these stuthes have been done with young, normal subjects so the findings cannot be generalized to elderly, confused clients.
Very little attention has been given to the effects of touch on communication with the institutionalized elderly. Burnside" reported a subjective improvement in responses when she used touch with a group of six regressed clients with chronic brain syndrome. A trend toward improvement in psychotic behavior in ten institutionalized elderly clients when they were touched at regular intervals during the day was noted by Greenberg. Stuthes with other groups of clients have shown positive affectional effects from the use of intentional, unnecessary touch by nurses. Aguilera13 found an increased verbal interaction, rapport, and approach behavior between psychiatric clients and the nurse when touch was used along with a verbal request. Several stuthes with hospital clients indicated that touching increased the rate at which rapport is established and the number of positive acceptance responses of clients."'15
There is some evidence to indicate that elderly, confused clients may be deprived of the positive effects of touch to a greater extent than other clients. Several stuthes have shown that clients who are in more serious condition, or who are more severely impaired, received fewer unnecessary touches than more normal clients.13'16 According toa study by Watson,16 instrumental touch accounts for 68% of the touching done in a nursing home. In addition, Aguilera 3 speculated that the decreased acceptance of the nurses to touching depressive clients, as opposed to schizophrenics, may have been related to the fact that the depressed group was older.
Nurses often have recommended the use of caution in using touch with clients for fear that it may be misinterpreted due to cultural factors and/or personal space considerations. A study by DeAugustinis, Isani, and Kumler17 indicated that touch may be misinterpreted by client or nurse as much as 50% of the time. However, who gives the touch, the relationship of the persons in communication, the reason for the touch, and where the touch is given may have strong influences on its perception. DeWever18 found that although clients in a nursing home often perceived discomfort when the nurse placed an arm around their shoulders, the nurse almost always perceived the touch as comfortable.
Numerous observations have been made by nurses that touching produces favorable affectional or communicative TeSuItS.5'13'14'15'" Thus it would seem that a more intentional, skillful use of touch in communication with elderly confused clients would increase their ability to relate and respond to the nurse, and would support them in coping with the stresses of the nursing home environment. The purpose of this study was to examine the effects of touch, when used with a verbal request, in communication with elderly confused clients in a nursing home environment.
Three hypotheses were formulated.
1. There will be an increase in attention of elderly confused clients when touch is combined with a verbal request.
2. There will be an increase in relevant verbal response of elderly confused clients when touch is combined with a verbal request.
3. There will be an increase in appropriate action response of elderly confused clients when touch is combined with a verbal request".
Setting and Sample
The sample for the study consisted of 32 female subjects selected from two intermediate nursing care facilities located in the same small midwestern city. One was a 141 -bed private facility and the other a 60bed county facility. All female residents in each facility who the nurse in charge identified as having some degree of confusion for six months or more and who were at least 65 years of age were considered potential subjects. These clients were approached by the researcher and asked if they were willing to participate in the study. If verbal consent was given, they were screened for ability to carry out the action requested. Sight, hearing, verbalization, tactile sense, physical ability to do the action, and mental status were evaluated. Mental status was evaluated using Pfieffer's20 Short Portable Mental Status Questionnaire (SPMSQ). Subjects with five or more errors on the SPMSQ, indicating moderate or severe intellectual impairment, were included in the study. Consent forms were sent to the families or guardians of those clients who met the criteria to participate. A total of 32 subjects was obtained and the subjects randomly were assigned to experimental and control groups.
Data were collected in three areas: attention or nonverbal response, verbal response, and action response.
Attention was assessed by the observed nonverbal behavior that the client exhibited during and after the treatment. The research tool used for recording the nonverbal behavior during the interaction was devised by the researcher. This tool includes three categories of possible nonverbal behaviors that would indicate attending on the part of the subject. A positive response in any one of these areas was given one point, with a total of three points possible. The three categories are facial expression (including smiling, nodding the head up and down, raising the eyebrows, or blinking the eyes); eye contact, which means that the subject looks toward the nurse; and body movement, including touching the nurse or turning the body toward her. Any responses judged as inappropriate by the researcher and observer were given no points.
Verbal response was noted at the time of data collection and also was tape-recorded by the observer. The researcher and observer analyzed the taped verbal responses to determine whether or not the verbalization was appropriate to the situation. The subject was rated on response given after the verbal request was stated, not after her name. A response of "yes" or "no" was given one point. Two points were assigned for a relevant verbal response, with a maximum of two points per subject.
Appropriate action response was measured by the researcher's and observer's observation that the client either performed the requested action, made some movement to do so, or made no appropriate movement. No points were given for an unrelated action or for no action, one point was given for actually performing the requested action. A maximum of two points per subject was possible.
DEMOGRAPHIC DATA BY FACILITY
All of the interactions in the study were performed by the nurse-researcher. An observer was used to assist with timing, tape-recording, and observations. All interactions took place in the client's room during the afternoon. Dressed in a full nurse's uniform, the researcher held a tray containing several calendars in front of her with her left hand, which was not moved during the interaction. She stood two feet in front of the client and made the verbal request: "Mrs _____ , (pause) I've brought you a new calendar. Please take one from the tray." The researcher placed her right hand lightly on the forearm of clients in the experimental group while the request was made. For the control group, the verbal request was used alone. Subjects were observed for responses for one-and-ahalf minutes following the request. Experimental and control procedures were performed alternately. After the treatment and observations were made, mental status was reassessed to ascertain if it was basically the same as on the day of screening.
Description of Sample
Of the 32 subjects, 29 were widowed, two were married, and one was single. Thirty -one subjects were Caucasian; one was Black. Subjects in control and experimental groups were similar in all categories. Demographic data related to the subject sample are given in Table 1.
Subjects in the two facilities were compared and were found to be similar, except for months since admission, which were 16.6 in the private facility and 39.0 in the county facility. Demographic data for subjects in the two facilities are given in Table 2.
All three hypotheses were tested using the Wilcoxon rank sum test at an alpha level of 0.05, for an experimentwise alpha of 0.15.
Hypothesis 1. Findings showed <0.05, which supported the research hypothesis. The research hypothesis was accepted, indicating that there was, indeed, increased attention (nonverbal responses) when touch was used. Table 3 shows Wilcoxon scores for attending responses.
Hypothesis 2- Using the Wilcoxon rank sum test, findings showed p>0.10, which did not support the research hypothesis that there will be an increase in relevant verbal response of elderly confused clients when touch is combined with a verbal request.
Hypothesis 3. Using the Wilcoxon rank sum test for analysis, findings showed pX).01, which did not support the research hypothesis that there will be an increase in appropriate action response of elderly confused clients when touch is combined with a verbal request.
The findings of this study give support to previous stuthes that show touch to be valuable in establishing rapport with clients and in developing a more positive nurse-client relationship.13,14,15,19 They indicate that touch is an important affectional and communicative tool. The increase in nonverbal responses of subjects with whom touch was used would indicate that the relationship aspect of the communication was enhanced, even though no significant increase in reaction to the content aspect was observed.7 This finding is important not only in establishing and maintaining a nurse-client relationship, but also pertains to helping clients remain responsive to their environment. By increasing stimuli in this way, increased responses were noted. This may be extremely important in providing an optimal environment for nursing home clients and in prevention of the hazards associated with sensory deprivation.
It is noteworthy that the only two subjects who responded in all three categories of nonverbal responses had among the fewest errors of the SPMSQ, both with a score of six at the time of data collection. In addition, those with SPMSQ scores under ten showed a trend toward increased responses in all categories. From these observations, it might be speculated that responsiveness decreases as mental status decreases.
Due to the limited number of subjects in the study, it is difficult to draw conclusions concerning relevant verbal responses and/or appropriate action responses when touch is used. A trend toward an increase in these responses was noted in this study. Aguilera13 observed increased verbal interaction between psychiatric clients and the nurse when touch was used over a period of 15 working days. It is possible that the use of touch with elderly confused clients over a longer period of time also might show significant increases.
Another possible factor in the outcome of the study may be the limited number of personal contacts and stimuli in the nursing home environment. It is possible that clients desire interactions with others and respond whenever their abilities allow. In this study, not one of the potential subjects approached indicated an unwillingness to talk with the nurse or to participate in the study.
Since the findings in this study indicate that touch is important in relational aspects of communication with elderly confused clients, it should be consciously incorporated as nurses develop more effective communication technologies for use with these clients. Effective communication is essential in the nurse-client relationship, through which the maintaining and increasing of optimal self care is accomplished. This relationship is also of vital importance in assisting clients to cope with their environment.
An important method of assisting elderly nursing home clients is in providing an appropriate environment for maintaining optimal self care. Increased stimuli in the environment, such as touch, increase responsiveness and may enhance not only communication but all experiences in the nursing home setting. Therefore touch may be of importance in preventing the hazards associated with sensory deprivation in the nursing home environment.
Several stuthes have suggested that elderly confused clients may receive fewer unnecessary touches than other clients,13'16 which indicates that in developing a skillful and effective use of touch with these clients, it is necessary for nurses to examine their feelings and attitudes toward real closeness (both physical and emotional) with them. With an awareness and understanding of self in the relationship, the nurse can begin to consciously incorporate touch in developing the most effective means of communications with individual clients who may be confused and/or elderly.
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DEMOGRAPHIC DATA BY FACILITY