By the year 2000, a projected 32 million senior citizens will reside in this country. Of this number, at least 3 million will need institutional care sometime during their later years. Providing high-quality care to this population is the goal of long-term care nurse administrators. What makes this challenge more difficult is the lack of evidence available to guide administrators in making decisions about how to organize in order to be effective.
Quality care is the result of many interacting activities between clients, nursing staff, and administration. Tlie focus of this investigation was limited to examining the relationship between quality of care, job satisfaction, and communication patterns between residents and staff in a 300-bed, extended care facility. Initial observations were made to establish a baseline of information about the ordinary communication patterns used by clients and staff on a day-to-day basis. Nursing staff were then introduced to a communication framework entitled "Confirmation/Disconfirmation" and questioned about their perceptions of the quality of patient care at their facility and about the satisfaction they felt about their jobs.
To explain the theoretical bases of the current study, three topic areas will be presented. They include: confirmation/ disconfirmation communication; job satisfaction; and quality of care.
The term "confirmation" refers to any interpersonal response, verbal or non-verbal, offered by one individual toward another which acknowledges, endorses, or accepts the recipient. "Disconfirmation" entails the opposite and makes the receiver feel negated, discounted, or ignored.1
Concepts of confirmation and disconfirmation were first described by theologian Martin Buber,2 psychiatrist R. D. Laing,3 and communication scholars Watzlawick, Beavin, and Jackson.4 In a later study with Larsen, these terms became known as "confirming" and "disconfirming."5
Examples of confirming behaviors include: showing verbal and non-verbal interest in what the speaker is saying; directly responding to the person's statements; head nodding; good eye contact; repeating or requesting clarification of what the other person says; and expressing agreement, disagreement or neutrality. Examples of disconfirming behavior include: off-handedly responding to the speaker; appearing disinterested or distracted (verbally or non-verbally); interrupting; remaining silent when a response is indicated; introducing an unrelated topic; demeaning the speaker; displaying a nonverbal response which doesn't match the verbal response; and engaging in behavior other than what seems appropriate at the time.
Since Sieburg's original work, several other investigators have examined and applied this communication framework.6-8 In one of these studies, Sundell found the presence of a reciprocal relationship with confirming/disconfirming behaviors - when an individual communicates in a disconfirming manner, he/she is likely to receive a disconfirming response in return.6 Similarly, when an individual communicates in a confirming manner toward another, he/ she tends to receive confirmation in return.6 liie presence of this reciprocal response suggested to the current investigators that exploration into confirming/disconfirming communication patterns between staff and residents in a long-term care facility could prove enlightening.
It was believed that this new communication pattern might be helpful in understanding how client/employee communication behaviors could impact employees' job satisfaction and the quality of nursing care. Organizational research studies in the area of job satisfaction have shown that positive attitudes among nursing staff promote morale, productivity, and effectiveness.9
The third variable, quality of care, is an essential outcome to be considered in the delivery of nursing service. The quality of care concept implies the assurance that performance is monitored and evaluated against objective standards of care in order to maintain service and correct deficiencies.10 However, consensus in the assessment of quality of care has been difficult to develop due to the differing concepts of quality held by nursing staff, medical staff, patients and the facilities' owners.11 A measure reflecting a broad-based assessment of quality of care is needed.
The theoretical relationships for this investigation were based on the following: 1) that there is a reciprocal relationship of confirming/disconfirming communication patterns; 2) that increasing the prevalence of confirming behaviors between nursing staff and clients in a long-term care facility would lead to a more positive attitude among staff; and 3) that a more positive attitude among staff would increase job satisfaction and the quality of patient care.
Specific hypotheses tested in this investigation were:
1) There is a difference in the incidence of confirming behaviors following the implementation of a program designed to introduce the confirmation-disconfirmation communication framework; and
2) There is a correlation between measures of job satisfaction and measures of quality of care.
This was a descriptive, correlational investigation assessing the level of employee job satisfaction, perception of the quality of nursing care, and assessment of the prevalence of confirming/ disconfirming communication patterns between nursing staff and clients in a long-term care facility.
The setting selected was a 300-bed, long-term care private institution located near a university in a southern California metropolitan area. Several schools from the university had used this facility at different times for student placement and research. The facility employed over 400 people in the nursing department.
The Seiberg instrument was used to measure confirmation/disconfirmation communication behaviors. Reliability and validity of this instrument has been established in several studies.6"8·12 The Minnesota Job Satisfaction Short Form Questionnaire was selected for use in this investigation.13 The 20-item questionnaire is self- administered, requiring a response choice to be made from a range beginning with "very dissatisfied" (1 point) to "very satisfied" (5 points) (Manual, p 3). Quality of care was measured by the one-item questionnaire developed by Georgopoulos and Mann and modified for this investigation to reflect a 5-point rather than a 7-point Likert-type scale.14
In order to examine the concepts of interest, the investigators used a research assistant, skilled in recognizing confirmation/disconfirmation communication patterns, to observe employees in the workplace. Inter-rater reliability of .93 was achieved on the Sieburg Confirmation/Disconfirmation Instrument prior to data collection. Baseline observations were made on 70 nurses employed on all three shifts on three nursing units.
Following the collection of baseline information, an in-service program presenting the confirmation/disconfirmation communication framework was given to the nursing staff of all shifts by the investigators. In preparing for the in-service program, the investigators enacted three vignettes depicting possible incidents in the life of a long-term care facility. The first vignette reflected the loneliness of an elderly resident who had not had contact from her family in some time. The nurse's disconfirming response ignored the loneliness expressed and focused on completing hygiene tasks until eventually the resident became silent.
The second vignette described the fearfumess and timidity felt by a frail elderly client. The nurse's response was again disconfirming, discounting the emotions expressed as unreasonable. The third vignette directed attention to the communication behaviors of nurses at the change of shift report. The nurse going off duty was describing a very busy night that prevented her from completing some duties usually assumed by the night shift. The on-coming nurse discounted what was being reported and responded in anger.
These vignettes were videotaped in a laboratory and edited for educational purposes. During the in-services at the long-term care facility, the videotape was presented. After viewing the tape, the investigators led a discussion of the principles underlying this new communication framework. Participants were then asked to complete a questionnaire assessing employee job satisfaction, perception of quality of care, level of education, workload, and job classification.
No identifying data were collected with the questionnaire. Six weeks following the in-service education program, observations were made again. The confirmation/disconfirmation communication patterns of 52 nurses and their clients were observed. Statistical analysis on the data collected indicated that a representative sample of staff from each shift were observed (days = 44%, evenings = 40%, nights - 16%). Nursing assistants composed 66%, LVN's 22.3%, and RN's 10.7% of the sample.
In the pre-inservice data, confirming communication responses from nurses occurred in 83% of the observations. In the post in-service data, confirming responses from the nurses occurred in 89% of the observations.
In the study, an overall job satisfaction score of 88 was achieved. This rating was higher than the norms obtained for full-time nurses (75.4; Manual, p 50) or nursing assistants (80.6; Manual, p 74) found by the Minnesota researchers. Quality of care was reported to be "very good" in a range from poor to excellent. There was a significant relationship (r=.86) between the quality of care and job satisfaction. There were no significant relationships found between the quality of care or job satisfaction and years of employment, years of education, workload, or job classification.
Although this was a small study, using two data collection periods in one facility, there were some surprises in the findings. Chief among these were the high scores in both the confirmation/ disconfirmation, and the quality of care measures. It was heartening to discover such a positive environment in the longterm care setting. This finding could also be a reflection of the positive effect of ongoing relationships with the university or specifically, the attention focused on staff/resident communication by this investigation.
The first hypothesis of this investigation, "There is a difference in the prevalence of confirming communication behavior following the implementation of a program designed to introduce the confirmation/disconfirmation communication framework" was not statistically significant. Although an increase in confirming behaviors was observed, the increase was not sufficiently large enough to reach significance.
The second hypothesis of this investigation, "There is a correlation between measures of job satisfaction and measures of 'quality care'," was supported.14 This linkage has important implications for nurse administrators. In an era of cost containment, efforts to improve the quality of client care may be constrained. Therefore, attention to variables associated with increased employee job satisfaction may prove to be a worthwhile investment in retaining experienced staff and increasing the quality of care delivered.
This study also found no relationship between the quality of care and job satisfaction of employees and their level of education, years of employment, workload, or job classification. These later variables have been found to be significant in other studies. Such findings may imply that the setting in which this investigation was conducted offers an opportunity for investigators to pursue studies in order to identify what practices produce such a high-quality work environment.
Although not specifically tested in this investigation, the findings suggest that the practice of using confirming communication behaviors is associated with higher levels of job satisfaction and quality of care for clients. Since this communication framework can be learned, it has the potential for improving the effectiveness of a long-term care facility in achieving quality care and satisfied employees.
At a time when much attention is directed toward the abuses discovered in long-term care, it is important that the essentials of quality nursing care be recognized and implemented. This study has identified three elements of high quality care. These are: high level of confirming communication patterns among residents and staff of a longterm care facility; high level of job satisfaction; and high level of quality of care perceived by the staff. Through continued studies of what is right with nursing homes, a sound basis of information can be developed to support decisions that will improve the quality of nursing care to the elderly.
- 1. Sieburg E: Dysfunctional Communication and Interpersonal Responsiveness in Small Groups, doctoral dissertation. University ofDenver, 1969.
- 2. Buber M: Dislance and relation. Psvchiatrv 1957; 20:97-104.
- 3. Laing RD: The Seifand Others. New York, Pantheon. 1961.
- 4. Walzlawick P, Beavin J, Jackson D: Pragmatics of Human Communication. New York, WW Norton, 1967.
- 5. Sieburg E, Larson C: Dimensions of interpersonal response. Presented at the International Communication Association Convention, Phoenix, 1971.
- 6. Sunde 11 VJ: The Operation of Confirming and Disconfirming Verbal Behavior in Selected Teacher-Student Interactions, doctoral dissertation. University of Denver, 1972.
- 7. Clarke FPP: Interpersonal Communication Variables as Predictors of Marital Satisfaction- Atiraction, doctoral dissertation. University of Denver, 1975.
- 8. Heineken J: Disconfirming Responses in Psychiatric Patients, doctoral dissertation. University of Denver, 1980.
- 9. Seybolt J, Walker D: Altitude survey proves to be a powerful tool in nursing turnover. Hospitals 1980; May: 1.
- 10. Donabedian A: Abstracts of Medical Care Administration. Cambridge, Harvard University Press, 1973.
- 11. Mannisto M: An assessment of productivity in health care. Hospitals 1980; 54(18):71-76.
- 12. Mathews AJ: Confirming and Disconfirming Behaviors, Self-Acceptance, and Personal Values: A Descriptive Study of LibrarianUser Interactions, doctoral dissertation. University of Denver, 1977.
- 13. University of Minnesota: Manual for the Minnesota Satisfaction Questionnaire, bulletin 45. St Paul, University of Minnesota Press, 1967.
- 14. Georgopoulos B, Mann F: The Community General Hospital. New York, The Macmillan Company, 1962.