As clinical practitioners, nurses are trained to be aware of clients' communication patterns, both verbal and nonverbal. Practitioners learn to compare spoken words with facial expressions and to draw hypotheses of dissonance or consonance about the two. This ability to perceive clients' communication styles is integral to the nursing relationship. Blazer (1990) notes that
to promote therapeutic communications between professionals and older adults, the professional must remain alert to nonverbal communication. Changes in facial expression, gestures, and even change in posture suggest problems that are not apparent in the dialogue (p. 30).
Communicating with older adults who have lost the ability to control their affect presents a challenge to both nurses and laypeople alike, especially because central nervous system (CNS) disorders that hinder facial expression may cause concurrent difficulties in enunciation. This article presents practical suggestions for interacting with affected older adults within the framework of the nurse-client relationship. The term "facially inexpressive" will be used to describe the situation of clients who have lost the capability of facial expression from organic causes.
OVERVIEW OF THE PROBLEM
While several studies (Ekman, 1993; Feyereisen, 1986; Reilly & Bellugi, 1996) attest to the significance of emotional expression in communication, there is a dearth of investigation into the absence of facial expression. Some researchers propose that nonverbal cues carry much of the meaning in human interaction (Russell & FernandezDoIs, 1997). Additional investigators believe when verbal and nonverbal cues contradict each other, the nonverbal supersede in the communication of emotion (DePaulo, Rosenthal, Eisenstat, Rogers, & Finkelstein, 1978). Given these findings, individuals who are unable to convey facial expressions are likely to be misunderstood as conveying a message that was not intended.
It is because of the greatly heightened risk of miscommunication that creation of an intervention strategy is important. The purposes of this article are to:
* Examine the genesis and possible effects of facial inactivity in older adults on the nurse-client relationship.
* Offer techniques to both alleviate potential negative effects and maximize effective, sensitive, therapeutic communication.
The loss of the ability to communicate through facial expressions, or the loss of affect as evidenced by a flat or subdued emotional level, denies both practitioners and clients an extremely valuable asset to effective discourse. This is not to say effective communication cannot occur without the presence of facial activity. Affect is an asset, not a precondition, of communication. While exchanges with clients whose facial displays of emotion are impaired are possible, it is important to note that inability to reflect affect in facial movements often is accompanied by an inability to speak with usual clarity. A discussion on the etiology of facial inexpression elucidates this point.
Loss of physiognomic functioning may be caused by a number of physical conditions. These conditions have in common the consequence of immediate or progressive failure to control the facial muscles completely. The loss of flexibility in facial musculature results in the gradual but inevitable slackening of the muscles, and thus, in the loss of the ability to shape one's face into the numerous expressions normally possible. Among the conditions that may produce such an effect are Parkinson's disease, Huntington's chorea, cerebrovascular accident, Lou Gehrig's disease (ALS), and Pick's disease. While loss of expressive abilities may happen at any age, the disorders producing this effect occur more often in older adults, who as a group are more susceptible to neuromuscular dysfunction.
It is easy for practitioners to assume a client is not cognitively intact because the client does not look alert. In this way, appearances can be deceiving and may hinder and even hurt the nurse-client relationship. While each client must be treated individually, the following are some suggestions for interventions with facially inexpressive clients.
Use Your Senses
Listen very carefully to what the client is saying. Try to lip read to gain clues about the content of what is being said. Watch the eyes to see how the client feels about what is being said.
Do Not Pretend to Understand
Do not claim or feign understanding about what the client is saying. It is preferable to ask for clarification, even repetitively, rather than to flounder through the whole conversation (e.g., "I didn't quite catch the last part of what you said, Mrs. G., could you repeat it?" or "I'm not sure I understand. Would you mind telling me again?") Clients who experience difficulty in displaying their emotional states may be used to taking more time to communicate but may become frustrated if the nurse repeatedly fails to address their concerns. Although asking the client for elucidation may be awkward or time consuming, the client will likely appreciate the sincerity and functionality of the nurse's requests.
Maximize Use of Words That Have Been Understood
At times, it may seem that accurate communication is hopeless even when the nurse asks for numerous clarifications. The objective of communication is not to frustrate the client. Therefore, do not think it necessary to catch every single word phonetically. Use judgment to determine if repetition is required, or summarize what the client has said and ask for verification (e.g., "So the medication has been helpful, is that right?" or "So it would be fair to say that..."). It may be helpful to remind the frustrated client that people require clarification of verbal exchanges under the most normal of circumstances.
Ask for Elaboration
If these initial attempts are unproductive, seize the most salient phrase understood and encourage the client to elaborate on it. This technique may be performed by asking a question about the phrase or by restating it. This action will provide another chance to obtain a more clear idea of what the client is saying (e.g., "Can you tell me more about the pain, Mr. B.?" or "You have pain?").
Use Nonverbal Cues
Use available nonverbal cues such as hand and arm gestures, body posture, and head positioning to guide your hypotheses (e.g., excited hand gesticulations show agitation, excitement; slumped posture shows boredom, fatigue). While nonverbal cues do not tell the whole story, they are useful when coupled with verbal data. Clients should be encouraged to use nonverbal behaviors to improve communication.
Be Aware of and Record Communication Patterns
Over time it may become easier to understand the client. Comprehension may come more easily and more quickly after one learns the client's speech patterns and becomes more familiar with them. Recording these specificities may help the nurse recall clients' mannerisms. These notes also may prove valuable if it becomes necessary to introduce the case to another practitioner.
Be Alert to Communicative Substitutes
Usually clients adopt alternate means of expressing themselves, that is, the loss of a specific ability is replaced by a residual ability. Certain difficult-to-pronounce words may be discarded routinely in favor of others (e.g., increased use of nicknames), or specific gestures may assume extended meaning (e.g., a wave of the arm meaning "leave me alone").
Watch for Holophrastic Speech
Client repetition of certain phrases may be noted. This behavior is not necessarily symptomatic of mental dysfunction. Rather, the client may be using a phrase as a symbol for a broader thought or feeling (e.g., "Bad news" to indicate dissatisfaction or "What a day" to express novelty). The use of these holophrases often is observed accompanying other conditions such as dementia, stroke, and impairments involving the vocal apparatus. Holophrastic speech seeks to maximize speech content while minimizing speech effort. This behavior is relevant particularly to discussion of facial expression because affected clients must learn to make optimum use of verbal abilities and nonverbal behaviors.
Find a Quiet Place to Converse
It is helpful to conduct conversations in a quiet place free of distractions. Multiple conversations, music, or television only add confusion to a situation already requiring attentive effort. Finding a private area to converse also is a necessary courtesy to any client.
Each of the organic causes of facial inexpression varies in the effects it will impose on a client. Some conditions, such as stroke, may leave an individual with severe muscular limitations but with full mental capacities. Other conditions may involve more encompassing cognitive decline. Review the client's clinical record, especially the evaluation of cognitive status, if available. It is both prudent and respectful to enter into the nurseclient relationship assuming the client is completely alert and cognizant. Modifications in speed and complexity of the nurse's speech may be made accordingly as evaluation of and familiarity with clients yield more information about their capabilities. The goals are, first, to be open to whatever cognitive level the client presents, and second, to be able to adjust clinical practice to find a way to communicate with the client at their level.
The topic of communicating with facially inexpressive individuals contains wider implications for working with members of the general geriatric population. The outlined technical suggestions may be applied to unaffected older adults with the observation that it may be difficult to engage older adults meaningfully because of their outward appearance. The relationship between physical aging and social functioning seems to be inverse, making it easy to assume incognizance. The physical deterioration intrinsic to the aging process can eventually limit older adults' social energy. This primary aging process is compounded by the secondary aging effects of disease, emotional distress, and other possible factors. It is this mixture of physical and emotional issues nurses must address as a whole when caring for older clients.
The nursing relationship involving facially inexpressive clients necessitates an awareness by both nurse and client of the communication problems that may exist within the nurse-client relationship and, perhaps more important, outside of that relationship. Nurses may be asked to assist facially inexpressive clients and their families in development of effective communication skills (Boss, 1996). Communication for these clients must involve the practice and use of nonverbal behaviors and other compensatory mechanisms. "Homework" assignments may be used to facilitate alternate means of communication for individuals whose normal repertoire of behaviors is limited. Effective communication, using whatever means possible, will help facially inexpressive clients manage their impairment across a range of situations. The aim of the nurseclient relationship then is to transfer the learned knowledge to all life relationships.
Of course, the goals of improved communication cannot be met without the cooperative involvement of the older adults. These goals may be reached by creating a relationship of trust and productivity. With these aspirations in mind, nurses may employ or modify the techniques presented in this article or create new or person-specific approaches. Actual practice with facially inexpressive clients provides the best forum for revealing new methods of treatment.
Ms. R. is an 85-year-old Black woman who suffered a right cerebrovascular accident resulting in left hemiparesis. She also had been diagnosed with Parkinson's disease. It is difficult to differentiate whether Ms. R.'s physical conditions are a result of the stroke or the Parkinson's disease. It is likely the symptoms of each overlap and affect each other. Whatever the cause, Ms. R. presents absolutely no affect except when she laughs. Movements on the nonparetic side of her body are stiff and slow, and seem effortful to initiate. Her speech is slurred and soft, making it difficult to follow.
Mentally, Ms. R. is completely cognizant. She does not seem to have developed any dementia, a possible effect of Parkinson's disease. Her thoughts are clear and organized, although never highly complex, and she makes great effort to be socially graceful. Adherence to social pleasantries may help her feel competent and involved. Ms. R. is outgoing and friendly and seems to look forward to social interactions.
At first, Ms. R.'s speech was extremely difficult to understand. Often it was impossible to guess how she felt about the people or events she was describing because her voice was devoid of inflection. Ms. R. frequently fell back on the phrase "Oh boy" to denote surprise, frustration, or to cover silences. As time progressed, it became easier to interpret which feeling she was expressing with that verbal cue by attending to the context of the discussion and predicting what she would most likely be feeling based on earlier experiences with her.
It also became less strenuous to comprehend her words, although a high attention level still was needed. There were times when it became necessary to ask Ms. R. to repeat what she had said, especially when she mentioned a new name, but Ms. R. seemed to appreciate the sincerity and necessity of the reiteration. After several weeks, she had yet to speak in depth of how she felt about her condition. This reluctance to discuss the communication difficulties provides additional impetus to probe the intricacies of facial expression.
Communication with facially inexpressive older adults fulfills not only the immediate practical and emotional needs of the client but also the ever-present need to relate to others. One erroneously may deny interactions to older adults who are facially inexpressive based on their appearance. However, the need to form relationships does not diminish with age or onset of physical disability. In fact, it may increase.
- Blazer, D. (1990). Emotional problems in Uter life: Intervention strategies for professional caregivers. New York: Springer.
- Boss, B.J. (1996). Pragmatics: Right brain communication. Axon, 17(A), 81-85.
- DePaulo, B.M., Rosenthal, R., Eisenstat, R.A., Rogers, P.L., & Finkelstein, S. (1978). Decoding discrepant nonverbal cues. Journal of Personality and Social Psychology, 36, 313-323.
- Ekman, P. (1993). Facial expression and emotion. The American Psychologist, 48, 384391.
- Feyereisen, P. (1986). Production and comprehension of emotional facial expressions in brain damaged subjects. In R. Bruyer (Ed.), The neuropsychology of face perception and facial expression. Hillsdale, NJ: Erlbaum.
- Reilly, J.S., & Bellugi, U. (1996). Competition on the face: Affect and language in ASL motherese. Journal of Child Language, 2J(I), 219-239.
- Russell, J.A., & Fernandez-Dols, J.M. (1997). The psychology of facial expression. New York: Cambridge University Press.