Received: 22 Feb. 2009
Accepted: 5 Apr. 2009
Original Article
Obstacles in nurse-elderly patient relationship from the patients' point of view
Soheila Bakhtiari*, Shahla Mohammadzadeh**, Zahra Moshtaq***
Abstract
BACKGROUND: Elderly population is increasing worldwide. The elderly are hospitalized more and have a longer stay compared to patients of all ages. Nurse-elderly patient relationship has a key role in improving nursing care and increasing patient’s satisfaction of health care system.
METHODS:
This was a cross-sectional study conducted from June to August 2005. The sample consisted of 110 elderly
patients hospitalized in the internal surgical wards of Isfahan University of Medical Sciences, selected by convenience
sampling method. Data were collected by interviewing patients based on a structured questionnaire including questions
about obstacles related to nurses, the elderly patients, and environment and working conditions.
RESULTS:
There were 63 (57.3%) males and 47 (42.7%) females with the mean age of 69 years. From the elderly patients'
point of view, the main obstacle related to nurses was that of their disrespect towards the elderly patients (98.2%), the main
obstacle related to the elderly patients was that of their diseases and medicine side-effects affecting their talking (76.4%),
and the main obstacle related to environment and working conditions was that of crowded wards and rooms (70%).
CONCLUSION:
There are important obstacles in nurse-elderly patient relationship. It is necessary to include aging process
and its related changes as well as relationship with elderly patient in nursing curricula. Also, nursing staffs should receive
in-service education regarding relationship with the elderly patients.
KEY WORDS: Elderly, older people, nursing, nurse-patient relationship, communication skills.
IJNM R 2009; 14(2): 77-82
O
ne of the 21st century achievements is
the increase of lifespan and the elderly
population. About one million people
in the world reach the age of 60 every month. It
is predicted that in 2050 more than 21 percent of
the world population will be the elderly, and
the young population will reduce from 33 to 20
percent.1 About 50 to 80 percent of patients
hospitalized in internal surgical wards are over
65 years old.2 The elderly not only are hospitalized more but also have a generally longer stay,
with an average of 7.3 days compared to 4.5
days for patients of all ages.3 Hospitalization is
often a terrible experience for the elderly patients since the hospital environment and routine is far different from what they are used to.4
During the hospitalization, there are some
health care personnel and nurses who spend
much time with the patients and therefore have
the opportunity to help them with the high
quality care and also preventing complications.3,5
Communication is an inevitable part of nursing care not only with the elderly but with all
patients. Effective communication is one of the
most important nursing skills. It is lamentable
that some of the health care team members do
not know how to make an effective relationship
with the elderly patients and do not devote any
time for this necessity.6 Relationship with the
elderly patients needs special considerations.7,8
At the onset of a relationship, each of us bring
* MSc, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
** MSc, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran Azad University of Medical Sciences, Tehran,
Iran.
*** MSc, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Correspondence to: Soheila Bakhtiari MSc.
E-mail: bakhtiari@nm.mui.ac.ir
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with our own ideas, values, concepts, and
world view.9 This fact should be kept in mind in
caring for the elderly patients. Changes related
to sensory system can affect the quality of
communication.10,11 Disability to make a relationship leads to disappointment and agitation
and cause depression and social isolation, of
which the elderly are at a higher risk.12 Nursepatient relationships are ideally towards decreasing stress in patient and her/his family
and making them capable of self-care.13 Lack of
communication and ineffective relationship often create problems in health care system,
threatens professional credibility, and impose
extra expenses on the patient and health care
system.8 Effective communication between
nurse and elderly patient is an important factor
into patient's satisfaction, successful treatment,
and patient’s acceptance of health care and
treatment process which in turn increase the
credibility of nursing profession in the society
as well as nurses’ job satisfaction. Evidence has
showed that there are important obstacles in
nurse-elderly patient relationships.14,15 Therefore, it is necessary to consider elderly patients’
attitudes towards the obstacles in their relationships with nurses.
The aim of this study was to identify the elderly patients’ point of view towards the obstacles in their relationships with nurses in three
categories: nurses related, the elderly patients
related, and those related to environment and
working conditions.
Methods
A descriptive cross-sectional study was carried
out at six university hospitals in Isfahan (Iran)
from June to August 2005. The study population included the elderly patients hospitalized
in the internal surgical wards of the six university hospitals of Isfahan University of Medical
Sciences in 2005. The sample consisted of 110
patients aged 60 years old or over who were
willing to participate in the study, selected by
convenience sampling method. Data were collected by interviewing the patients based on a
questionnaire structured by the researchers. The
questionnaire included four sections; first sec-
tion included demographic characteristics of the
patients and other three sections included questions on communication obstacles related to
nurses (28 questions), patients (10 questions),
and environment and working conditions (9
questions).7 To make answering easy for the
elderly patients, the questionnaire was designed
with yes/no questions. To assess the content
validity, the questionnaire was sent to lecturers
of the Nursing and Midwifery School and was
edited according to their comments. To assess
the reliability with test-retest method, 10 elderly
patients filled out the questionnaire with one
week interval. The correlation between the two
measurements was 0.85 which was acceptable.16
The data from these 10 elderly patients was not
included in the study. This study was approved
by the ethics committee of the Tehran University of Medical Sciences. Patients were informed
about the purpose of the study and informed
consent was obtained verbally from all patients.
Participation was entirely voluntary and the
decision to participate or not to had no impact
on the care of the patient. Data were analyzed
using SPSS software (version 11.5) and descriptive statistical methods (frequency distribution,
percentage, and mean) and bi-nominal test.
Results
There were 63 (57.3%) males and 47 (42.7%) females with the mean age of 69 years. Sixty patients (54.5%) were illiterate and 9 (8.2%) had
some high school education. Ninety five patients (86.4%) had a history of hospitalization
and 59 (53.6%) were hospitalized once or twice.
Also, 46 patients (41.8%) had some vision and
22 (20%) had some hearing problems. Using binominal test, items with significantly more
“Yes” responses were considered as obstacles.
The relationship obstacles related to nurses, the
elderly patients, and environment and working
conditions from the elderly patients' point of
view are shown in table 1, 2, and 3 respectively.
Items with no significant difference between
“Yes” and “No” responses and items with significantly more “No” responses are also presented at the end of each table.
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Table 1. The relationship obstacles related to nurses
Percentage of agreement
Nurses' disrespect towards the elderly patients
98.2%
Not responding to the patients' questions
93.6%
Cold shouldering the patient
92.7%
Not listening to the patient carefully
91.8%
Guarding against patients' criticism
88.2%
Neglecting patient's vision or hearing problems
87.3%
Talking too fast and quick
84.5%
Nurses being tired
84.5%
Ignoring the patients’ feelings
80.9%
Being busy with the ward's routine works
80%
Talking to the patient from a far distance
79.1%
Talking without eye contact
76.4%
Not explaining medical treatment interventions to the patients
73.6%
Not introducing themselves to the patient
72.7%
Not seeking permission from patients for medical treatment interventions
71.8%
Using medical terms which are not familiar for the patient
69.1%
Postponing talking to the patient to a time suitable according to themselves
68.2%
Calling the patient with first name
65.5%
Ignoring the patients' anxiety
65.5%
Having a language or dialect different from that of the patient
61.8%
Having too formal and restrict behavior
61.8%
Items with no significant difference or with significantly more no response
Significant difference between nurse and patient age
58.2%
Difference between nurse and patient in educational level
54.5%
Talking to patients in standing position
47.3%
Judging the patients behaviors
42.7%
Not being continuously on patient bedside
37.3%
Providing patients with advice and suggestions for their decision making
22.7%
Having behavior in an intimate way
10%
Table 2. The relationship obstacles related to the elderly patients
Percentage of agreement
The influence of diseases and drug side-effects on the way of talking
76.4%
Terseness and unwilling to talk
75.5%
Depression, fear, and/or anxiety
73.6%
Forgetfulness and lack of memory
70.9%
Physical problems such as pain
70%
Isolation and seclusion
64.5%
Items with no significant difference or with significantly more no response
Acoustic and visual deficit
59.1%
Impatience and intolerance
55.5%
Delay in answering the questions
47.3%
Tardy motion
28.2%
Table 3. The relationship obstacles related to environment and working conditions
Percentage of agreement
Crowded wards and rooms
70%
Having very sick patients in the ward
66.4%
Small wards and rooms
62.7%
Heavy work load of the nurses
60%
Items with no significant difference or with significantly more no response
Not well designed ward (not having easy to use phone system)
59.1%
Nurses in lack of time
56.4%
Cold or hot weather
50
Not adequate light in rooms and wards
43.6%
Communication with other staffs of medical caring system
26.4%
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Discussion
The findings of the present study revealed some
important points:
a) From the elderly patients’ point of view,
the obstacles in relationship with nurses that are
related to the nurses can be categorized in five
groups, 1. physical obstacles such as tiredness
of the nurse (84.5%), 2. nurse's lack of communication skills such as not listening carefully to
the patient (91.8%), 3. lack of knowledge and
information such as not responding to the patient's questions (93.6%), 4. negative attitude of
nurses towards aging and the elderly patients
such as disrespecting their age (98.2%), and 5.
cultural obstacles such as having a language or
dialect different from that of the patient (61.8%).
According to these findings, the main obstacle related to the nurse from the elderly patients’ point of view was that of nurses’ disrespect to the elderly (98.2%). Indeed, aging increases the expectations from the people
around, and the elderly expects a high respect.
The nurses are significantly younger than elderly patients and it sounds that nurses have not
been able to make a relationship with the elderly based on the respect and polite behavior they
expect. This can be due to the nurses' negative
attitude towards aging. McLafferty and Morrison17 showed that the nurses' attitude towards
working with elderly is rather negative. They
also found that those who had little experience
in elderly care, those under 25 years old, and
men (compared with women) had less positive
attitudes towards the elderly. McCabe's study 18
on the patients’ experiences of nurse-patient
communication in Ireland defined four major
notions: lack of communication, attending, empathy, and friendly nursing accompanying with
a sense of humor. In contrast to the literatures
which suggest that nurses are not good at
communicating with patients the findings of
this study indicated that nurses can communicate well with patients when they use a patientcentered approach.
b) The second group of obstacles from the
elderly point of view was related to themselves
and the main obstacle was the influence of diseases and drug side-effects on the way of talk-
ing (76.4%). Indeed, physical and psychological
illnesses as well as natural changes of aging
process affect the nurse-elderly relationships.
Alavi19 in a qualitative study showed that the
psychological situation and characteristics and
also the social and economic status of the patients are among the obstacles in nurse-elderly
patient relationships. Cegala et al20 studied how
educating patients about communication skills
affects their acceptance of medical advices. Results showed that the patients in the first group,
who received educational booklet along with
instructions 2-3 days before visiting a doctor,
accepted all the medical advices in comparison
to the patients in the third group, who received
no instruction. Also, they accepted medical advices more than the patients of the second
group who received and read a brief pamphlet
containing the key points of the educational
booklet while in the waiting room to visit the
doctor. In addition, patients with higher education accepted medical advices more. But there
was no significant relationship between race,
sex, age, or severity of disease with acceptance
of medical advices.
c) The third group of obstacles from the elderly patient’s point of view was related to the
nurses' working conditions and environment.
These obstacles can be categorized in two
groups: obstacles related to environment such
as crowded wards and rooms (70%), and obstacles related to the working conditions such as
having very sick patients in the ward (66.4%)
and having heavy work load (60%). The main
obstacle related to the nurses' working conditions and environment was that of crowded
wards and rooms (70%). In the educational
hospitals, the high number of medical and nursing students in the wards can turn to an obstacle in nurse-patient relationship. Alavi19
found that some factors such as crowded and
noisy wards, lack of time, stress, and work load
pressure are important obstacles in nurseelderly patient relationships. Another study by
Lyytinen et al21 determined the kind of care
older patients receive in hospital during the first
72 hours after admission. The results showed
that the patients’ arrival on the ward consisted
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Bakhtiari et al
of routine procedures and periods of waiting.
The patients’ daily schedule was determined by
the ward's routines. They had very little control
or influence over their own care and limited
privacy. Interaction between the patient and
personnel was minimal and lasted for only
short periods of time.
There are some limitations to the present
study and suggestions for future researches. In
the present study, we reported obstacles in
nurse-elderly patient relationship from the elderly patients’ point of view. Park and Song15
studied the differences between nurses and elderly patients’ understandings of their relationship obstacles. Results showed that even though
there was no significant difference between
their understandings of the obstacles, each side
highlighted obstacles related to the other, but
both gave the same scores to the obstacles related to working conditions and environment.
To reach an effective nurse-patient communication we should consider both patients’ and
nurses’ attitudes towards the relationship obstacles. Although our study was a multicenter,
it was done only in one city that according to
cultural, educational, and socioeconomic differences may affect the results. Also, communication patterns may be different in various care
settings and further studies in nursing homes
are warranted.22
The authors declare that have no conflict of
interest in this study and they have surveyed
under the research ethics.
Conclusion
According to the findings of this study, there
are important obstacles in nurse-elderly patient
relationship which could be addressed in three
groups: related to nurses, to patients, and to the
setting in which nursing care takes place. It
seems necessary to include a course on aging
process and its related changes as well as skills
of relationship with the elderly patients in the
nursing education curricula to improve the
knowledge and attitude of nursing students
towards the elderly patients. Also, the hospital
administers should highly take into consideration the working environment and conditions of
the clinical nurses. The communication skills to
make an effective relationship with elderly patients should be included in the in-service education of the nursing personnel and nurses'
knowledge and practice of these skills should
be evaluated continuously.
Acknowledgment
Our special thank is dedicated to patients who
participated in this study. Also we thank hospital wards head nurses and staffs who help us
conducting this research.
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