Abstract
Effective communication between nurses and patients is an important factor to quality nursing care but ineffective nonverbal communication could take a toll on health care. Therefore, understanding the factors that influence nonverbal communication between nurses and hospitalized older adults could help solve communication problems, thus improve nursing care. A sample of 13 nurses and 4 student nurses from two hospitals in Cameroon participated in the study. Data were collected using participant observations and semi-structured interviews, and analyzed using open coding and constant comparative analysis. Three categories were identified as influencing factors: nurse views of hospitalized older adults, hospitalized older adult-related factors, and nurse intrinsic factors. Effective nurses’ nonverbal communication with hospitalized older adults relies mostly on nurses’ intrinsic factors. Identification and nurturing of the positive nurse intrinsic factors are important to develop effective nonverbal communication skills among nurses.
Introduction
Older adults make up a significant proportion of the population worldwide (Mohseni et al., 2019). Older adults accounted for 1 billion people, with 32 million in sub-Saharan Africa in 2019, which is projected to reach 101 million by 2050, an increase of 218% (United Nations Department of Economic and Social Affairs Population Division, 2019). This makes the older adult population in sub-Saharan Africa the second most rapidly growing population of all regions globally (Naidoo & Van Wyk, 2019). This rapid growth implies that there will be increased needs for geriatric healthcare services (Hammar et al., 2017; Kydd et al., 2014), and that nurses will be expected to care for older adults more than any other patient (Gallo, 2019). Yet hospitalized older adults are not a homogeneous group, as they have a wide range of experiences that influence their perceptions (Jack et al., 2021) and their interpretation of nurse nonverbal communication (Keutchafo et al., 2020). Also, older adults may experience hearing deficits, changes in attention and coding of the information, which may restrict their interaction, participation, and effective communication (Forsgren et al., 2016; Sanecka, 2014). This also indicates that effective communication with older adults will be an essential nursing skill (Skoglund et al., 2018).
Communication is the cornerstone of every human society, which sustains social life (Ahmadi & Kiani, 2019). In healthcare settings, effective communication is the basis of any relationship, especially of nurse-patient relationships (Windover et al., 2014). In geriatric care, communication is important to understand older adults’ needs and to support their health and well-being (Hafskjold et al., 2015). Communication, which includes verbal and nonverbal components, is more complicated than the mere transmission of information (de Guzman et al., 2019; Zani et al., 2014). The nonverbal aspect of communication is defined as “behavior of the face, body, or voice minus the linguistic content”; “everything but the words” (Hall et al., 2019, p. 272). It also includes how we behave, how we sound, and what is expressed between each other (Blanch-Hartigan et al., 2018). Nonverbal communication has different modalities, which include haptics (the use of touch), artifacts (the presence of physical and environmental objects), proxemics (the use of space and distance), chronemics (the use and perception of time), kinesics (forms of movement of the body), physical appearance (body type and clothing), silences, and vocalics (aspects of the voice; Boggs, 2015; Stanyon et al., 2016).
Factors found to influence effective communication between nurses and patients have been described as nurse related, patient related, environmental, physical, and psychological factors. Authors have identified nurse related factors as job dissatisfaction, workload, insufficient time. Uncontrolled patient family presence is a patient-related factor, and a busy environment is an environment-related factor (Amoah et al., 2019; Andriyanto, 2019; Loghmani et al., 2014; Tay et al., 2011). Physical factors are identified as room sizes/space, shortage of nurses, ambient noise, lack of privacy, and time constraints. Psychological factors like personality traits, anxiety, level of self-esteem, and psychological disorders, and culture, rules, rituals, laws, religion are described as social factors (Al-Kalaldeh et al., 2020; Arungwa, 2014; Coleman & Angosta, 2017; Hemsley et al., 2012; Savio & George, 2013). When communication is effective, patients feel cared for, respected, and more able to describe their concerns (Jack et al., 2021). On the other hand, patients’ negative experiences in their interactions with nurses would inevitably shape their subsequent communication with them, and patients would be less motivated to disclose their needs and feelings to nurses (Chan et al., 2018).
Ageist attitudes have been recognized as a factor influencing older adults (World Health Organization [WHO], 2021). Ageism comprises discrimination, prejudice, and stereotypes toward a person based on their age (Ayalon et al., 2019). Ageist attitudes and biases can lead to age-based disparities in healthcare including diagnostic procedures, decision making, and types of treatment offered. In addition, ageist attitudes are reflected in interpersonal interactions that are patronizing or involve “elder speak” (Wyman et al., 2018). Ageism in healthcare limits older adults’ access to appropriate and respectful care, and results in adverse clinical outcomes (Inouye, 2021). Communication that is free of age-related bias is essential to high quality, patient-centered care.
Effective communication with hospitalized older adults is an important part of nursing care and can present unique challenges. Although the importance of communication in healthcare has long been recognized (Chan et al., 2019), special attention needs to be directed to nonverbal communication. Words express only a part of the message being communicated, with the rest of the message conveyed by gestures, tone, and attitude (Lambrini & Loanna, 2014). Additionally, factors affecting nonverbal communication between nurses and patients should be recognized and considered so that the effectiveness of nurse communication can be enhanced and the quality of care improved (Tran et al., 2020; Yazew et al., 2021). This research aimed to describe conditions that influence effective nurse nonverbal communication with hospitalized older adults in Cameroon.
Methods
A qualitative design was used in this study. Although guided by inductive approaches reflected in grounded theory methods (Strauss & Corbin, 2015), our aim was not to develop theory. Rather, we used some grounded theory data collection and analysis techniques to develop an interpretive understanding of the largely unexplored topic of nurse nonverbal communication with hospitalized older adults in Cameroon.
Study Settings and Context
The study was conducted in two public hospitals in the East Region and the Central Region of Cameroon because older adults receive healthcare in hospital settings. There is no national effort to develop long-term care settings in the country yet (WHO, 2017b). Both hospitals are part of the central level of the three-level pyramidal Cameroonian healthcare system and serve as referral and teaching hospitals. Although one hospital has a geriatric unit, in both hospitals, older adults are admitted, mixed with younger adults but categorized based on their illness. The nurses who worked in these hospitals are certified nurses, registered with the nursing council or not because registration is not compulsory for practice in Cameroon. Diploma nurses study for 3 years in a nursing college after a high school certificate. Degree certified nurses study 3 or 4 years in a university after a high school certificate. Nursing assistants study for 18 months after the O level certificate is obtained in high school. Yet they constitute a portion of the healthcare workers as they are often team leaders and unit managers over diploma and degree nurses. Additionally, geriatric specialized nurses undergo a 2-year program in gerontological nursing and obtain their certificate without an accredited exam. In this study, the United Nations cut-off of 60 years and older referring to the older adult population in Africa was considered. While most high-income countries have accepted the chronological age of 65 years and older, the age of retirement, as a definition of an older adult (Zverev, 2013), socio-economic and disease reasons suggest that 65 years is not readily applicable to the African context (WHO, 2016).
Study Participants and Sampling
Ten nurses, including five nurses in each hospital, were recruited to participate in the study for overt participant observation, using a purposive, open sampling approach (Corbin & Strauss, 2015). These were nurses with any nursing experience, who could articulate in English or French, were involved in the day-to-day care of older adults admitted in the hospital, and demonstrated a willingness to participate in the study. The eligible nurses were approached and gave their consent to be overtly observed and interviewed during and about their interactions with hospitalized older adults. Further, four student nurses who were doing clinical placements in the hospitals and caring for hospitalized older adults, two middle unit managers, and one nurse assistant were also recruited following preliminary data analysis to identify and follow clues from the initial analysis, clarify uncertainties, fill gaps, check hunches, and test interpretations as the study progressed (Chun Tie et al., 2019). Those who could articulate in English or French, were involved or not in the day-to-day care of hospitalized older adults admitted, with any experience, were sampled. This was because there were nurses with less than 2 years of experience who were communicating with older adults, student nurses who were on clinical placement, as well as nurse managers who sometimes administered care to patients. To be recruited for interviews, nurses were approached in the nursing station when they seemed free and provided with the information related to the study to obtain their consent. Thereafter, individual interviews at a convenient time to them were arranged.
Data Collection
Data were collected by the principal investigator (EWK) between July 2018 and January 2020 using overt participant observations and individual interviews. Data collection commenced with a month-long of overt observations of interactions between 10 nurses and hospitalized older adults. The researcher observed how these nurses communicated nonverbally with older adults during different types of interactions. The observations were recorded as field notes promptly after each observation because the PI was not granted permission to video record. An observation guide, which consisted of a set of questions under the rubric “What is going on here?” as suggested by Corbin and Strauss (2015), gave structure to the note-jotting. After, there was an immediate rewriting of each observation while the event was still fresh in the memory. The interactions included nursing care related tasks, social interactions, and health education interactions. Data analysis of the observations guided the development of an interview guide, which was refined throughout data collection, and was used to conduct individual in-depth interviews with nurses.
Concerning individual interviews, nurses observed using nonverbal communication with hospitalized older adults were then approached for further participation in the study when they seemed not too busy by the nurse’s station or during lunch breaks. Thereafter, dates and times for the interviews were arranged. The initial interviews were informed by the analysis of observations as the interview with each participant was related to the captured observations of his or her interactions with hospitalized older adults. The interviews informed each other as each interview was transcribed and analyzed immediately to inform subsequent interviews and theoretical sampling. That allowed the generation of increasingly focused but not leading questions for subsequent interviews (Charmaz, 2014). The first open-ended question asked to each participant was: “How do you communicate nonverbally with hospitalized older adults?” This was followed by probing questions, which allowed for the PI to ask for more clarity about the observations captured and the emerging concepts. Also, when a concept emerged from the analysis, it was added in the subsequent interviews. For instance, when the concept “older adults are like children” came from one participant, that question was then added in the subsequent interviews. Fourteen interviews were conducted in French, except three interviews which were conducted in English because French is mostly spoken in these two regions of Cameroon. Interviews, which lasted about 60 minutes, were conducted at the time most convenient for the participants in the nursing station. Interviews were continued until data saturation of seventeen nurses was achieved.
Data Analysis
To analyze the data, written texts of the observations were broken into detailed pieces while the interviews were transcribed verbatim. Grounded theory data analysis strategies of open-coding and constant comparative analysis were used to identify and organize categories (Corbin & Strauss, 2015). The researcher used NVIVO version 12 qualitative data analysis computer software to import transcripts, write memos, code conceptual categories, properties, and dimensions from the data, and conduct data analysis. Data were initially coded sentence-by-sentence using an inductive open coding approach. The researcher then refined and grouped similar codes into categories and subcategories using constant comparison.
Ethical Considerations
Ethical clearance was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (reference number HSS/2008/017D) before the commencement of the study. Permission to conduct the study from the two participating hospitals in Cameroon was also obtained. A covering letter and informed consent explaining the purpose and nature of the study were given to each participant. The participants were informed that they could withdraw from the study at any time with no due penalty or repercussion. They were assured that no information given by them would be shared with another person without their authorization. They were not to receive monetary benefits for participating in the study. The participants were allowed to ask any questions before the voluntary signing of both consents to participate in the study and to be observed and/or audio-recorded. To maintain anonymity, pseudonyms were used.
Rigor
To ensure the trustworthiness of the data and analysis, the criteria of credibility, transferability, dependability, and confirmability described by Lincoln and Guba (1985) were used. Credibility in the study was promoted by member check, where the researcher confirmed what she observed during interviews with the nurses, and went back to nine of the participants with the corresponding transcripts for their validation and confirmation. Peer debriefing was done with two senior colleagues to confirm categories and themes. Confirmability was ensured by triangulating data sources (observations and interviews) and validating audiotaped and transcribed transcripts against categories and themes through constant comparison. Dependability was ensured by data quality checks. This was done by the consultation with expert seniors in grounded theory and the peer review of coding by senior qualitative researchers. Transferability was established by rich descriptions of informants, study context, research procedures, and the provision of quotes from the interviews to enrich findings. As for the positionality, from a symbolic interactionist position, the authors believe that (1) the realities are considered to exist for human beings in a world of shared symbolic meanings, (2) the researcher and research participants are assumed to be interactively linked in a mutual relationship in the natural field to investigate their behaviors, and (3) human beings and shared meanings of reality can be defined only through interaction between and among the researcher and participants in the context of the phenomena of interest.
Findings
A sample of 17 participated in the study as described in Table 1. These included two middle unit managers, one first-line unit manager, nine certified nurses, one certified nurse assistant, and four student nurses. About 16 participants were female and 1 was male. This is common in Cameroon where nursing is considered a female dominant profession. The majority of nurses were aged 45 years and below. Their years of nursing experience ranged from 1 to 32 years.
Description of Sample.
Three categories of factors were identified as influencing the effectiveness of nurse nonverbal communication with hospitalized older adults. The categories were: (1) nurse intrinsic factors, including five sub-categories, (2) nurse views of older adults, including two sub-categories, and (3) hospitalized older adult related factors, which included two sub-categories.
Nurse Intrinsic Factors
There were nurse related factors that influenced nonverbal communication with hospitalized older adults. They included nurse beliefs, personal experiences, personality traits, and awareness of nonverbal communication. Despite nurses’ commitment to their work, their views of hospitalized older adults were influenced by cultural beliefs and negative stereotypes of aging in the wider community, and as a result, ageist attitudes toward older adults were evident in their descriptions of interactions with older adults in the research study contexts.
Nurse beliefs
Nurses’ views of hospitalized older adults are influenced by prejudices and stereotypes against older adults in the cultural setting, reflecting ageist attitudes toward older adults. These include a cultural belief that dying older adults are witches and wizards, and can mystically exchange their life with those of nurses attending to them, to live longer, as depicted in the following quotes: For example, in my village, there is this belief that if you administer care to an old patient that is almost dying, that patient can recover and transfer his death to you. [P12, geriatric specialized nurse, five years of experience] But we are in Africa, right? They say that wizards, especially dying old people, can exchange their body with the body of a younger person. [P7, diploma nurse, 9 years of experience]
Some nurses reported having accepted these beliefs. However, others rationalized these beliefs as not being relevant to their work as nurses with regards to their communication with hospitalized older adults. Yet they appeared to use various strategies for coping with fears related to these beliefs to care for patients as seen below: We are no longer afraid of anything, we have already seen a lot. What can still frighten us? Also, there are stereotypes like witchcraft happening in hospitals, preventing a nurse to sit on a patient’s bed and all that. I can’t do that. I am not afraid of anything. I sit on patients’ beds, I touch them. . . [P3, Diploma nurse, 23 years of experience] We do not ignore our customs or our beliefs because they exist but from the moment we have made commitments to specialize in geriatrics, we shouldn’t consider them much. [P12, geriatric specialized nurse, five years of experience]
The nurse beliefs also included their religious beliefs. One nurse reported that her Christian faith helped her not to be afraid of dying older adults, but to be in close contact with them: The fact that we are Christian gives us the strength to approach a dying older patient. Honestly, if we were are not Christians, I do not see how we will have this strength. We will always fear. We will always be afraid to go closer to these people. [P12, geriatric specialized nurse, 5 years of experience]
Another participant added that she prays for older adults silently, which is a way of coping with the fear of dying older adults as seen in the quote below: I am indeed a born again (Christian), that’s why I am not afraid of patients because spiritually I commit my day to God when I get up, I commit my work when I get here in the ward. Several times, I had to pray for patients. I do not pray aloud, I pray in my heart when I touch them. [P10, nurse assistant, 14 years of experience]
Personal experiences
This subcategory refers to nurse professional and personal experiences of contact with older adults. Nurses who had lived with their grandmother or grandfather reported having no problems communicating with hospitalized older adults. Nurses reported that they would use the same techniques they used with their relatives in communicating with the hospitalized older adults they nursed. Even though the hospital environment is not similar to their home environments, their past exposure was reported to facilitate nonverbal communication: I think that my growing up with my grandmother makes it easier for me to communicate with them. [P15, student nurse, first-year diploma program] It is not too different from interacting with my grandmother. . . because I have my grandmother, which also contributes to my way of interacting with older patients here. So, this is something that I was already doing, and that I carried over here in the geriatrics ward. [P10, nurse aid, 14 years of experience]
On the flip side, nurses associated nursing experience with the effectiveness of nonverbal communication. They implied that nurses with few years of experience are more likely to have less nonverbal communication skills with hospitalized older adults as captured below:
You have to have the skills in nursing and to know the benefits of nonverbal communication in geriatric care. You have to know how to communicate nonverbally then apply what you know depending on the situation.
Nurses who have just graduated do not have that experience. They cannot easily discern the needs of an older patient and respond to them appropriately. For example, you can walk into a room and find an older person tense, and it doesn’t mean anything to you. But for me, who is more experienced, I can discern that maybe he (the old patient) has issues with his loved ones, he is hungry, he is in pain, or he has messed his diaper [P2, middle unit manager, 32 years of experience]
Personality traits
Personality traits mainly referred to the innate character or behavior of someone that can potentially influence how one communicates nonverbally with hospitalized older adults. A nurse referred to personality as portrayed in the quote below: Well, there is also a fact. Habit is indeed second nature. You know, each person has his character or behavior, and with the skills we acquired from the nursing training, we use nonverbal communication dependently. [P4, geriatric specialized nurse, 11 years of experience]
However, a nurse with 9 years of nursing experience admitted that she is naturally a fearful person, and why when she is afraid of some older adults she avoids them. This prevents her from communicating nonverbally with the avoided patients: Some patients scare me. Well, maybe I am like that. I am fearful by nature because at home I close the doors as I walk by, the main door, the kitchen door. When someone leaves the main door open, I close it because I am like that. I am scared of things. It often happens that a patient scares me and I avoid him. [P7, diploma nurse, 9 years of experience]
Nurse awareness of nonverbal communication
Awareness of the nonverbal messages sent to others is essential, as it often explains why people respond to us the way they do. During observations, we observed that nurses were not always aware of their body language, nor their physical appearance, during interactions with hospitalized older adults. This was further confirmed by a participant who referred to the physical appearance of nurses that can influence nonverbal communication as seen below: Sometimes we use nonverbal communication without knowing. We should be aware of the style of gesture to use when communicating with an older patient. Nurses should be aware that, even by scratching my head, I am sending a message. That’s why I said that somehow you cannot communicate with a patient without nonverbal communication. Nurses need to understand that nonverbal communication is a serious matter. They also need to understand the benefits and the consequences of nonverbal communication. I forgot to mention that even physical appearance is part of nonverbal communication. You might walk in here like a hemp smoker, a message has already been sent to the patient so we need to be aware. [P4, geriatric specialized nurse, 11 years of experience].
A unit manager linked awareness of nonverbal communication to competency. She argued that nurses cannot claim to be competent in nonverbal communication if they are not aware of their nonverbal communication: That’s why I’m talking about competence and to be aware of the use of nonverbal communication. You have to be aware of that. That’s what skills are all about. It’s when you are aware that you’re competent in something. Because if you do things but you don’t know why you do them, you are not competent. [P5, unit nurse manager, 30 years of experience]
Love for the job
Participants reported that nurses need to love their jobs and older adults to be able to communicate nonverbally with them. In the context of the study and as confirmed by some participants, people enter the nursing profession for job security, even when they have “no calling” to be nurses. Therefore, nurses have to love their job and the older patients as echoed below: First, you have to love your job and you have to love the older patients. You have to love your patients because some older people come to the hospital in a very bad state whom if you are not a loving person, you may not even touch them. . . as I said earlier, you have to love what you do and love the older patients because to sit next to and touch someone’s shoulder takes love. [P5, nurse unit manager, 30 years of experience] You have to have a lot of love to practice in geriatrics, to be able to bear the whims of the older patients. We treat them with a lot of love and that’s what works. You have to be very patient, you have to love the work or you will do things carelessly. When you treat them carelessly, they feel it and they start to hate you. [P10, nurse aid, 14 years of experience]
Participants also described factors related to older adults they thought influenced nurse nonverbal communication.
Nurse views of hospitalized older adults
Nurses’ descriptions of their interactions with hospitalized older adults varied based on their views of hospitalized older adults. Some nurses described their nonverbal communication in ways that infantilized the older adults and reflected ageist attitudes. For example, one nurse stated: I told you that older patients, especially at a certain age, are considered babies. Yet a baby and an adult are different. For a baby to understand, it takes repetitions and many gestures so that the baby can understand you, while the adult is easy, but with older patients, you have to repeat yourself several times for them to understand you, they are just like babies. [P12, geriatric specialized nurse, 5 years of experience]
A specialized nurse in gerontology also saw older adults as children as seen in the quote below: They are a bit like children with whims, with desires. They are really like children. They behave like children so sometimes it makes it difficult to talk to them because they don’t understand like children don’t. We have to use gestures. [P9, geriatric specialized nurse, 6 years of experience]
On the other hand, some nurses had positive views about older adults that included their keen sense of observation and interpretation of nonverbal cues. Consequently, those nurses paid special attention to their nonverbal communication and the effect it may have on older hospitalized patients, as illustrated in these quotes: This is why we smile and we have serene facial expressions so that the patient does not feel his condition through our face because the old people especially because they have lived a long time, so they can interpret a lot of things, they easily see some things you are not saying verbally. [P10, nurse aid, 14 years of experience] It is just to say that older people know many things and are very observant. They see everything even if they are silent. It’s as if they analyze any movement or anything in our way of doing things. This makes us vigilant with our nonverbal communication. [P11, diploma nurse, 13 years of experience]
Hospitalized Older Adult-Related Factors
Some factors were related to older adults, which can influence nonverbal communication. These include older adults’ financial situation and older adults’ moods. In Cameroon, there are out-of-pocket payments for healthcare services in public hospitals, where patients pay for their consultation fee, their medication, and their hospitalization fee beforehand. With this regard, participants mentioned the financial situation of older adults as an influencing factor as demonstrated in a quote below: The financial limitation is an obstacle to nonverbal communication because when the patient does not have money and I too do not have money to help him, I avoid the patient. At some point, it becomes embarrassing for him too. Because he knows his financial situation, he pulls back. Well honestly, when I can’t do anything myself to help him, and with the workload, I forget that the patient is there. [P7, diploma nurse, 9 years of experience]
For the above-mentioned instance, it was observed that some nurses stood at the door to ask the patients if they had bought their medication. In the case where patients had no medication, nurses sometimes did not bother to enter the room to interact or communicate further with the older patient. They skipped that patient and went to the next one. When they saw that a particular patient was not having his medication for days, they gave up even asking him. They assumed that when the medication was available, the family would alert the nurses.
On the other hand, hospitalized older adults who were seen as “rich” influenced the nonverbal communication of nurses positively. In the quote below, a participant reported avoiding the use of a phone while administering care. Yet, this participant was observed using a phone during interactions with older adults: In case rich older patients, you might walk in their room while having a conversation on the phone about drinking a beer. They would automatically think that if you drink beer, you cannot touch them because you are a drunkard. Sometimes when I am on the phone in front of patients, it sends a message that the patient has already decoded. So, I mind my nonverbal communication. [P4, geriatric specialized nurse, 11 years of experience]
Hospitalized older adults’ positive mood was reported by some nurses as a facilitator of nonverbal communication, as shown in the following extracts below: Their mood will determine what I do. If they are in a positive mood, it is easier to smile at them and spend more time with them. [P9, geriatric specialized nurse, 6 years of experience] One day, I walked into a room and saw a sad patient, and I smiled toward him until he could respond to me. The patient’s sadness was what pushed me to use a smile as a nonverbal communication strategy and it worked. [P12, geriatric specialized nurse, 5 years of experience]
However, one participant mentioned that nurses should constantly adapt their nonverbal communication based on the older adults’ mood as seen in the quote below.
Nonverbal communication differs. When she arrives at D1 (admission ward), it’s the welcoming phase and the first contact. As days go by, she may have problems or that she is unhappy. You can see that there is a change compared to the 1st day, and that leads you to change gradually the nonverbal communication with her. [P2, middle unit manager, 32 years of experience]
Discussion
This paper aimed to explore and describe factors that influence nurse nonverbal communication with hospitalized older adults in two public hospitals in Cameroon from the nurse perspectives. The findings revealed that both the nurse related factors and hospitalized older adult-related factors influenced effective nurse nonverbal communication with hospitalized older adults. These findings are supported by O’Hagan et al. (2014) and King et al. (2015) who reported that both nurse and patient related factors contribute to effective communication.
With regards to nurse related factors, the findings indicated that nurse beliefs, personality traits, personal experiences, and love for their job played an important role in influencing nurse verbal communication with hospitalized older adults. This explains what Bateson (1972), in his circular transactional model of communication, described as intrinsic factors considered as intrinsic to the sender of the message. The most striking intrinsic factor reported in this study to influence nurse communication with hospitalized older adults was the cultural beliefs, where nurses believed that dying hospitalized older adults could perform witchcraft during hospitalization. This belief hindered some nurses from getting close to or touching a dying older patient; thus, negatively affecting nonverbal communication. Similar findings have been reported in Ghana, where Amoah et al. (2018) reported that cultural beliefs were a barrier to effective communication between nurses and patients. However, culture has been identified as both facilitator and barrier to effective communication (Del Pino et al., 2013; Savio & George, 2013) and it has been linked to the quality of care (Tork et al., 2019).
The findings of this study further highlighted that nurse religious beliefs facilitate nonverbal communication with hospitalized older adults, whereas, in Ghana, patients’ religious beliefs were reported as barriers to effective communication with nurses (Amoah et al., 2019). For instance, it was reported that Muslim patients expected nurses to bow when attending to them. Those who did not bow to every patient because of limited time were seen as insolent. This negatively affected the level of communication with patients (Amoah et al., 2019). Cameroon is a predominantly Christian country which may explain why some participants reported that their Christian beliefs played a role in their nonverbal communication. This shows that culture and religion should not be underestimated when exploring factors influencing effective nurse nonverbal communication with hospitalized older adults.
Our findings also highlighted nurse awareness of their behaviors in influencing their nonverbal communication with older adults. Although nonverbal messages are often subconsciously transmitted, many of the nurses were aware and mindful of their value when communicating with patients, and made efforts to discern if their behaviors reflect the values that patients expected (Ahmadi & Kiani, 2019; Wiechula et al., 2016). Others have reported that awareness of one’s nonverbal messages leads to a greater understanding of the messages exchanged (Sudirman & Sidin, 2016). Awareness also explains why people respond to us the way they do, and influences how the other person communicates with us (McCabe & Timmins, 2013). It is therefore crucial for nurses to be aware of their body language and the use of personal space when communicating with patients (Tork et al., 2019).
One’s work experience was also reported as one of the factors influencing effective nurse nonverbal communication with hospitalized older adults. Participants indicated that nurses with more years of experience could communicate nonverbally with older adults more easily than less experienced nurses could. Similarly, in other studies, more years of experience was mentioned as one of the influencing factors of communication. It has been shown that experienced nurses tend to remember how to communicate with patients and had better communication skills (Farzi et al., 2022; Tran et al., 2020; Yazew et al., 2021). Contrary to our findings, Radsma (1994) argues that long-time practicing nurses have high tendencies to ineffective communication skills. This is because they may have got used to the same way of communicating that they are no longer aware of their nonverbal behaviors which can influence their communication with patients.
In our findings, patients’ financial status was reported to influence nurse nonverbal communication with hospitalized older adults. In Cameroon, the cost of purchasing healthcare is relatively high for the average older adult because there are out-of-pocket payments for every healthcare service rendered, even if this is in public hospitals (Emeh, 2020). Patients pay for their consultation, medication, and hospitalization fees before treatment. In this study, nurses reported avoiding patients who have limited finances to pay for basic medical care while in hospital. This could be explained as a nurses’ way of saving the patients from embarrassment, caused by failure to pay for their own basic health needs. Avoiding hospitalized older adults who could not pay for their basic care could be seen as missing opportunities for meaningful interactions and nonverbal communication (Kerr et al., 2019), which could be needed by these patients.
The study revealed that some nurses had ageist attitudes as they saw hospitalized older adults as infants or witches or wizards. The existence of ageism in healthcare settings makes it crucial to design interventions targeting healthcare professionals and students as well (Tullo et al., 2010). To improve attitudes toward and communication with older adults, the WHO (2017a) recommended that healthcare professionals promote healthy aging by ensuring that their practice enables and empowers the autonomy and independence of older adults. It has been suggested that educational programs for healthcare professionals and nurses, and the promotion of empathy through simulation and games can improve attitudes toward and communication with older adults (Inouye, 2021; Martínez-Arnau et al., 2022).
Conclusion
Understanding the nurse intrinsic factors and other nurse related factors for effective nonverbal communication with hospitalized older adults is important when developing training material for nurses. Addressing factors that can impede effective nurse nonverbal communication with hospitalized older adults is important. This includes debunking all religious and cultural beliefs as well as negative stereotypes that the nurses may have about hospitalized older adults through education of nurses and the public to enhance the older adults care in Cameroon and Sub-Saharan Africa. Nurses should be assisted to know and appreciate the value of their nonverbal communication when dealing with all patients irrespective of their financial status.
Footnotes
Acknowledgements
IREX funding through the UASP alumni small grants program is acknowledged for providing a platform for the development of this manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from the College of Health Sciences of the University of KwaZulu-Natal for data collection.
